A nurse is assisting with the care of a client who has hypocalcemia. For which of the following signs should the nurse monitor?

Kernig's sign

Brudzinski's sign

Chvostek's sign

Cullen's sign

Answer and Explanation

The Correct Answer is C

(A) Kernig’s sign: Kernig’s sign is a clinical sign in which severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees. It is commonly associated with meningitis, not hypocalcemia.

(B) Brudzinski’s sign: Brudzinski’s sign is a symptom of meningitis. It is not associated with hypocalcemia.

(C) Chvostek’s sign: This is the most appropriate answer. Chvostek’s sign is a clinical sign of existing nerve hyperexcitability (tetany) seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve.

(D) Cullen’s sign: Cullen’s sign is a medical term referring to superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. It is not associated with hypocalcemia.

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Correct Answer is C

Explanation

(A) Limit the client’s visitors to one at a time: While it’s important to maintain a peaceful environment for the client, limiting visitors may not be necessary unless the client’s condition is being negatively affected by too many visitors or if there are restrictions due to infection control.

(B) Avoid touching the client: Touch can be a powerful form of communication, especially when a client is unresponsive. Gentle touch can convey caring and presence, so avoiding touch is not typically recommended unless there’s a specific reason to do so (like if the client is in pain).

(C) Continue to talk to the client as if they are alive: This is the most appropriate answer. Even if a client is unresponsive, they may still be able to hear and understand. Continuing to talk to the client can provide comfort and reassurance.

(D) Whisper when talking in the client’s room: Whispering is not necessary and can even be confusing or distressing for the client. It’s better to speak in a normal, calm, and reassuring voice.

A. Dry skin B. Diarrhea C. Hyperventilation D. Abdominal pain

Correct Answer is C

Explanation

A. Dry skin:

Dry skin is not typically associated with respiratory alkalosis. Instead, it may occur in conditions such as dehydration or impaired skin integrity.

B. Diarrhea:

Diarrhea is not typically associated with respiratory alkalosis. Respiratory alkalosis primarily involves changes in the respiratory system, leading to alterations in blood pH and carbon dioxide levels.

C. Hyperventilation:

Hyperventilation is a characteristic finding in respiratory alkalosis. It is a compensatory mechanism where the client breathes rapidly and deeply to blow off excess carbon dioxide, attempting to restore acid-base balance.

D. Abdominal pain:

Abdominal pain is not typically associated with respiratory alkalosis. While some individuals with respiratory alkalosis may experience symptoms such as dizziness, lightheadedness, or tingling sensations, abdominal pain is not a common manifestation of this acid-base imbalance.

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A nurse is assisting with the care of a client who has hypocalcemia. For which of the following signs should the nurse monitor?

Nursing Test Bank

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