A client has a total serum calcium level of 7.0 mg/dL (1.75 mmol/L). Based on this information, which action is most important for the nurse to include while measuring the client's vital signs?

Reference Range:

Total Calcium (9 to 10.5 mg/dL (2.25 to 2.62 mmol/L)]

Measure blood pressure in both arms.

Assess skin turgor for elasticity.

Observe the skin for signs of bruising.

Note the rhythm of the pulse.

Answer and Explanation

The Correct Answer is D

A.   While it is generally good practice to measure blood pressure in both arms for a comprehensive assessment, this is not the primary concern with hypocalcemia. Hypocalcemia primarily affects neuromuscular and cardiovascular systems, so while blood pressure monitoring is important, it does not directly address the critical symptoms associated with low calcium levels.
B.   Assessing skin turgor is a useful practice for evaluating hydration status and skin elasticity but is not specifically related to the management or symptoms of hypocalcemia. In hypocalcemia, skin changes are not the most relevant concern compared to neuromuscular symptoms.
C.   Hypocalcemia can increase the risk of bleeding and bruising due to impaired blood clotting mechanisms. Monitoring for bruising can be an important aspect of assessing the effects of low calcium levels on the client’s hemostatic function. Bruising can be a direct indicator of the impact of hypocalcemia on blood coagulation and is relevant to the clinical management of the condition.
D.   Hypocalcemia can affect cardiac function, potentially leading to changes in heart rhythm and rate. Monitoring the rhythm of the pulse is crucial, as it can help identify arrhythmias or other cardiac disturbances associated with low calcium levels.

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Correct Answer is A

Explanation

A. Asking the client to describe their feelings provides an opportunity to explore their symptoms in more detail, which might help in understanding their pain better. This approach respects the client's experience and opens a dialogue to assess their discomfort more accurately, especially if they are not expressing it verbally or are having difficulty quantifying it.
B. Administering medication without further assessment might be premature. The client's denial of pain and the presence of grimacing and guarding behavior suggest that there may be underlying discomfort, but it's crucial to assess the situation more thoroughly before administering medication.
C. While documenting the client’s verbal denial of pain is important, it should not be the only action taken. The client's non-verbal cues such as grimacing and guarding behavior suggest that they might be experiencing pain despite their verbal denial.
D. Confronting the client could be perceived as accusatory and might make them feel defensive or uncomfortable. It's important to approach the situation with empathy and understanding rather than confrontation.

A. Develop self-awareness of the nurse's personal values to avoid imposing these values on the client. B. Listen to the ethics committee discussions and then inform the client what actions should be taken. C. Challenge members of the healthcare team whose opinions differ from the wishes of the client. D. Educate the client about current nursing literature findings related to the client's ethical dilemma.

Correct Answer is A

Explanation

A. This action is essential for effectively representing the client. Developing self-awareness of personal values ensures that the nurse does not impose their own beliefs on the client’s decisions. Instead, the nurse can advocate for the client's wishes based on the client's values and preferences, not their own.
B. While listening to the ethics committee is important, the nurse’s role as an advocate is to represent the client’s wishes and interests, not to dictate actions based on committee discussions. Informing the
client what actions should be taken may not be appropriate if it does not align with the client’s values or
preferences.
C. While it is important to advocate for the client's wishes, challenging team members should be done respectfully and constructively. The goal is not to create conflict but to ensure that the client’s preferences are considered.
D. Educating the client about nursing literature may be helpful, but it is not the primary responsibility of the nurse when serving as an advocate in an ethics committee meeting. The focus should be on
understanding and representing the client’s values and wishes rather than providing educational
information, unless it directly influences the client’s decision-making process.

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A client has a total serum calcium level of 7.0 mg/dL (1.75 mmol/L). Based on this information, which action is most important for the nurse to include while measuring the client's vital signs? Reference Range: Total Calcium (9 to 10.5 mg/dL (2.25 to 2.62 mmol/L)]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client grimaces and demonstrates guarding behavior, but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?

Correct Answer is A

Explanation

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?

Correct Answer is A

Explanation

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A client has a total serum calcium level of 7.0 mg/dL (1.75 mmol/L). Based on this information, which action is most important for the nurse to include while measuring the client's vital signs?

Reference Range:

Total Calcium (9 to 10.5 mg/dL (2.25 to 2.62 mmol/L)]