A nurse is caring for a client who is a long-term alcoholic. The client presents to the emergency department with vomiting and diarrhea for several days. Which findings would the nurse expect to find in this client?
dysphagia
hypoactive deep tendon reflexes (DTR)
hypomagnesemia
positive Chvostek sign hypertension
The Correct Answer is C
A) Dysphagia: While dysphagia (difficulty swallowing) can occur in individuals with long-term alcohol use, especially if there is coexisting neurological damage or esophageal disorders, it is not specifically associated with vomiting and diarrhea in the context of this scenario. The primary concern here involves electrolyte imbalances.
B) Hypoactive deep tendon reflexes (DTR): Hypoactive DTRs are typically associated with hypermagnesemia rather than hypomagnesemia. In this case, the client's condition is more likely to lead to electrolyte deficiencies, including hypomagnesemia, due to vomiting, diarrhea, and poor nutritional intake.
C) Hypomagnesemia: Chronic alcohol use often results in nutritional deficiencies, and vomiting and diarrhea can further exacerbate this by depleting electrolytes. Hypomagnesemia is a common finding in long-term alcoholics due to poor dietary intake, gastrointestinal losses, and renal losses. This can lead to symptoms such as muscle weakness, tremors, and altered mental status. Hypomagnesemia is particularly concerning because it can affect cardiovascular stability and neuromuscular function.
D) Positive Chvostek sign: A positive Chvostek sign is indicative of hypocalcemia, which can occur secondary to hypomagnesemia. However, it is not as directly associated with chronic alcoholism as hypomagnesemia itself. The positive Chvostek sign involves a facial muscle spasm in response to tapping the facial nerve and indicates neuromuscular irritability due to low calcium levels. While related, the primary electrolyte imbalance expected here is hypomagnesemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Popsicle:
A popsicle is appropriate for a clear liquid diet because it is made from clear liquids and does not contain any solids or pulp. Clear liquids are defined as those that are transparent at room temperature, making popsicles a suitable option.
B) Milkshake:
A milkshake is not suitable for a clear liquid diet due to its creamy consistency and solid particles. Clear liquid diets require that all items be transparent and free of any solid components.
C) Orange juice with pulp:
Orange juice with pulp is not appropriate for a clear liquid diet because it contains pulp, which is considered a solid. Clear liquid diets exclude any liquids that have solid components or particulate matter.
D) Yogurt:
Yogurt is not allowed on a clear liquid diet as it contains solids and has a creamy texture. Clear liquid diets are limited to liquids that are completely transparent and free of solids.
Correct Answer is D
Explanation
A) Covering the client with a blanket:
Covering the client with a blanket may help manage chills, but it does not address the underlying cause of the symptoms. Stopping the transfusion takes precedence in ensuring patient safety.
B) Assessing the client's skin for a rash:
Assessing for a rash can help determine if an allergic reaction is occurring, but the priority is to stop the transfusion to prevent further complications and address the immediate risk.
C) Notifying the provider:
Notifying the provider is important for reporting and further management, but the immediate action should be stopping the transfusion to prevent potential adverse effects.
D) Stopping the transfusion:
Stopping the transfusion is the priority action as it addresses the immediate risk of a transfusion reaction, such as an allergic reaction or transfusion-related infection. This action helps prevent further complications and ensures the client's safety.
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