A nurse is assessing a client who has received treatment for hypocalcemia. Which of the following findings indicates the treatment has been effective?
Moist mucous membranes
Negative Chvostek's sign
Weight gain
Urine output 25 mL/hr
The Correct Answer is B
A. Moist mucous membranes: While moist mucous membranes may indicate adequate hydration, they are not specific to the treatment of hypocalcemia. The goal of hypocalcemia treatment is to correct calcium levels in the body, which would be reflected by the resolution of clinical signs related to low calcium, such as Chvostek's sign.
B. Negative Chvostek's sign: Chvostek's sign is a clinical sign that suggests hypocalcemia, where tapping the facial nerve causes twitching of the facial muscles. A negative Chvostek's sign indicates that calcium levels have normalized, meaning the treatment for hypocalcemia has been effective. The absence of this sign is a reliable indicator that the treatment has corrected the calcium deficiency.
C. Weight gain: Weight gain is not a typical or direct indicator of hypocalcemia treatment success. While some treatments for hypocalcemia might impact overall metabolism, weight gain is not a specific or reliable sign of calcium normalization. The most relevant sign would be the absence of symptoms related to calcium deficiency, such as a negative Chvostek’s sign.
D. Urine output 25 mL/hr: Urine output of 25 mL/hr is below the normal threshold, which is typically at least 30 mL/hr. While urine output can be affected by various factors, it is not a reliable marker for effective treatment of hypocalcemia. Treatment success is better assessed by signs related to calcium levels, such as the negative Chvostek’s sign, rather than urine output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Elevate the head of the bed: Raising the head of the bed to at least 30 to 45 degrees is the first and most essential action to reduce the risk of aspiration during enteral feeding. This position helps ensure that the formula flows into the stomach by gravity and minimizes the potential for reflux of gastric contents into the lungs, which can lead to aspiration pneumonia.
B. Attach the barrel of the syringe to the tube after removing the plunger: This step is necessary for gravity-based enteral feeding when using a syringe. However, it should only be done after confirming tube placement and ensuring the patient is positioned properly. Attaching the syringe before proper safety precautions increases the risk of aspiration.
C. Insert air into the tube before pulling back gastric contents: Injecting air into the gastrostomy tube is part of the verification process to confirm tube placement, often followed by aspirating gastric contents. While this is important, it is not the very first action. The client's head must be elevated first to ensure safety before any manipulation of the tube begins.
D. Flush the tube with 30 mL water: Flushing is necessary to ensure tube patency and to prevent blockage before and after feedings. However, it is not the first step in the procedure. Elevating the head of the bed comes before flushing to prevent aspiration during any subsequent feeding or fluid administration.
Correct Answer is A
Explanation
A. "You should limit your consumption of seafood to avoid exposure to mercury. Certain fish contain high levels of mercury, which can negatively impact fetal brain development. Pregnant individuals are advised to limit consumption of high-mercury seafood and choose safer options like salmon, shrimp, and cod, keeping weekly intake within recommended limits.
B. "You should not eat hard cheeses, such as Romano, Parmesan, and Asiago, to avoid listeriosis."
Hard cheeses are typically safe to eat during pregnancy because they are low in moisture and unlikely to support Listeria growth. It is soft, unpasteurized cheeses like brie and queso fresco that pose a higher listeriosis risk.
C. "You should decrease your salt intake to avoid preeclampsia." There is no strong evidence that reducing salt intake prevents preeclampsia. Pregnant individuals should follow normal dietary guidelines unless otherwise directed by a healthcare provider due to existing hypertension or kidney conditions.
D. "You should start using artificial sweeteners to decrease the risk of gestational diabetes."
Artificial sweeteners do not prevent gestational diabetes and some types may have unclear safety profiles in pregnancy. Emphasis should be placed on balanced nutrition and managing total carbohydrate intake rather than replacing sugar with artificial alternatives.
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