A nurse is assisting with the care of a client who has hypocalcemia. For which of the following signs should the nurse monitor?
Kernig's sign
Brudzinski's sign
Chvostek's sign
Cullen's sign
The Correct Answer is C
(A) Kernig’s sign: Kernig’s sign is a clinical sign in which severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees. It is commonly associated with meningitis, not hypocalcemia.
(B) Brudzinski’s sign: Brudzinski’s sign is a symptom of meningitis. It is not associated with hypocalcemia.
(C) Chvostek’s sign: This is the most appropriate answer. Chvostek’s sign is a clinical sign of existing nerve hyperexcitability (tetany) seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve.
(D) Cullen’s sign: Cullen’s sign is a medical term referring to superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. It is not associated with hypocalcemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. “Your cholesterol levels should be monitored monthly while taking this medication”: Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor used to treat high blood pressure and heart failure. It does not typically affect cholesterol levels, so monthly cholesterol monitoring is not usually necessary.
B. “Make sure your diet contains a lot of potassium-rich foods.”: While a balanced diet is important for overall health, patients taking lisinopril should be cautious about consuming too much potassium. Lisinopril can increase potassium levels in the body, and consuming too many potassium-rich foods could lead to hyperkalemia, a condition characterized by high levels of potassium in the blood.
C. “Monitor your blood pressure on a regular basis.”: This is correct. Since lisinopril is used to treat high blood pressure, it’s important for patients to monitor their blood pressure regularly to ensure the medication is working effectively.
D. “Notify your doctor immediately if you become pregnant.”: This is correct. Lisinopril is not recommended during pregnancy as it can harm the unborn baby. If a patient becomes pregnant while taking lisinopril, they should notify their doctor immediately.
E. “Report the development of a persistent dry cough.”: This is correct. A persistent dry cough is a common side effect of ACE inhibitors like lisinopril. If a patient develops this symptom, they should report it to their healthcare provider.
Correct Answer is B
Explanation
A. Data collection:
Data collection is the initial step of the nursing process where the nurse gathers information about the client's health status, including physical, psychological, sociocultural, and spiritual factors. While data collection is essential for planning, in this scenario, the nurse is already involved in the collaborative process of preparing a discharge plan, indicating the phase of planning.
B. Planning:
Planning involves developing a comprehensive plan of care based on the assessment data collected. It includes setting priorities, establishing goals, identifying interventions, and coordinating resources to meet the client's needs. In this scenario, the nurse, social worker, and physical therapist are working together to plan the client's discharge, which involves determining the appropriate support, resources, and interventions needed for a successful transition.
C. Evaluation:
Evaluation occurs after implementation, where the nurse assesses the client's response to the interventions implemented and determines whether the goals and outcomes have been achieved. While evaluation is an essential part of the nursing process, it occurs after planning and implementation.
D. Implementation:
Implementation involves carrying out the plan of care developed during the planning phase. It includes initiating interventions, providing treatments, and coordinating care to meet the client's needs. In this scenario, the nurse, social worker, and physical therapist are in the process of developing the discharge plan, which precedes implementation.
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