A nurse is collecting data from a client who has hypoparathyroidism. Which of the following findings should the nurse expect?
Negative Chvostek’s sign
Flaccid muscles
Numbness of the hands
Hypercalcemia
The Correct Answer is C
Choice A: Negative Chvostek’s sign is the absence of facial twitching when the facial nerve is tapped. This is a normal finding and does not indicate hypoparathyroidism. A positive Chvostek’s sign is a sign of hypocalcemia, which can occur in hypoparathyroidism.
Choice B: Flaccid muscles are weak and limp muscles that lack tone and resistance. This is not a typical finding of hypoparathyroidism, as low levels of parathyroid hormone can cause muscle spasms, cramps, and tetany.
Choice C: Numbness of the hands is a common finding of hypoparathyroidism, as low levels of parathyroid hormone can cause hypocalcemia, which affects the nerve function and sensation. Numbness can also occur in the feet, lips, and tongue.
Choice D: Hypercalcemia is a high level of calcium in the blood. This is not a finding of hypoparathyroidism, as low levels of parathyroid hormone can cause hypocalcemia, which is a low level of calcium in the blood. Hypercalcemia can be a sign of hyperparathyroidism, which is the opposite condition of hypoparathyroidism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Providing emotional support is important for a client who has ulcerative colitis, as the condition can affect their quality of life and mental health. However, this is not the priority action for a nurse who is caring for a client who is experiencing an acute exacerbation of ulcerative colitis, as it does not address the immediate physical needs of the client.
Choice B reason: Evaluating fluid and electrolyte levels is the priority action for a nurse who is caring for a client who is experiencing an acute exacerbation of ulcerative colitis, as the client is at risk of dehydration, hypovolemia, and electrolyte imbalances due to diarrhea, vomiting, and poor oral intake. The nurse should monitor the client’s vital signs, urine output, weight, skin turgor, mucous membranes, and laboratory values such as serum sodium, potassium, chloride, bicarbonate, blood urea nitrogen (BUN), and creatinine.
Choice C reason: Promoting physical mobility is beneficial for a client who has ulcerative colitis, as it can help prevent complications such as deep vein thrombosis (DVT), pulmonary embolism (PE), and pressure ulcers. However, this is not the priority action for a nurse who is caring for a client who is experiencing an acute exacerbation of ulcerative colitis, as the client may have abdominal pain, fatigue, and weakness that limit their mobility. The nurse should encourage rest and provide comfort measures such as positioning, heat therapy, and analgesics.
Choice D reason: Reviewing stress factors that can cause disease exacerbation is helpful for a client who has ulcerative colitis, as stress can trigger or worsen inflammation in the bowel. However, this is not the priority action for a nurse who is caring for a client who is experiencing an acute exacerbation of ulcerative colitis, as it does not address the immediate physical needs of the client. The nurse should teach the client about stress management techniques and refer them to appropriate resources such as counseling or support groups.
Correct Answer is A
Explanation
Choice A: Maintain the client in Fowler’s position. This is correct because Fowler’s position, which is a semi-sitting position with the head of the bed elevated 45 to 60 degrees, can facilitate the drainage of gastric contents and reduce the risk of aspiration.
Choice B: Use sterile water to irrigate the nasogastric tube. This is incorrect because sterile water is not necessary to irrigate the nasogastric tube, unless the client is immunocompromised or has a high risk of infection. Tap water or normal saline can be used to irrigate the nasogastric tube, following the provider’s orders or the facility’s protocol.
Choice C: Moisten the client’s lips with lemon-glycerin swabs. This is incorrect because lemon-glycerin swabs can dry out and irritate the client’s lips and oral mucosa, especially if used frequently. The nurse should use water-soluble lubricant or lip balm to moisturize the client’s lips and mouth.
Choice D: Measure abdominal girth daily. This is incorrect because measuring abdominal girth daily is not enough to monitor the progression of the intestinal obstruction and the effectiveness of the gastrointestinal decompression. The nurse should measure abdominal girth more frequently, such as every 4 hr or every shift, and report any changes or abnormalities.
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