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 B
Explanation
Metabolic alkalosis.
Choice A rationale:
The given blood gas results show a pH of 7.53, which is alkaline (above the normal range of
7.35 to 7.45), and a high bicarbonate level of 36 mEq/L (normal range is 22 to 26 mEq/L). This combination indicates metabolic alkalosis, a condition where there is an excessive accumulation of bicarbonate in the blood, leading to increased pH.
Choice B rationale:
Metabolic alkalosis is characterized by increased blood bicarbonate levels, which can occur due to conditions like vomiting, diuretic use, or excessive ingestion of bicarbonate-containing substances. It results in symptoms such as muscle twitching, tetany, and respiratory depression.
Choice C rationale:
Respiratory alkalosis is characterized by an elevated blood pH and low carbon dioxide levels (hypocapnia). However, the bicarbonate level is not directly related to respiratory alkalosis, making this choice incorrect based on the given information.
Choice D rationale:
Metabolic acidosis is characterized by a decreased blood pH and low bicarbonate levels. The presented blood gas results show an alkaline pH and high bicarbonate, making this choice incorrect.
Correct Answer is D
Explanation
The correct answer isd. Assess for indications of pulmonary embolism.
Choice A rationale:
Administering a sedative is not appropriate as the priority intervention. Sedatives can depress respiratory function, which is already compromised in this patient.
Choice B rationale:
Preparing for mechanical ventilation might be necessary if the patient’s condition worsens, but it is not the immediate priority. The priority is to identify the underlying cause of the symptoms.
Choice C rationale:
Massaging the calf area for tenderness is not relevant in this context. While calf tenderness can be a sign of deep vein thrombosis (DVT), which can lead to pulmonary embolism, the immediate priority is to assess for pulmonary embolism directly.
Choice D rationale:
Assessing for indications of pulmonary embolism is the priority because the patient’s symptoms (shortness of breath, chest pain, recent use of birth control pills, smoking history, and abnormal ABG values) strongly suggest a pulmonary embolism.Early identification and treatment are crucial to prevent further complications.
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