A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect? (Select all that apply.)
Negative Chvostek’s sign
Positive Trousseau’s sign
Muscle cramps
Abdominal distention
Tingling sensation around the lips
Correct Answer : B,C,E
Choice A Reason:
A negative Chvostek’s sign is not expected in a client with hypocalcemia. The Chvostek’s sign is a clinical indicator of hypocalcemia, where tapping the facial nerve triggers facial muscle twitching. A positive Chvostek’s sign indicates neuromuscular irritability due to low calcium levels. Therefore, a negative Chvostek’s sign would not be consistent with hypocalcemia.
Choice B Reason:
A positive Trousseau’s sign is a classic indicator of hypocalcemia. This sign is elicited by inflating a blood pressure cuff on the upper arm to a level above the systolic pressure for several minutes. The resultant carpopedal spasm (involuntary contraction of the hand and wrist muscles) is a positive Trousseau’s sign, indicating neuromuscular irritability due to low calcium levels.
Choice C Reason:
Muscle cramps are a common symptom of hypocalcemia. Low calcium levels increase neuromuscular excitability, leading to involuntary muscle contractions and cramps. These cramps can occur in various muscle groups, often causing significant discomfort.
Choice D Reason:
Abdominal distention is not typically associated with hypocalcemia. While abdominal distention can result from various gastrointestinal issues, it is not a direct symptom of low calcium levels. Hypocalcemia primarily affects neuromuscular function rather than causing abdominal distention.
Choice E Reason:
Tingling sensation around the lips, also known as perioral tingling, is a common symptom of hypocalcemia. This occurs due to increased neuromuscular irritability caused by low calcium levels, leading to sensations of tingling or numbness around the mouth.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Instructing the client to take deep, rhythmic breaths can help in managing pain by promoting relaxation and reducing muscle tension. Deep breathing exercises are a common nonpharmacological intervention for pain relief. However, for localized back pain, this method might not be as effective as applying an ice pack directly to the affected area.
Choice B Reason:
Encouraging the client to apply a heating pad for 2 hours at a time can provide relief by increasing blood flow and relaxing muscles. However, prolonged use of heat can sometimes exacerbate inflammation, especially if the pain is due to an acute injury. Therefore, it is generally recommended to alternate between heat and cold therapy.
Choice C Reason:
Applying an ice pack to the client’s back for 1 hour is effective in reducing inflammation and numbing the pain. Cold therapy is particularly useful in the initial stages of pain management as it helps to constrict blood vessels, reducing swelling and providing immediate pain relief. This method is often recommended for acute pain and injuries.
Choice D Reason:
Removing distractions from the client’s room can create a more restful environment, which may help in overall pain management. However, this action alone is unlikely to provide significant relief for localized back pain. It is more of a supportive measure rather than a primary intervention for pain relief.
Correct Answer is A
Explanation
Choice A Reason:
Cranial nerve VII, also known as the facial nerve, is responsible for controlling the muscles of facial expression. When assessing this nerve, a nurse would expect to see symmetrical facial movements, such as a symmetrical smile. This indicates that the facial nerve is functioning properly on both sides of the face. Any asymmetry could suggest a problem with the facial nerve, such as Bell’s palsy or a stroke.
Choice B Reason:
The position of the tongue is controlled by cranial nerve XII, the hypoglossal nerve, not cranial nerve VII. The hypoglossal nerve is responsible for the movements of the tongue, and a midline position indicates normal function of this nerve. Therefore, this response is not relevant to the assessment of cranial nerve VII.
Choice C Reason:
Turning the head against resistance is a test for cranial nerve XI, the accessory nerve. This nerve controls the sternocleidomastoid and trapezius muscles, which are involved in head and shoulder movements. Assessing the ability to turn the head against resistance helps evaluate the function of the accessory nerve, not the facial nerve.
Choice D Reason:
Pupillary constriction in response to light is a function of cranial nerve III, the oculomotor nerve. This nerve controls the muscles that constrict the pupil in response to light, a reflex known as the pupillary light reflex. This response is not related to the function of cranial nerve VII.
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