The nurse is assessing a client with hypocalcemia.
What clinical manifestation would the nurse expect to note in this client?
Positive Trousseau's sign.
Hyperactive deep tendon reflexes.
Hyperactive bowel sounds.
Muscle twitching.
The Correct Answer is A
Trousseau’s sign is a test for hypocalcemia that involves inflating a blood pressure cuff on the arm and observing for carpal spasm. A positive sign indicates low calcium levels in the blood, which can cause neuromuscular irritability.
Choice B is wrong because hyperactive deep tendon reflexes are a sign of hypomagnesemia, which is a low level of magnesium in the blood.
Choice C is wrong because hyperactive bowel sounds are a sign of hyperkalemia, which is a high level of potassium in the blood.
Choice D is wrong because muscle twitching can be caused by many factors, such as anxiety, caffeine, or electrolyte imbalance, and is not specific to hypocalcemia.
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Correct Answer is C
Explanation
This is because acute renal failure is a condition where the kidneys lose their ability to filter waste and excess fluid from the blood. This can lead to fluid overload, electrolyte imbalances, and metabolic acidosis. Therefore, the nurse should monitor the patient’s urine output and fluid balance to assess the severity of the renal impairment and prevent complications.
Choice A is wrong because administering a potassium-sparing diuretic would worsen the patient’s hyperkalemia, which is a common complication of acute renal failure.
Choice B is wrong because encouraging the patient to consume a high-sodium diet would increase the patient’s fluid retention and blood pressure, which can further damage the kidneys.
Choice D is wrong because administering intravenous antibiotics is not a priority intervention for acute renal failure unless there is a specific indication of infection.
Correct Answer is B
Explanation
Hyponatremia is a condition where the serum sodium level is below 135 mEq/L, which can affect the normal functioning of cells, muscles, and organs.
Administering intravenous fluids with a high sodium content can help restore the sodium balance and prevent complications such as confusion, seizures, and coma.
Choice A is wrong because encouraging the patient to consume a low-sodium diet would worsen the hyponatremia and increase the risk of electrolyte imbalance.
Choice C is wrong because administering a diuretic medication to increase urine output would cause further fluid and sodium loss and exacerbate the hyponatremia.
Choice D is wrong because encouraging the patient to increase fluid intake would dilute the sodium concentration and lower the serum sodium level.
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