Communication
A young man is brought to the emergency department by police officers after he was discovered walking down the middle of a busy city street, yelling and shouting about religious persecution. The patient is restrained in handcuffs but is ambulatory and remains accompanied by the officers. He is agitated and paces about the room. His speech alternates between loud declamations about God and mumbling to himself. To assess this patient, the nurse must establish the ability to communicate with him. Which behaviors by the nurse would be unlikely to be helpful in de-escalating the patient’s current behaviors and laying the groundwork for obtaining the patient’s cooperation with care?
A. Appearing calm and speaking in a quiet but clear voice
B. Using good eye contact with the patient
C. Insisting that the patient sit down or lie down on the cart for an examination
D. Using direct and simple language when asking the patient to follow a direction
What is C
With mental health patients, just as with any other patient, the foundation for establishing an effective nurse-patient relationship begins with respectful, caring, and compassionate communication. Using a controlled and quiet tone of voice, appearing calm and accepting, making good eye contact with the patient, being aware of one’s own body language, listening and taking seriously what the patient is saying, validating the patient’s feelings, and rephrasing information provided by the patient to corroborate understanding can all be helpful in establishing a good rapport. Speaking clearly, in simple and direct terms, can help an agitated patient listen and focus. It is always essential for the nurse to be aware of personal safety, as well as the safety of the patient, and thus sometimes the assistance of additional staff and personnel will be required.
To the extent possible, avoid asking the patient to do something or to stop doing something that will not interfere with the communication process. In this example, there is no reason the patient must sit down or lie down for the interview to continue. At some point he may need to sit or lie down so a physical examination can be performed, but this will be much more difficult to accomplish if his cooperation cannot first be enlisted by establishing a relationship of trust with his health care providers.
A 24-year-old patient with type 1 diabetes is brought to the emergency department by ambulance after friends discovered that he was too weak to get out of bed. The patient is able to provide a history of nausea, vomiting, diarrhea, and fever for 3 days. The following vital signs are obtained: blood pressure, 98/75 mm Hg; heart rate, 130 beats per minute; respiratory rate, 32 per minute; and temperature, 38.3°C (101°F). The nurse notes that the patient has Kussmaul’s breathing and knows that this is a normal compensatory mechanism for:
A. Respiratory alkalosis.
B. Metabolic alkalosis.
C. Respiratory acidosis.
D. Metabolic acidosis.
What is D
Kussmaul’s breathing is a sign of diabetic ketoacidosis (DKA). The patient is at risk for development of this complication of his type 1, insulin-dependent diabetes, which often occurs as a result of illness and infection. With DKA, insulin deficiency plus the actions of catecholamines, cortisol, and glucagon, which antagonize insulin, cause an increased release of fatty acids and ketogenesis. The increased formation of ketones causes an accumulation of ketoacids in the serum, resulting in a metabolic acidosis. The respiratory system attempts to compensate for this metabolic acidosis by excreting, or blowing off, acid in the form of carbon dioxide. Kussmaul’s breathing is characterized by deep and rapid respirations.
This patient’s history of fluid loss through vomiting and diarrhea, as well as the osmotic diuresis that occurs with the hyperglycemia of DKA, are putting the patient at risk for profound dehydration, as reflected in the patient’s blood pressure and heart rate.
A pregnant patient with hydramnios presents to the emergency department with contractions. While waiting for transport to the delivery area, the patient’s water breaks, and a cord prolapse is visible. The most priority nursing intervention for this patient is:
A. Place the patient in the left lateral position.
B. Place the patient in the knee-chest position.
C. Place the patient in reverse Trendelenburg position.
D. Place the patient in low Fowler position.
What is B
Patients with hydramnios are at higher risk for a prolapsed cord because the extra fluid allows for more force to the umbilical cord, increasing the risk of it flushing out of the uterus. It is also more common with prematurity and breech presentation. The patient should immediately be placed in the knee-chest position or in the Trendelenburg position. The nurse should also maintain constant pressure on the fetal head to decrease cord compression until the child can be delivered. The left lateral position (A) would be appropriate in a patient with fetal bradycardia to alleviate pressure on the cord in utero and improve maternal venous return. The reverse Trendelenburg and low Fowler positions (C, D) would increase pressure on the prolapsed cord.
A patient provides a history of having discovered a raccoon in the yard, and thinking that it appeared ill, tried to feed it. In doing so, the patient believes that secretions from the raccoon’s mouth came into contact with an open wound on the patient’s hand. The patient has come to the emergency department because he fears that he may need a rabies vaccine. Which of the following statements are correct?
