The nurse is caring for a client with a total calcium level of 7.0 mg/dL. To assess for Chvostek's sign, the nurse would:
strain all of the client's urine.
inflate a blood pressure cuff 20 mmHg above systolic measurement.
lightly percuss the client's cheek.
obtain a baseline height and weight.
The Correct Answer is C
C. Chvostek's sign is assessed by tapping or lightly percussing the facial nerve (facial muscles) at the angle of the jaw, just in front of the earlobe. A positive Chvostek's sign is indicated by facial twitching, especially around the mouth, nose, and eye, in response to this percussion. It indicates neuromuscular irritability due to low calcium levels.
A. Straining urine is typically done to collect urine for analysis or to detect urinary stones. It does not relate to the assessment of neuromuscular irritability, which is what Chvostek's sign evaluates.
B. This option does not pertain to assessing Chvostek's sign either. Inflating a blood pressure cuff above systolic measurement is a technique used to assess for Trousseau's sign, which is another clinical indicator of hypocalcemia but involves different physiological mechanisms than Chvostek's sign.
D. This option is unrelated to assessing Chvostek's sign or hypocalcemia. Baseline height and weight are typically obtained for nutritional assessment, growth monitoring, or as part of a general health assessment. They do not help in evaluating neuromuscular irritability associated with calcium levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D This action involves escalating the issue to a higher authority who can provide guidance and support. The nursing supervisor can assess the situation, provide advice on managing the critically ill client, and potentially reassign the nurse or provide additional resources.
A. This option does not address the immediate need to ensure the patient's safety and continuity of care. It's important to consider patient welfare and seek appropriate support before considering leaving the unit.
B. Discussing the client's care with another nurse could be a subsequent step, but it does not address the immediate need to ensure the nurse is qualified to provide the necessary care.
C. Proceeding without addressing the issue could jeopardize patient safety and is not ethically or professionally responsible. It's crucial to acknowledge limitations and seek appropriate assistance.
Correct Answer is C
Explanation
C. This reflex is an important protective mechanism that prevents objects from entering the throat and causing choking. Assessing the gag reflex before oral care can help ensure the safety of the client, especially if they have difficulty swallowing or are at risk for aspiration.
A. It's important to assess if the client is experiencing any pain, as oral care procedures can sometimes cause discomfort, especially if the client has oral lesions or sensitive gums. However, it is not a priority.
B. Presence of saliva: Saliva is essential for oral health, as it helps to cleanse the mouth and buffer acids produced by bacteria. Assessing the amount of saliva can indicate the overall oral hydration status and potential risk of dry mouth (xerostomia).
D. assessing the condition of the skin around the mouth and on the lips is important. It can reveal issues such as dryness, cracking, lesions, or signs of infection but not directly related to oral care.
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