Patho Patho #69

Question

The nurse caring for a client diagnosed with myxedema coma places priority on performing which assessment:

Answers

  1. 1. Droopy appearing eyelids.
    • Rationale:

      This answer choice is not correct because droopy appearing eyelids, myxedema, are an expected manifestation associated with hypothyroidism, This is not a critical finding of myxedema coma.

  2. 2. The client’s intake in mL.
    • Rationale:

      This answer choice is not correct because assessment of heart rate is the more critical assessment due to significant bradycardia that can occur in a client with myxedema coma.

  3. 3. Rectal temperature.
    • Rationale:

      This answer choice is not correct because, although the client is at risk for decreased body temperature, heart rate is the most important assessment.

  4. 4. Apical heart rate.
    • Rationale:

      This answer is correct because apical heart rate assessment is the most critical assessment for a client with myxedema coma due to significant bradycardia associated with this disorder. Significant bradycardia will decrease cardiac output which negatively affects organ perfusion.

Overview

The focus of this question is asking the nurse to identify the priority assessment for a client with myxedema coma. Myxedema coma is a potential complication that occurs in clients with underlying hypothyroidism. Myxedema coma results in significant bradycardia and hypotension, therefore the nurse must place priority on assessing the client’s apical heart rate.

Explanation

Learning Outcomes

Myxedema coma is the most significant complication of hypothyroidism. Manifestations include decreased mental status, decreased body temperature, bradycardia, and hypotension. The nurse must place priority on assessing the client’s apical heart rate and rhythm to prevent complications from decreased cardiac output.

Test Taking Tip

A-B-C

Video Rationale