When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mmol/L), which intervention is most important for the nurse to implement?

Reference Range

lonized Calcium [Adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)]

Determine apical pulse rate and rhythm.

Observe color and amount of urine.

Assess strength of deep tendon reflexes.

Compare muscle strength bilaterally

Answer and Explanation

The Correct Answer is A

A.   An ionized calcium level significantly above the reference range can lead to cardiac dysrhythmias and requires immediate attention to assess cardiac function.
B.   While urine output and characteristics are important indicators of renal function, cardiac assessment takes priority due to the potential cardiac effects of hypercalcemia.
C.   Assessment of deep tendon reflexes is relevant since hypercalcemia can lead to muscle weakness and diminished reflexes. However, this should be done after assessing for any cardiac dysrhythmias.
D.   Comparing muscle strength bilaterally is important for assessing neurological integrity but is not the priority when hypercalcemia is suspected.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

The client presents with facial droop and garbled speech, which are classic symptoms of a stroke. The CT scan ruled out intracranial hemorrhage, aligning with ischemic stroke symptoms. The neurological assessment indicated left-sided facial droop, diminished hand grasp strength, and garbled speech, all of which are consistent with neurological deficits typically seen in a stroke.

A. Viral meningitis whose temperature changed from 101° F (38.3°C) to 102° F (38.9°C) B. Myxedema coma whose blood pressure changed from 80/50 mm Hg to 70/40 mm Hg. C. Subdural hematoma whose blood pressure changed from 150/80 mm Hg to 170/60 mm Hg. D. Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7.

Correct Answer is A

Explanation

A. The client with viral meningitis and a slight increase in temperature can be managed by a PN, as this change in status is less acute and requires standard nursing care and monitoring.

B. The client with myxedema coma experiencing a significant drop in blood pressure requires more complex and immediate intervention by an RN due to the critical nature of the condition.
C. The client with a subdural hematoma and a significant change in blood pressure needs close monitoring and potential interventions by an RN, given the risk of increased intracranial pressure.
D. The client with diabetic ketoacidosis and a decreased Glasgow Coma Scale score is in a critical state requiring close monitoring and management by an RN.

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When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mmol/L), which intervention is most important for the nurse to implement? Reference Range lonized Calcium [Adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)]

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Drag one condition and one client finding to complete the sentence(s). Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of as evidenced by. neurological defects as evidenced by

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

Correct Answer is A

Explanation

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When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mmol/L), which intervention is most important for the nurse to implement?

Reference Range

lonized Calcium [Adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)]