Myxedema coma is a life-threatening complication of long-standing and untreated hypothyroidism with one of the following characteristics.
- A. Hyperglycemia
- B. Hypothermia
- C. Hyperthermia
- D. Hypoglycemia
Correct Answer: A
Rationale: Myxedema coma is associated with hypothermia, not hyperthermia. Therefore, the correct characteristic of myxedema coma is hypothermia. This condition is a medical emergency that requires prompt recognition and intervention to prevent serious complications. The presence of hyperglycemia is not a defining characteristic of myxedema coma, making choice A the correct answer in this case. Hyperthermia and hypoglycemia are not typically seen in myxedema coma and are not consistent with the clinical presentation of this condition.
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You are teaching your clients the difference between Type I (IDDM) and Type II (NDDM) diabetes. Which of the following statements is true?
- A. Both types of diabetes mellitus clients are prone to developing ketosis.
- B. Type II (NIDDM) is more common and preventable compared to Type I (IDDM) diabetes, which is genetic.
- C. Type I (IIDM) is characterized by fasting hyperglycemia.
- D. Type II (NIDDM) is characterized by abnormal immune response.
Correct Answer: D
Rationale: The correct answer is D. Type II diabetes (NIDDM) is characterized by insulin resistance and a relative lack of insulin. It is not primarily characterized by an abnormal immune response. Option A is incorrect because only Type I diabetes clients are prone to developing ketosis due to a lack of insulin. Option B is incorrect because while Type II diabetes is more common and often preventable through lifestyle changes, it is not solely genetic. Option C is incorrect because Type I diabetes, not Type II, is characterized by fasting hyperglycemia due to an absolute lack of insulin production.
Which physiologic effect should the nurse expect in a client addicted to hallucinogens?
- A. Dilated pupils
- B. Constricted pupils
- C. Bradycardia
- D. Bradypnea
Correct Answer: B
Rationale: Clients addicted to hallucinogens often exhibit constricted pupils due to the effects of the drug on the sympathetic nervous system. This sympathetic stimulation causes the pupils to constrict rather than dilate. Choices A, C, and D are incorrect. Dilated pupils are more commonly associated with stimulant use, while bradycardia (slow heart rate) and bradypnea (slow breathing) are not typical effects of hallucinogens.
When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT:
- A. Amount of food and fluid taken during the last meal before treatment
- B. Respiratory rate, breath sounds, and location of congestion
- C. Teaching the client's relatives to perform the procedure
- D. Doctor's order regarding position restrictions and client's tolerance for lying flat
Correct Answer: B
Rationale: The correct answer is B because when assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on various aspects such as the amount of food and fluid taken before treatment to prevent complications during the procedure, teaching the client's relatives to perform the procedure correctly, and following the doctor's orders regarding position restrictions and the client's tolerance for lying flat. Respiratory rate, breath sounds, and location of congestion would be assessed during the procedure itself, not as part of the pre-assessment.
An adolescent client has bloodshot eyes, a voracious appetite, and dry mouth. Which drug abuse would the nurse most likely suspect?
- A. Marijuana
- B. Amphetamines
- C. Barbiturates
- D. Anxiolytics
Correct Answer: A
Rationale: The symptoms described, including bloodshot eyes, a voracious appetite, and dry mouth, are consistent with marijuana use. Bloodshot eyes are a common side effect of marijuana due to its effect on blood vessels in the eyes. Marijuana also often causes an increase in appetite (known as 'the munchies') and can result in dry mouth. Amphetamines typically cause symptoms like increased alertness, energy, and decreased appetite. Barbiturates and anxiolytics would not typically cause bloodshot eyes, a voracious appetite, and dry mouth as described in the scenario. Therefore, the most likely drug abuse the nurse would suspect in this case is marijuana.
During the Emergent phase of a burn, the most fatal electrolyte imbalance in a burned client is:
- A. Hypokalemia
- B. Hyperkalemia
- C. Hypernatremia
- D. Hyponatremia
Correct Answer: A
Rationale: During the Emergent phase of burns, the most fatal electrolyte imbalance is Hypokalemia. This is due to the shift of potassium from the intracellular space to the extracellular space, leading to low potassium levels in the blood. Choices B, C, and D are incorrect because Hyperkalemia, Hypernatremia, and Hyponatremia are not typically associated with the Emergent phase of burns and do not pose the same level of risk as Hypokalemia in this context.