A. The patient will not need a rabies vaccine because raccoons are not carriers of rabies.
B. The patient will not need a rabies vaccine if the raccoon can be captured and confined for a period of 2 weeks to observe for the development of rabies.
C. The patient will need a rabies vaccine because it is possible that the patient may have inoculated himself with rabies with this type of exposure.
D. The patient will need a rabies vaccine because all fur-bearing wild animals are potential carriers of rabies.
What is C
The patient will need a rabies vaccine because his open wound has been exposed to the saliva of a potentially rabid animal. This transmission method is basically no different than a bite wound in terms of exposure to the infected material. Any mammal can be infected with rabies, and raccoons are common rabies carriers, along with skunks, foxes, and bats. Lagomorphs (ie, rabbits and hares) and rodents (eg, squirrels, chipmunks, rats, and mice) are almost never found to be infected with rabies.
Signs of rabies among common rabies-carrying wildlife are unreliable. For this reason, any contact with the saliva of these animals is considered an exposure, and rabies prophylaxis is necessary.
A myasthenic patient presents with complaints of increased weakness of his extremities, blurring vision, trouble with head control, and drooling. The physician has ordered Tensilon (edrophonium chloride), 5 mg, intravenous push. Nursing considerations for giving this medication intravenously include:
A. Connecting the patient to a cardiac monitor and having Atropine immediately available.
B. Placing the patient flat or in the Trendelenburg position and giving the medication quickly in a large-bore antecubital IV line.
C. Mixing the medication in 100 mL of normal saline solution and giving it over 20 minutes.
D. Placing seizure pads on the bed rails prior to administration of the medication and having lorazepam immediately available.
What is A
Tensilon (edrophonium chloride) is a cholinesterase inhibitor that maintains and prolongs the presence of acetylcholine within the neuromuscular junction. Another way to think about this class of drugs is to consider them as being “pro-cholinergic.” In other words, they can cause such things as bradycardia, bronchospasm, and increased secretions.
Safety precautions when giving intravenous Tensilon include connecting the patient to the cardiac monitor, having suction available in case of increased secretions (which the patient in a myasthenic crisis may already have), giving a small portion of the total dose (2 mg) slowly, and observing for an untoward reaction and then giving the remainder of the dose by IV push slowly over a period of a few minutes. Having atropine available in case of the development of symptomatic bradycardia is advisable.
You are caring for a 10-year-old autistic child who has auditory defensiveness. Which of the following nursing interventions would be most important with this child?
A. Limit amount and duration of touching.
B. Dim the lights.
C. Allow the child to keep his clothes on.
D. Set alarms to sound only outside of the room.
What is D
The child with auditory defensiveness is sensitive to sound and should be placed in a quiet area of the emergency department; speak in a low slow calm voice, and set the alarms to sound outside the room. Children with tactile defensiveness are particularly sensitive to being touched (A). Children with visual defensiveness are particularly sensitive to visual stimuli such as flashing lights (B). Children with resistance to change should be allowed to keep their clothes on if possible, and keep the family within the child’s sight (C). General principles, when working with autistic children, include reducing stimuli, keeping communication simple and direct, limiting the number of staff involved in care, and allowing extra time to avoid rushing with the child.
The metabolic panel of the patient described in Question 2 reveals the following values: glucose, 650; sodium, 150; potassium, 3.5; creatinine, 1.9; blood urea nitrogen, 54; and serum osmolarity, 315. The patient has already received 1 L of normal saline solution. Which of following orders would the nurse anticipate as the most appropriate for this patient?
A. 1000 mL intravenous (IV) bolus of 5% dextrose in water; 10 mEq oral potassium
B. ½ normal saline solution at 125 mL/hour; 40 mEq potassium IV piggyback
C. Second 1000 mL IV bolus of normal saline solution; 20 mEq potassium IV piggyback
D. 1000 mL IV bolus of 5% dextrose lactated Ringer’s solution with 40 mEq potassium; 20 mEq oral potassium
What is C
The patient’s blood urea nitrogen and serum osmolarity reflect the patient’s high serum solute concentration and fluid volume depletion. The serum glucose level of 650 is responsible for an osmotic diuresis, and as previously noted, the patient’s gastrointestinal illness has contributed to fluid loss as well. One of the first goals of therapy for a patient in DKA is volume resuscitation, which is best accomplished by vigorous fluid replacement with glucose-free isotonic solutions, such as normal saline solution.
