A nurse in the outpatient clinic is caring for a client with a serum calcium level of 7.5 mg/dL (8.5-10.2 mg/dL). What nursing intervention is most important when providing care for this client? (Select All That Apply).

Prepare the client for hemodialysis.

Initiate safety precautions to protect the client from injury.

Administer to the client prescribed calcium supplement.

Assess the client for tetany.

Educate the client to avoid foods that are high in calcium.

Answer and Explanation

Correct Answer : B,C,D

A. Hemodialysis is not indicated for a low calcium level unless associated with severe renal failure or other metabolic disturbances.

B. Safety precautions are important due to the risk of fractures or injury caused by weakened bones and muscle spasms related to hypocalcemia.

C. Administering prescribed calcium supplements is a key intervention to correct hypocalcemia.

D. Tetany, a sign of severe hypocalcemia, should be assessed as it can lead to muscle cramps and spasms.

E. Educating the client to avoid foods that are high in calcium would not be appropriate, as the client requires calcium to address the low levels.

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Correct Answer is A

Explanation

A. The patient is the primary source of information regarding their pain tolerance, as pain is subjective and only the patient can accurately describe their experience.

B. A patient's roommate cannot reliably report on the patient's pain experience.

C. The CNA may observe signs of pain but cannot determine the patient's subjective pain tolerance.

D. The nurse can assess the patient's pain based on behaviors and reports but relies on the patient for direct information.

A. The client is able to stick out the tongue midline and side to side. B. The client follows an object with the eyes without nystagmus or strabismus. C. The client has equal strength when moving both shoulders against resistance. D. The client is able to hear normally with the whispered voice test.

Correct Answer is C

Explanation

A. Sticking out the tongue assesses cranial nerve XII (hypoglossal nerve), not XI.

B. Following an object with the eyes assesses cranial nerves III, IV, and VI, not XI.

C. Cranial nerve XI (the accessory nerve) controls the sternocleidomastoid and trapezius muscles, and testing involves shoulder shrugging and head rotation against resistance.

D. Hearing normally assesses cranial nerve VIII (vestibulocochlear nerve).

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A nurse in the outpatient clinic is caring for a client with a serum calcium level of 7.5 mg/dL (8.5-10.2 mg/dL). What nursing intervention is most important when providing care for this client? (Select All That Apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When collecting data, the nurse understands which individual is the primary source of information regarding pain tolerance.

Correct Answer is A

Explanation

While conducting a focused neurological assessment, the nurse includes testing the function of cranial nerve XI in a client. What assessment findings indicate the nerve is intact and functioning?

Correct Answer is C

Explanation

A nurse in the outpatient clinic is caring for a client with a serum calcium level of 7.5 mg/dL (8.5-10.2 mg/dL). What nursing intervention is most important when providing care for this client? (Select All That Apply).

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