A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect? (Select all that apply.)
Positive Trousseau's sign
Muscle cramps
Tingling sensation around the lips
Negative Chvostek's sign
Abdominal distention
Correct Answer : A,B,C
A. Positive Trousseau's sign: A positive Trousseau’s sign (carpal spasm induced by inflating a blood pressure cuff) is a classic indicator of hypocalcemia due to increased neuromuscular excitability.
B. Muscle cramps: Hypocalcemia leads to increased nerve excitability, causing muscle cramps, spasms, and tetany.
C. Tingling sensation around the lips: This is a common early sign of hypocalcemia, known as perioral paresthesia, due to increased nerve excitability.
D. Negative Chvostek's sign: A client with hypocalcemia would have a positive Chvostek’s sign, which is facial twitching when the facial nerve is tapped.
E. Abdominal distention: Hypocalcemia is more associated with diarrhea and hyperactive bowel sounds, not abdominal distention, which is more typical of hypokalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I can discuss client information in the hallway outside a client's room." Discussing client information in a public or semi-public area is a violation of HIPAA (Health Insurance Portability and Accountability Act).
B. "I will need permission from a client to share health information with a relative." Under HIPAA, health information cannot be shared with family members unless the client gives explicit permission.
C. "I can share a client's diagnosis with any member of the health care team." Information should only be shared with team members directly involved in the client's care. Not all healthcare workers need access to all client information.
D. "I will need written permission from the provider to allow a client to access their electronic medical record." Clients have the right to access their medical records without needing provider permission. The facility may have specific procedures, but a provider cannot block access unless there is a legal or safety concern.
Correct Answer is A
Explanation
A. "The client's room number and diagnosis are written on the hallway communication board." This is a breach of client confidentiality because it publicly displays protected health information (PHI) where unauthorized individuals, including visitors and non-essential staff, could see it. This violates HIPAA (Health Insurance Portability and Accountability Act) regulations.
B. "The history and physical in the electronic medical record describes the client's previous suicide attempt." The electronic medical record (EMR) is a secure and appropriate place for documenting the client's health history. Access is restricted to healthcare providers involved in the client’s care.
C. "The time when the client can next have pain medication is written on their bedside communication board." This does not violate confidentiality, as it is relevant to the client’s direct care and is visible only to the healthcare team and the client.
D. "The client is wearing a color-coded bracelet that states they are a fall risk." Color-coded bracelets are a standard safety practice in hospitals to communicate important patient care needs to staff. This does not disclose specific medical information beyond the fall risk status.
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