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 ["A","B","C","D","E"]
Explanation
In the scenario provided, the nurse should take further action based on the following findings: The client's distended abdomen, reports of nausea, and coughing suggest possible intolerance to the tube feedings or another complication. A gastric residual volume of 550 mL is significantly higher than the standard safe limit of 500 mL, indicating delayed gastric emptying or feeding intolerance. The pH of gastric aspirate at 4.5 is within normal limits, suggesting that the tube is likely placed correctly. However, the elevated heart rate of 110/min could be a response to discomfort or underlying stress. The pulse oximetry reading of 90% on room air is below the normal range, which typically is 95-100%, indicating potential impaired gas exchange or early signs of respiratory distress. These findings warrant immediate nursing interventions and possibly a reassessment of the feeding regimen, along with measures to improve the client's respiratory function and comfort. It is essential to monitor for further signs of aspiration, respiratory distress, or other complications, and to communicate these findings to the healthcare team for appropriate management.
Correct Answer is C
Explanation
A. Completing an incident report about the breach of confidentiality may be necessary, but it
should not be the first action. The immediate concern is addressing the behavior and reminding the nurse of proper protocol.
B. While it may be true that permission from the risk manager is required to access certain
records, this response does not address the immediate issue of the unauthorized access. It's more important to address the behavior directly.
C. This is the most appropriate action because it directly addresses the unauthorized access to the client's medical record. Reminding the nurse of the proper protocol for accessing medical records can help prevent further breaches of confidentiality.
D. Contacting facility security to remove the nurse from the unit may be excessive at this stage and should be considered if the behavior persists after reminders about proper protocol.
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