Patients in DKA are in a profound state of metabolic disruption. As this patient’s metabolic acidosis proceeds, excess hydrogen ions will be “sequestered” inside of cells. For this to occur, potassium ions must exit the cell and enter the serum to maintain electrical neutrality. Early in DKA, patients will have a high serum potassium level. As the state of metabolic disruption goes on uncorrected, potassium will be washed out of the system and a hypokalemia will result. Beware the patient in DKA with a normal serum potassium level! As soon as the patient’s hyperglycemia begins to be corrected with intravenous insulin, potassium will be driven back inside the cell and out of the serum, resulting in hypokalemia. In fact, the patient in DKA with a normal or low serum potassium level should have replacement of potassium begun prior to administration of insulin. Potassium will most likely be given in intravenous form, but if the patient is able to tolerate oral intake, potassium by mouth also can be considered.
In a 21-year-old female who is 14 weeks pregnant, which of the following assessment findings would suggest that the patient has pyelonephritis?
A. Hematuria
B. Dysuria
C. Costovertebral angle tenderness
D. Supra pubic discomfort
What is C
Patients with renal involvement from a urinary tract infection may have flank pain or costovertebral angle tenderness upon palpation. Pregnancy would not alter presentation symptoms. Patients may also have chills, fever, nausea, and vomiting. Hematuria (A), dysuria (B) and suprapubic discomfort (D) commonly occur with lower urinary tract infections and may also be present with pyelonephritis, but the symptoms are not specific to pyelonephritis.
You are caring for a patient who sustained frostbite to the hands and feet. Which of the following would the nurse anticipate when planning care for this patient?
A. An order for ibuprofen
B. Placing both feet in a basin of warm water
C. Gently patting both feet dry after warming is complete
D. Placing feet in a depend position to improve circulation
What is A
Ibuprofen may be ordered to decrease production of inflammatory mediators. The feet should be placed in a gently swirling warm water bath without the feet touching the bottom or sides to prevent trauma (B). The feet should be air dried to prevent further trauma (C). The feet should be elevated because the feet will swell after thawing (D).
A 50-year-old man presents to the triage desk with complaints of fever and cough. Past medical history includes surgery for an anterior pituitary tumor and panhypopituitarism. Which of the following would be an expected assessment finding in this patient?
A. Hyperglycemia
B. Hypertension
C. Facial puffiness
D. Hypernatremia
What is C
This patient has a deficiency in all of the anterior pituitary hormones. Deficiency in thyroid-stimulating hormone (TSH) can cause symptoms of low thyroid function such as facial puffiness, cold intolerance, and dry skin. Patients with adrenocorticotropic hormone deficiency (ACTH) are at risk for adrenal crisis with fever, hypoglycemia (A), hypotension (B), and hyponatremia (D). This patient is at risk for adrenal crisis and will need glucocorticoid replacement.
A patient who is deaf arrives at the triage desk accompanied by a family member. Which of the following options is a best practice when working with patients who are deaf or hard of hearing?
A. Ask the family member to interpret.
B. Ask a colleague who signs to interpret.
C. Exaggerate lip movements while speaking to make lip reading easier.
D. Maintain eye contact when speaking.
What is D
Best practices for communicating with patients who are deaf or hard of hearing include (1) maintaining eye contact while speaking, and if you have to turn away, waiting until you reestablish eye contact before speaking; (2) making sure your face and mouth are clearly visible; and (3) speaking at a normal pace and avoiding exaggerated lip movements (C) or raising your voice. Patients who are hard of hearing are covered by both the Americans with Disabilities Act and the Civil Rights Act. Hospitals must provide reasonable accommodations, which includes qualified sign language interpreters or certified deaf interpreters. Family members and employees who are not qualified language interpreters do not meet Americans with Disabilities Act standards. Qualifications for sign language interpreters are set by each state. If interpreter services are not available, document all attempts to obtain services.
Which of the following arterial blood gas measurements is consistent with diabetic ketoacidosis?
pH PaCO2(mm Hg) PaO2 (mm Hg)
A. pH - 7.26 PaCO2 - 40 PaO2 - 80
B. pH - 7.34 PaCO2 - 32 PaO2 - 95
C. pH - 7.24 PaCO2 - 25 PaO2 - 105
D. pH - 7.48 PaCO2 - 35 PaO2 - 130
What is C
In diabetic ketoacidosis, the serum arterial or venous pH is less than 7.30. The PaCO2 is dropping as the body tries to compensate for the acidosis by blowing off the CO2; thereby, lowering that value and increasing the O2 (hyperventilating).
