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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Grasps the catheter 10.16 to 12.7 cm (4 to 5 in) from the tip The catheter should be held at least 5 to 7.6 cm (2 to 3 inches) from the tip to maintain better control and prevent contamination.
B. Cleanses the meatus using a clean cotton ball Aseptic technique requires a separate antiseptic swab or cotton ball for each stroke to avoid introducing bacteria.
C. Cleanses the meatus from the center in a circular motion Cleaning from the center outward prevents introducing bacteria into the urethra, which is essential for infection prevention.
D. Applies clean gloves before beginning the procedure Sterile gloves, not clean gloves, must be used during catheterization to maintain aseptic technique.

A. "Although this is your first incident, we will have to terminate your employment." B. "We will review the incident report to determine the cause of the missed medication." C. "I will need to report this incident to the state board of nursing." D. "The facility's legal team will be contacting you to discuss the incident."

Correct Answer is B

Explanation

A. "Although this is your first incident, we will have to terminate your employment." This response is punitive and does not align with a just culture, which seeks to identify the cause of errors rather than immediately disciplining staff.
B. "We will review the incident report to determine the cause of the missed medication." This aligns with just culture principles by focusing on finding the root cause (e.g., workload issues, system inefficiencies) rather than blaming the nurse.
C. "I will need to report this incident to the state board of nursing." A missed medication dose that caused no harm typically does not require reporting to the state board. Just culture focuses on improving processes rather than unnecessary punishment.
D. "The facility's legal team will be contacting you to discuss the incident." Involving legal action for a minor, non-harmful event is excessive and contradicts just culture, which emphasizes education, accountability, and system improvements over legal consequences.

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A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

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Explanation

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