A nurse is collecting data from a client who has hypocalcemia. Which of the following findings should the nurse expect?
Tingling of the lips
Hypoactive bowel sounds
Skeletal muscle weakness
Decreased deep-tendon reflexes
The Correct Answer is A
A) Tingling of the lips:
This is the correct choice. Hypocalcemia, which is low calcium levels in the blood, can lead to neurological symptoms such as tingling sensations around the lips and in the extremities. This occurs due to the effect of low calcium levels on the nervous system.
B) Hypoactive bowel sounds:
Hypocalcemia primarily affects neuromuscular function rather than gastrointestinal function. While calcium imbalances can impact gastrointestinal motility, hypoactive bowel sounds are not typically associated with hypocalcemia.
C) Skeletal muscle weakness:
Skeletal muscle weakness is a common symptom of hypocalcemia. Low calcium levels affect the ability of muscles to contract effectively, leading to weakness and fatigue.
D) Decreased deep-tendon reflexes:
Hypocalcemia can actually lead to increased deep-tendon reflexes rather than decreased reflexes. Calcium plays a role in neuromuscular transmission, and low levels can result in hyperexcitability of nerves, leading to increased reflexes rather than decreased reflexes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
(A) "I’ll breathe deeply and cough every 4 hours."
Deep breathing and coughing exercises should be done more frequently, typically every 1-2 hours while awake, to help prevent respiratory complications such as atelectasis and pneumonia.
(B) "I’ll splint my incision with a pillow to cough."
This statement indicates an understanding of the instructions. Splinting the incision with a pillow helps support the surgical site, reduces pain, and makes coughing more effective and less uncomfortable. This technique is important for clients to use to help clear secretions from the lungs postoperatively.
(C) "I’ll start to use the incentive spirometer when I can get out of bed."
The use of an incentive spirometer should begin as soon as possible, usually while the client is still in bed, to encourage deep breathing and prevent postoperative respiratory complications. It should not be delayed until the client can get out of bed.
(D) "I’ll lie flat in bed to cough and deep breathe."
Lying flat is not the optimal position for deep breathing and coughing exercises, as it can make it more difficult to fully expand the lungs. The client should be positioned with the head of the bed elevated or sitting up to facilitate better lung expansion and more effective coughing.
Correct Answer is D
Explanation
A. A critical pathway for clients who have had a stroke:
Critical pathways are structured multidisciplinary care plans that outline essential steps in the care of patients with specific conditions. While critical pathways are valuable tools for standardized care, they are not specifically focused on health promotion activities for clients with hypertension.
B. Standards of care for monitoring clients who have a history of blood pressure elevation:
Standards of care typically outline the minimum level of care that should be provided to clients based on evidence-based practice. While monitoring clients with a history of blood pressure elevation is important, it does not encompass the comprehensive health promotion activities related to hypertension.
C. Acute care facility protocols for clients experiencing an abrupt change in mental status:
Acute care facility protocols are designed to guide the management of acute changes in a patient's condition. While relevant to patient care, these protocols do not specifically address health promotion activities for clients with hypertension.
D. Clinical practice guidelines for the management of high blood pressure:
Clinical practice guidelines provide evidence-based recommendations for the management of specific health conditions. They typically include information on health promotion activities, risk factor modification, lifestyle interventions, and pharmacological management for clients with hypertension. Therefore, clinical practice guidelines are the most appropriate resource for information on health promotion activities for clients with hypertension.
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