Which of the following best describes Chvostek's sign assessment?
Assessing a client's blood pressure using a sphygmomanometer.
Assessing a client's muscle contractions by tapping on the facial nerve.
Assessing a client's heart rate using a stethoscope.
Assessing a client's respiratory rate using a pulse oximeter.
The Correct Answer is B
A. Assessing blood pressure with a sphygmomanometer is unrelated to Chvostek's sign, which specifically evaluates neuromuscular excitability.
B. Chvostek's sign is assessed by tapping the facial nerve near the cheekbone. A positive response, such as twitching of the facial muscles, indicates hypocalcemia or neuromuscular irritability.
C. Assessing heart rate with a stethoscope does not involve evaluating neuromuscular function or calcium levels.
D. Monitoring respiratory rate with a pulse oximeter is unrelated to Chvostek's sign and does not assess neuromuscular excitability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A urine output of 32 mL/hour is slightly below the normal threshold (30 mL/hour) but does not indicate an immediate threat requiring intervention.
B. Confusion and disorientation are signs of severe hyponatremia, which can lead to cerebral edema and life-threatening complications such as seizures or coma. This finding requires immediate intervention to prevent worsening neurological impairment.
C. A blood pressure of 106/82 is within an acceptable range and does not indicate a critical issue in this context.
D. Bilateral 2+ pedal edema is not uncommon in elderly clients and does not directly indicate a severe complication of hyponatremia requiring immediate action.
Correct Answer is B
Explanation
A. Administering oxygen is important, but the priority is reversing the opioid-induced respiratory depression with naloxone. Oxygen alone will not address the underlying cause of the decreased level of consciousness.
B. Administering naloxone (Narcan) is the priority intervention because it is an opioid antagonist that will reverse the effects of morphine and other opioids, improving respiratory function and consciousness.
C. Opening the airway is important, but the primary issue here is opioid overdose, which requires naloxone administration for reversal of respiratory depression.
D. Placing the patient in the shock position is not indicated in this scenario. The focus should be on reversing opioid toxicity, not on positioning for shock.
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