Question

A client who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse completes these actions?

1. Observe breathing patterns.

2. Assess blood pressure.

3. Measure body temperature.

4. Palpate for pedal edema.

Answer 1

When assessing a client with early signs of myxedema coma due to primary hypothyroidism, the priority order is to first observe breathing patterns, then assess blood pressure, measure body temperature, and lastly palpate for pedal edema.

Step-by-step explanation:

In managing a client with early signs of myxedema coma due to primary hypothyroidism, it is critical to prioritize assessment actions to stabilize the patient's condition. The nurse should observe the patient's breathing patterns first because respiratory failure is a major concern and can be life-threatening in myxedema coma. Following this, assessing the blood pressure is essential due to possible hypotension resulting from the hypothyroid state. Next, measuring body temperature is important as hypothyroid patients may present with hypothermia. Lastly, palpating for pedal edema would be relevant for evaluating fluid retention but is less critical for immediate stabilization when compared to the other assessments.