A patient with primary hypothyroidism is showing early signs of myxedema coma.
In what order should the nurse perform the following assessments? (Rank the first action at the top with the remainder in descending order.)

Measure body temperature.

Palpate for pedal edema.

Observe breathing patterns.

Assess blood pressure.

Answer and Explanation

The Correct Answer is C,A,D,B

Step 1: Observe breathing patterns. Respiratory depression is a critical symptom of myxedema coma that requires immediate attention.

Step 2: Measure body temperature. Hypothermia is a common symptom of myxedema coma and can provide important information about the severity of the patient’s condition.

Step 3: Assess blood pressure. Hypotension can occur in myxedema coma and can indicate the severity of the patient’s condition.

Step 4: Palpate for pedal edema. While this can be a symptom of hypothyroidism, it is not typically a primary concern in a patient showing signs of myxedema coma.

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Correct Answer is C

Explanation

Choice A rationale

While the frequency of a problem can provide some context, it is not the most important consideration when gathering evidence for evidence-based decision-making. The frequency of a problem does not necessarily correlate with the quality or relevance of the evidence available.

Choice B rationale

Personal values are important in decision-making processes, but they are subjective and can vary greatly among individuals. Therefore, they are not the most important consideration when gathering objective, scientific evidence for evidence-based practice.

Choice C rationale

Relevance to the situation is the most important consideration when gathering evidence. Evidence must be directly applicable to the specific problem and context in order to be useful in informing decision-making. This includes considering the specific characteristics of the patient population, the nature of the problem, and the setting in which care is being provided.

Choice D rationale

Past experience with similar problems can provide valuable insights and context, but it is not the most important consideration. Past experiences are individual and subjective, and what worked in one situation may not work in another. Evidence-based practice requires the use of current, high-quality research evidence, which may or may not align with past experiences.

A. Rhythm of the apical pulse. B. Volume of pedal pulses. C. Degree of skin elasticity. D. Length of capillary refill.

Correct Answer is A

Explanation

Choice A rationale

In a patient with a recent exacerbation of heart failure who is feeling uncomfortable and anxious, with a sensation of flopping in the chest, the rhythm of the apical pulse should be prioritized. This is because changes in heart rhythm can indicate worsening heart failure or other serious cardiac conditions.

Choice B rationale

While the volume of pedal pulses can provide information about peripheral circulation, it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.

Choice C rationale

The degree of skin elasticity can provide information about hydration status, but it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.

Choice D rationale

The length of capillary refill can provide information about peripheral circulation and overall cardiovascular status, but it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.

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A patient with primary hypothyroidism is showing early signs of myxedema coma. In what order should the nurse perform the following assessments? (Rank the first action at the top with the remainder in descending order.)

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A patient with a recent exacerbation of heart failure is feeling uncomfortable and anxious, with a sensation of flopping in the chest.While waiting for an electrocardiogram (ECG), which assessment should the nurse prioritize?

Correct Answer is A

Explanation

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A patient with primary hypothyroidism is showing early signs of myxedema coma.
In what order should the nurse perform the following assessments? (Rank the first action at the top with the remainder in descending order.)