A nurse is assessing a client for a positive Chvostek's sign following a thyroidectomy. Which of the following areas on the client's head should the nurse tap to assess the client for tetany?
The Correct Answer is B
To assess a client for a positive Chvostek’s sign, the nurse should tap gently on the cheek, specifically two centimeters in front of the ear, over the facial nerve (also known as CN VII). This test is used to check for hypocalcemia, a condition that can lead to tetany, which is the involuntary contraction of muscles. A twitch of the facial muscles in response to this tapping indicates a positive Chvostek’s sign. This is particularly relevant following a thyroidectomy, as the procedure can indirectly affect the parathyroid glands, potentially leading to hypocalcemia
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Allow the client to sign the consent with an X. The client has the right to give informed consent if they understand the procedure and its risks and benefits, even if they cannot read or write. The nurse should witness and document the client's signature with an X and verify their identity and understanding. The other options are not appropriate because they violate the client's autonomy and dignity.
Correct Answer is D
Explanation
A hacking cough, especially at night or when lying down, is a common manifestation of left-sided heart failure, as fluid accumulates in the lungs and causes pulmonary congestion and dyspnea. Neck-vein distention and ankle edema are more indicative of right-sided heart failure, as fluid backs up into the systemic circulation and causes peripheral edema and jugular venous pressure elevation. Anorexia may occur in either type of heart failure, but it is not specific to left-sided heart failure.
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