The nurse notices an abnormal movement in the client's hand and wrist while taking their blood pressure. What action should the nurse take?

Request a neurological consult

Have another nurse take their blood pressure

Review the client's lab values.

call the healthcare provider for orders.

Answer and Explanation

The Correct Answer is C

A. Request a neurological consult: This is likely a metabolic issue (hypocalcemia), not a neurological disorder.

B. Have another nurse take their blood pressure: Rechecking BP does not address the underlying cause of the abnormal movement.

C. Review the client's lab values: Carpopedal spasm (Trousseau's sign) during BP measurement suggests hypocalcemia. The nurse should check serum calcium levels to confirm.

D. Call the healthcare provider for orders: The nurse should first review lab results to provide accurate data when notifying the provider.

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Correct Answer is A

Explanation

A. Cardiac arrest: Cardiac arrest is a complication of severe hypothermia, not a risk factor.

B. Falling through the ice: Major risk factor for accidental hypothermia due to immersion in cold water.

C. Head trauma: Impaired thermoregulation in the brainstem can cause hypothermia.

D. Drug use: Certain drugs (e.g., alcohol, sedatives) impair the body’s ability to regulate temperature, increasing hypothermia risk.

A. Respiratory Alkalosis B. Metabolic Acidosis C. Metabolic Alkalosis D. Respiratory Acidosis

Correct Answer is D

Explanation

A. Respiratory Alkalosis: Alkalosis results from hyperventilation, which is not expected with thoracic trauma.

B. Metabolic Acidosis: Metabolic acidosis occurs due to renal failure, lactic acidosis, or diarrhea, not thoracic trauma.

C. Metabolic Alkalosis: Alkalosis can result from vomiting or excessive bicarbonate intake, not respiratory failure.

D. Respiratory Acidosis: Severe thoracic trauma can impair lung expansion, leading to hypoventilation and CO₂ retention, causing respiratory acidosis.

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The nurse notices an abnormal movement in the client's hand and wrist while taking their blood pressure. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is not a risk factor for accidental hypothermia?

Correct Answer is A

Explanation

A client is in a motor vehicle accident with severe thoracic trauma. Which acid-base imbalance is most likely to develop?

Correct Answer is D

Explanation

The nurse is reviewing the client's following arterial blood gases: pH 7.33, PaCo2 47, HCO3 24. Which manifestation would the nurse expect the client to be experiencing with this imbalance?

Which of the following manifestations are commonly seen in an end stage renal disease patient with fluid overload?

The nurse is providing education to the client with a new arteriovenous fistula and the client asks "when I touch my fistula feel it vibrate, what does that mean? What statement by the nurse is the correct way to answer the client's question?

A nurse is caring for a client who has hyperkalemia and is to receive intravenous insulin. Which of the following should the nurse recognize as an adverse outcome?

What are the warning signs of hypovolemia?

The nurse is caring for a client who has chronic renal disease and is receiving therapy with erythropoietin (epoetin alpha). Which of the following laboratory results should the nurse review as an indication of a therapeutic effect of this medication?

A nurse is reviewing the BUN and creatinine levels of an older adult client who has chronic kidney disease. The nurse should expect which of the following findings?

A nurse is caring for a client who has metabolic alkalosis. Which of the following actions should the nurse take?