A nurse is monitoring laboratory values for a client who is receiving hemodialysis and has a serum calcium level of 7.2 mg/dL. For which of
Hyperactive deep tendon reflexes
Hypoactive bowel sounds
Positive Chvostek's sign
Lethargy
The Correct Answer is C
Choice A: This is incorrect because hyperactive deep tendon reflexes are not associated with low serum calcium levels. Hyperactive deep tendon reflexes can indicate hypomagnesemia, hyperthyroidism, or spinal cord injury.
Choice B: This is incorrect because hypoactive bowel sounds are not associated with low serum calcium levels. Hypoactive bowel sounds can indicate ileus, peritonitis, or opioid use.
Choice C: This is correct because positive Chvostek's sign is associated with low serum calcium levels. Positive Chvostek's sign is a facial muscle spasm that occurs when tapping on the cheek near the ear. It indicates hypocalcemia, which can be caused by hemodialysis, renal failure, or parathyroid dysfunction.
Choice D: This is incorrect because lethargy is not associated with low serum calcium levels. Lethargy can indicate hypercalcemia, dehydration, hypoglycemia, or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Restricting the client's calorie intake to no more than 2,000 calories per day is not an appropriate action, as it can impair wound healing and increase the risk of infection or malnutrition. The nurse should provide adequate calories and protein to meet the increased metabolic demands and support tissue repair and regeneration.
Choice B reason: Changing sterile gloves between caring for wounds on different areas of the body is an appropriate action, as it can prevent cross-contamination and infection of the burn wounds, which are susceptible to bacterial colonization and sepsis.
Choice C reason: Limiting movement or bending of the client's affected extremities is not an appropriate action, as it can cause contractures, joint stiffness, or muscle atrophy in the burned areas. The nurse should encourage early and frequent range of motion exercises and use splints or positioning devices to maintain functional alignment and mobility.
Choice D reason: Administering a diuretic if the client's urine output falls below 30 mL/hr is not an appropriate action, as it can worsen dehydration, electrolyte imbalance, or renal failure that can occur after severe burns. The nurse should monitor fluid status and urine output closely and administer intravenous fluids as prescribed to maintain adequate hydration and perfusion.
Correct Answer is B
Explanation
Choice A reason: Providing the client with small-handled adaptive utensils is not necessary for a visually impaired client. The client may prefer to use their own utensils or regular ones that they are familiar with.
Choice B reason: Describing the food placement as though the plate were a clock is a helpful technique to orient the client to their meal and avoid spills or accidents. The nurse should also ask the client about their preferences and needs before serving the food.
Choice C reason: Discouraging conversations during the client's mealtime is not appropriate for a visually impaired client. The nurse should encourage social interactions and respect the client's dignity and autonomy.
Choice D reason: Arranging for an assistive personnel to feed the client is not indicated for a visually impaired client. The nurse should promote the client's independence and self-care abilities as much as possible.
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