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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A) "If a client refuses a medication, you can place it in your pocket to administer later."
This statement is incorrect. Placing a medication in the pocket for later administration is not an appropriate practice and can lead to unauthorized possession and potential diversion of controlled substances. However, the second part of the statement, "You are required to have a second nurse witness disposal of a controlled substance," is correct.
B) "We use an automated dispensing device to track the use of controlled substances."
Automated dispensing devices are commonly used to track the administration and removal of controlled substances. This helps to ensure accountability and prevents diversion.
C) "Activities of the automated dispensing machine will be reviewed periodically."
Regular review of the activities of the automated dispensing machine helps to monitor for any discrepancies or irregularities in the handling of controlled substances, thus enhancing safety measures.
D) "We count the amount of a controlled substance available before removal from a medication drawer."
Counting the amount of controlled substance available before removal from a medication drawer is a crucial step in ensuring accurate inventory management and preventing unauthorized removal or diversion.
Correct Answer is B
Explanation
A. Small for gestational age:
While being small for gestational age can contribute to respiratory difficulties in newborns, it is not directly associated with respiratory distress syndrome or respiratory acidosis. Other factors, such as prematurity or intrauterine growth restriction, may play a more significant role.
B. Cesarean birth:
Cesarean birth can predispose newborns to respiratory difficulties, including respiratory distress syndrome. During vaginal birth, the compression of the chest during passage through the birth canal helps expel lung fluid, whereas babies born via cesarean section may have more retained lung fluid, leading to respiratory distress.
C. Ventricular septal defect:
Ventricular septal defect is a congenital heart defect and is not directly associated with respiratory distress syndrome or respiratory acidosis. However, congenital heart defects can affect the cardiovascular system, leading to respiratory compromise in some cases.
D. Maternal history of asthma:
While maternal asthma can increase the risk of respiratory problems in newborns, it is not directly related to respiratory distress syndrome or respiratory acidosis. Maternal asthma may increase the likelihood of the newborn developing asthma or other respiratory conditions later in life.
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