In caring for a patient experiencing a threatened abortion, which of the following nursing diagnoses would be noncontributory in planning for discharge instructions?
A. Risk for potential fluid volume deficit
B. Anticipatory grieving
C. Acute pain
D. Risk for potential electrolyte disturbance
What is D
Loss of a pregnancy occurring before 20 weeks of gestation is termed spontaneous abortion and can occur for a number of reasons. Classification of spontaneous abortion can be viewed across a spectrum, including threatened, inevitable, incomplete, and complete abortion. A threatened abortion is characterized by vaginal bleeding, usually slight to light, with a completely closed cervical os. The patient may or may not have associated cramping or pain. Factors associated with spontaneous abortion include chromosomal abnormalities of the fetus, uncontrolled diabetes in the mother, use of certain drugs, substance abuse, older maternal age, and traumatic injury. However, many times the reason for the loss of pregnancy is simply unknown.
Nursing considerations in caring for a patient with threatened abortion include monitoring for fluid volume deficit, which could occur if the threatened abortion progresses along the spectrum to inevitable, incomplete, or complete, because this could be associated with increased bleeding. Pain and cramping may or may not be associated with this event, but the patient should be counseled that pain is not unanticipated and given instructions about the use of appropriate analgesic agents. Typically, non-narcotics and nonsteroidal anti-inflammatory agents are sufficient for pain control.
Worry about the possible loss of pregnancy can be a very real issue for the patient with a threatened abortion, as can grief if the pregnancy is ultimately not maintained. Often, the patient will be leaving the emergency department with many unanswered questions: Am I going to lose this baby? If I do not lose the baby, will the baby be alright? Have I done something wrong to cause this to happen? Did I fail to do something that I should have done, which caused this to happen? These questions are often unasked but concerning to the patient's partner as well.
Appropriate reassurance, empathy, and supportive information can help the patient recognize that the worry and grieving that she might be experiencing are not uncommon. This should be addressed as part of the patient's discharge information. Providing the patient with information about resources for help if the grief process becomes overwhelming might be included as well.
You are caring for a patient in the emergency department who was diagnosed with severe malaria after a hiking trip in Southern Asia. The patient has been prescribed intravenous quinidine. While administering this medication, the nurse should be prepared to intervene for which of the following:
A. Hypertension
B. Hyperglycemia
C. Widening QRS complex
D. Shortening QTc interval
What is C
There are several forms of malaria, some more severe than others; P. falciparum malaria is the most severe type, must be treated aggressively, and is almost always fatal if untreated. Malaria has also become resistant to many drugs. Intravenous quinidine, most often used in cardiac settings, is also used to treat severe malaria. When caring for a patient receiving intravenous quinidine, the nurse should monitor for signs of toxicity including a widening QRS, lengthening QTc interval, and hypotension. The patient should also be monitored for hypoglycemia.
A patient arrives in the emergency department with major injuries after a motor vehicle crash. A medical alert bracelet is present, which indicates that the patient has primary adrenal insufficiency. Which of the following interventions would the nurse expect based on this information?
A. Normal saline solution
B. Hydrocortisone
C. Potassium
D. Phenytoin
What is B
Patients with adrenal insufficiency are at risk for adrenal (addisonian) crisis when they experience added stress such as an illness or trauma. These patients should receive hydrocortisone immediately to prevent a crisis. They should also receive normal saline solution with dextrose (A) because adrenal insufficiency is associated with hypoglycemia. In addition, the patient should be monitored for hyperkalemia (C) because patients in adrenal crisis retain potassium. Phenytoin (D) has been associated with adrenal crisis.
A tearful 16-year-old girl presents to the emergency department, accompanied by the parents of a friend. The girl explains that her friend's parents persuaded her to come to the emergency department because “my mom's boyfriend has been doing gross things to me.” Which initial triage question is appropriate?
A. “Are you sexually active?”
B. “What do you mean by gross”?
C. “When was your last menstrual period?”
D. “How long has this been going on?”
What is B
Initial clarification of the patient's chief compliant will necessarily change the direction of the triage interview and the utilization of any additional needed staff, such as a sexual assault nurse examiner. Although patients with all forms of abuse will be examined and intervention will be provided, an examination for sexual abuse differs significantly from that for physical abuse
A confused elderly woman has a blood glucose level of 800 mg/dL. Serum ketones are negative and arterial blood gases show a pH of 7.25. The nurse should anticipate an order to administer which of the following first?
