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

Trousseau's sign

Carpopedal spasm

Chvostek's sign

Korsakoﬀ's psychosis

Answer and Explanation

Correct Answer : A,B,C

Choice A reason: Trousseau's sign is indicative of hypocalcemia and is elicited by inﬂating a blood pressure cuﬀ on the arm.

Choice B reason: Carpopedal spasm is a muscular spasm involving the hands and feet that can occur with hypocalcemia.

Choice C reason: Chvostek's sign is a facial twitching that occurs when tapping on the facial nerve in front of the ear, which can be a sign of hypocalcemia.

Choice D reason: Korsakoﬀ's psychosis is associated with chronic alcoholism and thiamine deficiency, not directly with hypocalcemia.

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Correct Answer is B

Explanation

The correct answer is choice B. Raise the head of the bed.

Choice A rationale:

Increasing the patient’s oral fluid intake is important for hydration and thinning secretions, but it is not the immediate priority when oxygen saturation is critically low.

Choice B rationale:

Raising the head of the bed helps improve lung expansion and facilitates easier breathing, which can quickly improve oxygen saturation levels. This is a critical first step in managing low oxygen saturation.

Choice C rationale:

Initiating humidified oxygen therapy is essential for improving oxygenation, but it should follow the immediate action of raising the head of the bed to optimize breathing.

Choice D rationale:

Encouraging the patient to cough and deep breathe is beneficial for clearing secretions and improving lung function, but it is not the first action to take when oxygen saturation is critically low.

A. Discuss pain management with the client. B. Explain the need for sequential compression devices. C. Review the policy with the client and family. D. Ensure the operative site has been secured.

Correct Answer is B

Explanation

Choice A reason: Discussing pain management is important for patient comfort but does not directly prevent postoperative complications.
Choice B reason: Sequential compression devices are used to prevent deep vein thrombosis, a common postoperative complication, making this the correct answer.
Choice C reason: Reviewing policy with the client and family is part of the overall care but is not specific to preventing postoperative complications.
Choice D reason: Ensuring the operative site has been secured is a procedural task and does not directly prevent postoperative complications.

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

Nursing Test Bank

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