In which patient will the nurse expect to see a positive Chvostek sign?

A 24-year-old adult admitted for chronic alcohol abuse

A 75-year-old patient admitted for a broken hip related to osteoporosis

A 50-year-old patient admitted for acute hyperparathyroidism

A 7-year-old child admitted for severe burns

Answer and Explanation

The Correct Answer is C

Choice A reason: Chronic alcohol abuse may cause hypomagnesemia, which can mimic hypocalcemia symptoms, but a positive Chvostek sign is specific to low calcium. Alcoholism alone is less likely to cause this sign without concurrent hypocalcemia, making this choice incorrect.

Choice B reason: Osteoporosis in a 75-year-old involves bone density loss but does not typically cause hypocalcemia or a positive Chvostek sign. Calcium levels are usually normal unless other conditions exist, making this choice incorrect for the expected finding.

Choice C reason: Acute hyperparathyroidism can lead to hypocalcemia after parathyroidectomy or in secondary complications, causing a positive Chvostek sign (facial twitching when tapping the facial nerve). Low calcium triggers this neuromuscular response, making this the correct choice.

Choice D reason: Severe burns cause fluid shifts and potential electrolyte imbalances, but hypocalcemia is not a primary feature. A positive Chvostek sign is less likely without specific calcium depletion, making this choice incorrect for the expected finding.

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Correct Answer is C

Explanation

Choice A reason: A 3-inch needle is too long for most IM injections; 1–1.5 inches is standard for adults. This risks hitting bone or tissue, making this incorrect for safe injection.

Choice B reason: IM injections require a 90-degree angle to reach muscle. A 45-degree angle is for subcutaneous injections, making this incorrect for intramuscular administration technique.

Choice C reason: Aspirating before injecting ensures the needle is not in a blood vessel, preventing intravenous administration. This safety step is standard for IM injections, making it correct.

Choice D reason: Massaging the site can cause medication leakage or tissue damage. Gentle pressure is preferred, making massage incorrect for post-injection care in IM administration.

A. Administer diphenhydramine B. Stop the transfusion C. Notify the provider D. Obtain vital signs

Correct Answer is B

Explanation

Choice A reason: Administering diphenhydramine treats allergic symptoms but does not address the ongoing transfusion reaction. Stopping the transfusion prevents further allergen exposure, making this a secondary action.

Choice B reason: Stopping the transfusion is the first action, as itching and hives indicate an allergic reaction. Halting the infusion prevents worsening symptoms, like anaphylaxis, making this the priority intervention.

Choice C reason: Notifying the provider is necessary but follows stopping the transfusion. Ceasing the infusion immediately mitigates the reaction, ensuring patient safety, making notification a subsequent step.

Choice D reason: Obtaining vital signs provides data but delays addressing the reaction. Stopping the transfusion halts allergen administration, taking precedence over assessment, making this a secondary action.

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In which patient will the nurse expect to see a positive Chvostek sign?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an intramuscular injection to a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving a blood transfusion. The client reports itching and hives. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is assessing a client who has a new diagnosis of heart failure. Which of the following findings should the nurse expect?

A nurse is removing staples from a client’s surgical incision. Which of the following will ensure safe removal? (Select all that apply)

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