A. sodium bicarbonate
B. potassium chloride
C. high-dose insulin
D. large volume of IV fluid
What is D
Increased glucose, negative ketones, and acidosis are signs and symptoms of hyperosmolar hyperglycemic nonketotic coma. In the treatment of this state, the goals are rehydration and correcting electrolyte imbalances prior to potassium replacement and insulin.
A pregnant patient arrives in the urgent care setting and reports having a severe headache. Her blood pressure is 190/120 mm Hg. She is 24 weeks pregnant and has experienced minimal prenatal care. Which of the following laboratory values would lead the nurse to a suspected diagnosis of preeclampsia?
A. Urine protein 2+, or 420 mg
B. Platelet count of 230,000 μL
C. Aspartate aminotransferase level of 32 U/L
D. Serum creatinine level of 0.9 mg/dL
What is A
A urine protein level of 2+ or 420 mg (A) or proteinuria would be considered elevated and an indicator of preeclampsia. A platelet count of 230,000 μL (B) is elevated. A low platelet count is seen with preeclampsia (<150,000 μL). An aspartate aminotransferase level (C) of 32 U/L is considered normal (10–40 U/L). Liver enzymes are elevated with preeclampsia. A serum creatinine level of 0.9 mg/dL (D) is considered normal. A creatinine level would be elevated with preeclampsia
Continuous arteriovenous rewarming is implemented for a patient with severe hypothermia after prolonged cold exposure. Which of the following statements is true about this procedure?
A. Systolic blood pressure should be maintained above 80 mm Hg.
B. Maximum rewarming time is 4 hours.
C. The patient should be weighed to ensure that his or her weight is greater than 110 lb (50 kg).
D. The system may be clamped up to 5 minutes for transport.
What is A
To keep the system open, the patient’s blood pressure must be at least 60 to 80 mm Hg to ensure blood flow of at least 150 mL per minute through the system. The maximum recommended rewarming time is 3 hours (B) to prevent clotting in the tubing. The patient should be weighed before the procedure to ensure he or she weighs at least 90 lb (41 kg) (C) because the large femoral catheter may occlude vessels in a smaller person. System clamps should not be closed for more than 2 to 3 minutes to avoid clotting. Tubing should not be clamped for more than 2 to 3 minutes because clotting may occur (D).
A patient with Addison's disease presents with acute-onset profound weakness, a decreased level of consciousness, and hypotension. Adrenal crisis is diagnosed. Which of the following interventions would the nurse anticipate?
A. Hydrocortisone and rapid normal saline (NS) IV infusion
B. Dexamethasone and dextrose 5% in normal saline (D5NS) IV infusion at 30 mL/h
C. Vasopressin and mannitol IV, 500-mL bolus
D. Methylprednisolone and dextrose 5% in water (DSW) IV infusion at 50 mL/h
What is A
Adrenal crisis (acute adrenal insufficiency or Addisonian crisis) occurs when there is an acute supply-and-demand problem involving the adrenal gland: insufficient glucocorticoids, mineralocorticoids, and catecholamines are produced and secreted in response to an increased metabolic demand for them. The demand may come in the form of the acute stress response demanded when the body faces infection, inflammation, trauma, pregnancy, or a burn. The insufficiency in production of the adrenal hormones can result from primary adrenal disease, such as the autoimmune-mediated Addison's disease; from adrenal injury (trauma, hemorrhage); from a malignancy (either primary, as a metastatic site from a breast or lung source, or due to pituitary tumor); or from the abrupt cessation of chronic steroid use. The hormones that come from the adrenal cortex include the glucocorticoids (eg, cortisol) and mineralocorticoids (eg, aldosterone) that have profound effects on the body's stress response. Their actions include, for example, making the arterial system responsive to norepinephrine, potentiating the effect of epinephrine, raising blood glucose levels, mediating the inflammatory response, reabsorbing sodium and water to increase blood volume, and excreting potassium and hydrogen ions. The catecholamines (epinephrine and norepinephrine) come from the adrenal medulla and are responsible for the body's ability to “fight or take flight”: heightened arousal, increased heart rate, vasoconstriction on both the venous and arterial sides, enhanced myocardial contractility, and hyperglycemia.
