A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect? (Select all that apply.)
Positive Trousseau's sign
Muscle cramps
Tingling sensation around the lips
Negative Chvostek's sign
Abdominal distention
Correct Answer : A,B,C
A. Positive Trousseau's sign: A positive Trousseau’s sign (carpal spasm induced by inflating a blood pressure cuff) is a classic indicator of hypocalcemia due to increased neuromuscular excitability.
B. Muscle cramps: Hypocalcemia leads to increased nerve excitability, causing muscle cramps, spasms, and tetany.
C. Tingling sensation around the lips: This is a common early sign of hypocalcemia, known as perioral paresthesia, due to increased nerve excitability.
D. Negative Chvostek's sign: A client with hypocalcemia would have a positive Chvostek’s sign, which is facial twitching when the facial nerve is tapped.
E. Abdominal distention: Hypocalcemia is more associated with diarrhea and hyperactive bowel sounds, not abdominal distention, which is more typical of hypokalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Use IV tube ports when injecting medications." Latex-free IV ports should be used instead of rubber stoppers found in some IV bags and vials.
B. "Remove medication from multi-dose vials with the stopper in place." Many vial stoppers contain latex, so the nurse should use single-dose vials or vials labeled as latex-free.
C. "Secure loose cords in stockinette with tape." Stockinettes are sometimes made with latex, posing a risk to the client. Non-latex materials should be used instead.
D. "Schedule the client's surgery as the last procedure of the day." Clients with latex allergies should be scheduled first to minimize exposure to airborne latex particles from gloves and equipment used earlier in the day.
Correct Answer is ["A","B","C","D"]
Explanation
Cardiopulmonary:
Encourage deep-breathing exercises.
Check for pain.
Rationale:
Encouraging deep-breathing exercises helps improve oxygenation and prevent complications such as atelectasis, especially since the client's oxygen saturation initially dropped but improved with deep breathing.
Checking for pain is essential as the client has been prescribed PRN morphine for pain management.
"Inform client to achieve two to four breaths per session when using an incentive spirometer" is not selected because while incentive spirometer use is encouraged, the prescribed plan instructs use every hour while awake rather than focusing on a specific number of breaths per session.
Gastrointestinal:
Promote intake of oral fluids.
Apply barrier ointment after bowel movements.
Rationale:
Promoting oral fluid intake helps prevent dehydration and supports bowel function, especially since the client reports multiple loose stools and nausea/vomiting.
Applying barrier ointment after bowel movements helps protect the skin from irritation and breakdown due to frequent loose stools.
"Encourage the client to increase fiber in their diet" is not selected because fiber intake is usually increased for constipation, whereas in this case, the client has diarrhea, and fiber could worsen symptoms.
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