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 C
Explanation
A. Simple face mask: This can deliver oxygen at flow rates of 5-10 liters per minute and typically provides an oxygen concentration of about 35-50%.
B. Nasal prongs: Nasal prongs deliver oxygen at lower flow rates and may not be sufficient to raise the client's oxygen saturation to 90%.
C. Non-rebreather mask: This mask can deliver high concentrations of oxygen (up to 90-100%) at flow rates of 10-15 liters per minute. It has one-way valves to prevent the patient from rebreathing exhaled air, thus maximizing the delivery of oxygen.
D. Nasal cannula: Nasal cannulas deliver oxygen at lower flow rates (typically up to 6 liters per minute) and may not provide the necessary concentration to achieve an oxygen saturation of 90%.
Correct Answer is C
Explanation
A. Documenting client education on self-care needs is important but does not specifically relate to the postpartum status or immediate healthcare concerns.
B. While documenting vital signs like oral temperature is important for monitoring the client's health, this specific finding does not relate directly to the postpartum status unless it is elevated beyond normal ranges and indicates a potential complication.
C. Documenting the condition of the episiotomy site, including its approximation and length, is essential for assessing wound healing and preventing infection in the postpartum period.
D. While hydration is important for postpartum recovery, documenting fluid intake is not as crucial as assessing the healing of specific postpartum interventions like an episiotomy.
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