When acute adrenal insufficiency occurs, it is characterized by profound weakness, hypotension, tachycardia, confusion and an altered level of consciousness, hyponatremia, hypoglycemia, and hyperkalemia. Treatment, then, should include prompt and rapid infusion of isotonic crystalloid solution, such as normal saline or lactated Ringers. The patient will need an immediate dose of intravenous hydrocortisone, 100 mg, typically followed by repeated doses every 6 hours. If the blood glucose level is dangerously low, 50% dextrose may be given. If the patient remains hypotensive after fluid resuscitation and hydrocortisone have been given, intravenous vasopressors may become necessary. If the patient's hypotension persists, fludrocortisone acetate may be added.
The ED nurse is assessing a teen whose family is concerned that the patient may be at risk for suicide. Thebest initial question for the nurse to ask the patient is:
A. “Have you ever had these thoughts before?”
B. “Are you having any thoughts of wanting to kill yourself?”
C. “How are you planning to kill yourself?”
D. “How did you try to harm yourself?
What is B
“Are you having any thoughts of wanting to kill yourself?” is the best initial question for the nurse to ask, and it needs to be asked of the patient, not just the family. Contrary to popular belief, asking patients this question will not “put the idea in their head” and make them consider suicide. Being straightforward and asking the patient specifically about suicidal ideations is the correct answer. If the patient is having suicidal thoughts, asking about a “plan” is an appropriate follow-up question. Previous suicidal thoughts and/or attempts are a concern but can be addressed later in the assessment process. If the patient admits to current suicidal thoughts, then the patient's safety and protection from self-harm are priorities. Just as the ABCs of airway, breathing, and circulation are always foremost with medical/trauma patients, safety is key in the ED treatment of psychiatric patients. After clearing medical concerns, keeping the patient SAFE involves paying close attention to security, affect, feelings, and emotions.
An 80-year-old patient with type II diabetes is being treated in the emergency department for an episode of hypoglycemia associated with hypoglycemia unawareness. Which risk factor would be most concerning in this patient?
A. The patient lives alone
B. The patient has diminished taste
C. The patient has hearing loss
D. The patient has decreased manual dexterity
What is A
Older adults may not respond to hypoglycemia in the same way that younger adults respond because release of stress hormones may be reduced. Because of these age-related changes, the patient may not be aware that his or her blood glucose level has dropped. A patient living alone would be at higher risk of injury because his or her low blood sugar may not be discovered and treated in a timely manner.
Which of the following arterial blood gas results would be expected for a patient who is pregnant?
A. Compensated respiratory acidosis
B. Compensated respiratory alkalosis
C. Compensated metabolic acidosis
D. Compensated metabolic alkalosis
What is B
During pregnancy, oxygen consumption is increased by 15% to 20%, and the functional residual capacity is decreased because of the elevation of the diaphragm. Arterial blood gas results would show a decreased Pco2and decreased serum bicarbonate or a compensated respiratory alkalosis. All other responses (A, C, and D) would not be an expected finding.
Which of the following interventions is indicated for the treatment of a pediatric patient who sustained a brown recluse spider bite?
A. Application of a cold compress
B. Preparation for surgery
C. Administration of antivenin
D. Immobilization of the extremity below heart level
What is A
Because most brown recluse spider bites will heal in a few months, conservative treatment—such as the application of a cool compress, simple analgesics, elevation of the affected extremity, and wound cleansing—is indicated. Surgery (B) should be avoided. Antivenin (C) is administered to patients who have sustained a black widow spider bite and are symptomatic. Patients sustaining a pit viper bite are at risk for compartment syndrome, and the affected extremity should be immobilized at or below the level of the heart to reduce blood flow (D).
A patient with hypothyroidism is brought to the emergency department with a decreased level of consciousness. The nurse would anticipate the plan of care for this patient will include interventions for
A. hyperthermia and tachycardia.
B. dehydration and hyperglycemia.
C. potential airway obstruction and respiratory failure.
D. hypernatremia and hypoglycemia.
What is C
In patients with hypothyroidism, body processes slow down, and in severe cases myxedema coma may develop. Tongue swelling, which has the potential to obstruct the airway, can develop in patients with myxedema coma. Patients may also have a weak respiratory drive than can lead to respiratory failure. The pulse and temperature may be low (A), non-pitting edema occurs and hypoglycemia may occur from increased insulin sensitivity (B), and hyponatremia may occur from decreased renal blood flow and reduced sodium reabsorption (D).