A nurse is collecting data from a client who has hypomagnesemia. Which of the following findings should the nurse identify as a positive Chvostek's sign?
Image A
Image B
Image A
Image B
The Correct Answer is A
A. Chvostek's sign is a clinical sign observed during physical examination that may indicate hypocalcemia. It is elicited by tapping or lightly striking the facial nerve just anterior to
the earlobe, which can cause twitching of the facial muscles, particularly the muscles around the mouth and nose.
B. This image shows winging of the scapula. Winging of the scapula, also known as
scapular winging, is a condition characterized by the abnormal protrusion or prominence of the scapula away from the back wall of the thorax. Normally, the scapula lies flat
against the rib cage, providing stability and support for arm movements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Confidential health information should not be disclosed to family members without the
client's consent unless there is a legal or ethical obligation to do so, such as in cases of imminent harm or emergency situations.
B. Health information should not be disclosed to an employer without the client's consent unless required by law or for specific occupational health purposes.
C. Health information should not be disclosed to an insurance agency without the client's consent unless required by law or for specific insurance-related purposes.
D. Health information may be disclosed to a medical interpreter service as necessary to facilitate communication between the client and healthcare providers. However, the interpreter should be informed of confidentiality obligations.
Correct Answer is A
Explanation
A. Applying restraints over clothing helps to prevent direct skin contact, which can reduce the risk of skin irritation, abrasions, and pressure sores that might occur from prolonged contact with the restraint material. It also serves as a layer of padding, offering additional comfort for the patient. Moreover, clothing can act as a barrier against potential constriction of blood flow or nerve compression.
B. Two fingers should fit between the restraint and the client's body and not four fingers. This helps prevent excessive tightness, which can lead to restricted circulation and skin breakdown. This action promotes client safety and comfort.
C. Checking the client's skin integrity should be done done more frequently than the four hours to assess for any skin damage or irritation.
D. Tying the belt restraint to the side rail of the bed may pose a safety risk, as it could restrict the client's movement and lead to injury or discomfort. The belt restraint should be anchored to an immobile part of the bed.
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