The nurse is concerned that a patient recovering from a thyroidectomy is developing hypocalcemia. What findings did the nurse use to come to this conclusion? Select all that apply.
Contraction of the facial muscles.
Complaints of fingers tingling.
Carpal spasm with blood pressure measurement.
Asked when the foot numbness would go away.
Correct Answer : A,B,C
Choice A rationale:
The nurse considered contraction of facial muscles as a finding of hypocalcemia because it is associated with Chvostek's sign, which indicates neuromuscular irritability due to low calcium levels.
Choice B rationale:
Complaints of fingers tingling are indicative of hypocalcemia since tingling sensations (paresthesias) in the extremities can result from decreased calcium levels affecting nerve function.
Choice C rationale:
Carpal spasm with blood pressure measurement is known as Trousseau's sign and is associated with hypocalcemia. When the blood pressure cuff is inflated above systolic pressure, it can cause tetany in the hand if the calcium levels are low.
Choice D rationale:
Asking when foot numbness would go away does not directly relate to hypocalcemia or its symptoms. It is not a finding used to come to the conclusion of hypocalcemia in this scenario.
Choice E rationale:
The heart rate being 88 and regular does not directly indicate hypocalcemia. While hypocalcemia can lead to cardiac arrhythmias, a heart rate of 88 and regular is within the normal range and not a specific finding for hypocalcemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Hypophosphatemia is a condition characterized by low levels of phosphate in the blood, which can be caused by various factors, including malnutrition. In this case, the patient has a history of stomach ulcers, which might have contributed to poor nutrient absorption. The nurse should request a dietitian consult to ensure the patient receives an appropriate diet rich in phosphorus, which is essential for cellular function, bone health, and energy metabolism.
Choice B rationale:
Providing aluminum hydroxide antacids as prescribed is not the appropriate intervention for hypophosphatemia. Aluminum hydroxide antacids can bind to phosphate in the gastrointestinal tract, reducing its absorption and potentially worsening the patient's already low phosphate levels.
Choice C rationale:
Instructing the patient to avoid poultry, peanuts, and seeds is not suitable for this situation. These foods are good sources of phosphorus, and avoiding them would further deplete the patient's already low phosphate levels.
Choice D rationale:
Instructing the patient to avoid the intake of sodium phosphate is not necessary for hypophosphatemia. While sodium phosphate preparations are used as laxatives, there is no indication that the patient is taking them, and they are not relevant to the management of hypophosphatemia.
Correct Answer is ["A","D","E"]
Explanation
A, D, and E.
Choice A rationale:
Furosemide is a loop diuretic that promotes diuresis, causing an increase in urine output. It is essential for the patient to expect this effect and understand that it helps in reducing fluid overload.
Choice B rationale:
Feeling weak and dizzy is not an expected effect of furosemide. It is more commonly associated with dehydration or excessive fluid loss, which can occur if the medication causes too much diuresis.
Choice C rationale:
Taking furosemide before going to sleep is not recommended because it can lead to nighttime diuresis, disrupting sleep and potentially causing electrolyte imbalances.
Choice D rationale:
Swelling of the face or hands may indicate an adverse reaction to furosemide or an underlying medical issue. The nurse should instruct the patient to report any such symptoms promptly.
Choice E rationale:
Monitoring body weight daily is crucial for patients on diuretic therapy to assess fluid status and response to treatment. Rapid weight gain may indicate worsening fluid overload, while significant weight loss may indicate excessive diuresis.
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