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) 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 D
Explanation
(A) Develop client-specific goals and outcomes: While this is an important step in the nursing process, it is not the first step. Before developing goals and outcomes, the nurse needs to understand the client’s situation, which in this case involves determining the nature of the client’s grief.
(B) Incorporate the treatment into the client’s care: Incorporating treatment into the client’s care is part of the implementation phase of the nursing process. Before this step, the nurse needs to assess the client’s condition and plan the care, which includes understanding the nature of the client’s grief.
(C) Determine whether coping strategies were successful: Determining the success of coping strategies is part of the evaluation phase of the nursing process. This is typically done after the implementation of care and treatment. It is not the first step in caring for a client experiencing grief.
(D) Establish whether the client’s grieving is healthy or complicated: This is the most appropriate answer. The first step in the nursing process is assessment. For a client experiencing grief, this would involve establishing whether the client’s grieving is healthy (a normal response to loss) or complicated (prolonged or more intense grief that may require additional support or intervention). This understanding will guide the subsequent steps of the nursing process, including planning care and setting goals.
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