A nurse is collecting data from a client who has hypomagnesemia. Which of the following findings should the nurse identify as a positive Chvostek's sign?
Image A
Image B
Image A
Image B
The Correct Answer is A
A. Chvostek's sign is a clinical sign observed during physical examination that may indicate hypocalcemia. It is elicited by tapping or lightly striking the facial nerve just anterior to
the earlobe, which can cause twitching of the facial muscles, particularly the muscles around the mouth and nose.
B. This image shows winging of the scapula. Winging of the scapula, also known as
scapular winging, is a condition characterized by the abnormal protrusion or prominence of the scapula away from the back wall of the thorax. Normally, the scapula lies flat
against the rib cage, providing stability and support for arm movements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. A temperature of 37.5° C (99.5° F) is slightly elevated but can be expected postoperatively and does not typically require immediate intervention.
B. The client being difficult to arouse is concerning following opioid administration, as it may indicate over-sedation or the onset of respiratory depression. This requires immediate nursing action.
C. A respiratory rate of 10/min is low and can be a sign of opioid-induced respiratory depression, especially when combined with difficulty arousing the client. This is a critical value that
necessitates prompt nursing assessment and intervention.
D. Pulse oximetry of 88% on room air is below the normal range and indicates hypoxemia. This is a serious finding that requires immediate action to improve the client's oxygenation.
E. Pupils that are 3 mm, equal, and reactive to light, along with a blood pressure of 99/46 mm Hg, while on the lower side, are not as immediately concerning as the respiratory rate and level of consciousness.
F. A heart rate of 61/min is within normal limits and does not typically require intervention unless there are other signs of hemodynamic instability.
Correct Answer is D
Explanation
A. Inflating the catheter's balloon is not appropriate when resistance is encountered before reaching the bladder. It could cause trauma or injury.
B. Lowering the penis to a 45° angle may help facilitate catheter insertion initially, but if resistance is encountered, further interventions are needed.
C. Applying lidocaine gel to the urethra may help with discomfort during catheter insertion but will not address the issue of encountering resistance.
D. Twisting the catheter gently can help navigate any obstructions or curves in the urethra. This maneuver should be performed carefully to avoid causing trauma to the urethral mucosa.
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