As the nurse assesses a client’s blood pressure, the patient’s wrist severely flexes inward. The nurse questions the client’s response because this finding may indicate what condition?

Hyperchloremia

Hypercalcemia

Hypocalcemia

Hypomagnesemia

Answer and Explanation

The Correct Answer is C

Choice A reason: Hyperchloremia, elevated chloride levels, is associated with metabolic acidosis or dehydration, not neuromuscular symptoms like wrist flexion. Chloride imbalances affect acid-base balance, not calcium-dependent muscle contractions. The inward wrist flexion suggests a neuromuscular excitability issue, which is more characteristic of low calcium levels than chloride abnormalities.

Choice B reason: Hypercalcemia, high calcium levels, causes muscle weakness, lethargy, and reduced reflexes, not increased neuromuscular excitability like wrist flexion. Calcium excess stabilizes nerve membranes, reducing spasms. The symptom described aligns with hypocalcemia, where low calcium increases nerve excitability, leading to tetany or abnormal muscle contractions.

Choice C reason: Hypocalcemia, low calcium levels, increases neuromuscular excitability due to decreased stabilization of nerve membranes. This can cause tetany, characterized by involuntary muscle contractions, such as wrist flexion (carpopedal spasm). The symptom is a classic sign of hypocalcemia, often seen in conditions like hypoparathyroidism or vitamin D deficiency.

Choice D reason: Hypomagnesemia, low magnesium, can cause neuromuscular symptoms like tremors or seizures but is less commonly associated with specific signs like wrist flexion. Magnesium affects muscle relaxation, and its deficiency typically causes generalized excitability. Hypocalcemia is more directly linked to tetany and carpopedal spasms, as seen in the client.

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Correct Answer is C

Explanation

Choice A reason: Fever in a discharge-ready client suggests a new infection, which is concerning but not immediately life-threatening. The ABCD-E framework prioritizes airway and breathing issues. While fever requires evaluation, it is less urgent than respiratory distress, as it does not acutely compromise vital functions like oxygenation.

Choice B reason: Confusion in early dementia is common and concerning but not an immediate threat to life. The ABCD-E framework prioritizes airway, breathing, and circulation. Confusion may indicate worsening dementia or another issue, but it is less urgent than a client with acute respiratory distress, like wheezing.

Choice C reason: Wheezing in a pneumonia client indicates airway obstruction or bronchospasm, compromising breathing (B in ABCD-E). This is a life-threatening emergency requiring immediate intervention to ensure oxygenation. Respiratory distress takes priority over fever, confusion, or low urine output, as it directly affects a vital function critical for survival.

Choice D reason: Low urine output (50 mL/4 hours) in a postoperative client suggests possible hypovolemia or renal issues, affecting circulation (C in ABCD-E). While serious, it is less urgent than airway or breathing problems. Respiratory distress, like wheezing, takes precedence, as it poses an immediate threat to life.

A. pH 7.48, PaCO2 40 mmHg, HCO3- 24 mEq/L B. pH 7.30, PaCO2 30 mmHg, HCO3- 18 mEq/L C. pH 7.50, PaCO2 45 mmHg, HCO3- 30 mEq/L D. pH 7.35, PaCO2 38 mmHg, HCO3- 22 mEq/L

Correct Answer is B

Explanation

Choice A reason: pH 7.48, PaCO2 40 mmHg, HCO3- 24 mEq/L indicates alkalosis, not acidosis. Diabetic ketoacidosis (DKA) causes metabolic acidosis due to ketone accumulation, lowering pH and bicarbonate. Normal PaCO2 and HCO3- rule out DKA, as compensatory hyperventilation would lower PaCO2 in response to acidosis.

Choice B reason: pH 7.30, PaCO2 30 mmHg, HCO3- 18 mEq/L indicates metabolic acidosis with respiratory compensation. In DKA, ketone production lowers pH and bicarbonate, while hyperventilation reduces PaCO2 to compensate. These values align with DKA’s acid-base imbalance, reflecting the body’s attempt to correct acidosis through increased respiration.

Choice C reason: pH 7.50, PaCO2 45 mmHg, HCO3- 30 mEq/L indicates metabolic alkalosis, not acidosis. DKA causes acidosis from ketone accumulation, not alkalosis. Elevated bicarbonate and normal PaCO2 suggest a different condition, like vomiting-induced alkalosis, making this inconsistent with the metabolic acidosis seen in DKA.

Choice D reason: pH 7.35, PaCO2 38 mmHg, HCO3- 22 mEq/L indicates normal acid-base balance. DKA results in metabolic acidosis with low pH and bicarbonate due to ketone production. Normal values do not reflect the acidotic state of DKA, where compensatory mechanisms would alter PaCO2 and HCO3- significantly.

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As the nurse assesses a client’s blood pressure, the patient’s wrist severely flexes inward. The nurse questions the client’s response because this finding may indicate what condition?

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