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 B

Explanation

B. Aspirin:
Aspirin is the priority medication to administer first. It is crucial for preventing further clot formation in the coronary arteries, as it inhibits platelet aggregation. Administering aspirin early in the treatment of a suspected MI helps reduce the size of the infarction and limits further damage to the heart muscle. Aspirin should be given as soon as a myocardial infarction is suspected, unless contraindicated.

A. "The client has developed drooping facial features." B. "The client may benefit from a neurology consult." C. "The client has a history of hypertension." D. “The client is disoriented and pupils are slow to respond to light"

Correct Answer is C

Explanation

A) "The client has developed drooping facial features":
This statement provides essential information regarding a new symptom that the client has developed, which is drooping facial features. This is crucial information for the provider to understand the current status of the client's condition. However, it's more pertinent to the assessment and current issue rather than the client's background.

B) "The client may benefit from a neurology consult":
While a neurology consult may indeed be necessary based on the client's symptoms, it falls more under the assessment and recommendation components of the SBAR communication tool. The background component should focus on providing the provider with pertinent information about the client's current condition and relevant history.

C) "The client has a history of hypertension":
This statement is the correct choice. It provides important background information about the client's medical history, which is relevant to the current situation. The history of hypertension could potentially contribute to the development of drooping facial features, as certain complications of hypertension can lead to neurological symptoms.

D) “The client is disoriented and pupils are slow to respond to light":
While disorientation and pupil response are significant clinical findings, they are not mentioned in the stem of the question. The background component of the SBAR should focus on the specific information related to the current issue, which in this case is the development of drooping facial features.

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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

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the plan of care for a client who has a suspected myocardial infarction. Which of the following medication should the nurse plan to administer first?

Correct Answer is B

Explanation

A nurse is caring for a client who has hypertension and recently developed drooping facial features. When contacting the provider, which of the following statements should the nurse include as part of the background component of the SBAR communication tool?

Correct Answer is C

Explanation

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