A nurse is assessing a client who has an electrolyte imbalance with an elevated total calcium level of 12.8 mg/dL. Which of the following findings should the nurse expect?
Hyperreflexia
Diarrhea
Muscle twitching
Lethargy
The Correct Answer is D
A) Hyperreflexia:
Hyperreflexia is typically associated with low calcium levels (hypocalcemia), not elevated levels. An elevated calcium level often results in reduced neuromuscular excitability, leading to diminished reflexes rather than heightened ones.
B) Diarrhea:
Elevated calcium levels are more likely to cause constipation rather than diarrhea. Hypercalcemia often slows gastrointestinal motility, which can lead to decreased bowel movements and constipation.
C) Muscle twitching:
Muscle twitching is generally a symptom of hypocalcemia rather than hypercalcemia. Elevated calcium levels tend to depress neuromuscular activity, making muscle twitching less likely.
D) Lethargy:
Lethargy is a common symptom of hypercalcemia. High calcium levels can depress the central nervous system, leading to symptoms such as fatigue, weakness, confusion, and lethargy. This makes lethargy a likely finding in a client with an elevated total calcium level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Use petroleum jelly on a cotton ball to plug your ear when shampooing.
This technique helps prevent water from entering the ear during activities like showering. While it is useful for keeping the ear dry, it does not directly address preventing trauma or further hearing impairment post-surgery.
B) Clean dried blood in your ear canal with a cotton-tipped applicator.
Using cotton-tipped applicators can cause damage to the delicate ear canal and potentially disturb the surgical site. This action increases the risk of infection and trauma, potentially worsening hearing loss instead of preventing it.
C) Avoid blowing your nose for 1 month after surgery.
Refraining from nose blowing is essential because it prevents pressure changes that could disrupt the surgical repair. Such pressure changes can lead to complications like graft displacement, which can cause trauma and impair hearing.
D) Notify your provider if you have popping or crackling sensations in the affected ear.
Popping or crackling can be common as the ear heals and adjusts. These sensations typically do not indicate a problem unless accompanied by pain or other symptoms. Thus, while monitoring is important, it is not a primary preventative measure for trauma or hearing issues.
Correct Answer is B
Explanation
A) Offer the client a small meal if she is not nauseated:
While eating a small meal can help raise blood glucose levels, it is not the immediate priority in a severe hypoglycemia situation. The client might be unconscious or unable to swallow safely, making this action inappropriate as a first step.
B) Administer 1 mg of glucagon intramuscularly to the client:
Administering glucagon intramuscularly is the most crucial initial action. Glucagon rapidly increases blood glucose levels by stimulating glycogen breakdown in the liver. This is vital for quickly reversing severe hypoglycemia, especially if the client is unconscious or unable to ingest carbohydrates orally.
C) Contact the client's provider for further instructions:
Contacting the provider is essential, but it should occur after addressing the immediate hypoglycemic episode. Once the client's condition stabilizes, further guidance can be sought from the healthcare provider.
D) Transport the client to an emergency department for treatment:
Transporting the client to the emergency department is necessary if the hypoglycemia does not improve after administering glucagon or if the client remains unresponsive. However, it is not the first action; immediate glucagon administration takes precedence to stabilize the client's condition before considering transportation.
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