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.
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Related Questions
Correct Answer is C
Explanation
(A) Re-collection of data: Re-collection of data is not the next step after planning. It might be done as part of the evaluation step or if there are significant changes in the client’s condition.
(B) Implementation: This is the most appropriate answer. After the planning step of the nursing process, the nurse moves on to the implementation step. This is where the nurse executes the interventions that were identified during the planning step.
(C) Data Collection: Data collection is typically the first step in the nursing process, where the nurse gathers information about the client’s health status. It is not the next step after planning.
(D) Evaluation: Evaluation is the final step of the nursing process. It involves assessing the client’s response to the nursing interventions and determining whether the client’s goals have been met. It is not the next step after planning.
Correct Answer is C
Explanation
A. "My mouth is very dry."
Dry mouth is a common side effect of lorazepam, but it does not directly indicate the effectiveness of the medication in reducing preoperative anxiety.
B. "My leg feels numb."
Numbness in the leg is not a typical effect of lorazepam and does not indicate the effectiveness of the medication in reducing preoperative anxiety.
C. "I feel very sleepy."
Feeling sleepy or drowsy is a common side effect of lorazepam, and it indicates that the medication has effectively reduced the client's preoperative anxiety.
D. "I am not hungry any longer."
Decreased appetite can be a side effect of lorazepam, but it is not a direct indicator of the medication's effectiveness in reducing preoperative anxiety.
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