Which of the following best describes Chvostek's sign assessment?
Assessing a client's blood pressure using a sphygmomanometer.
Assessing a client's muscle contractions by tapping on the facial nerve.
Assessing a client's heart rate using a stethoscope.
Assessing a client's respiratory rate using a pulse oximeter.
The Correct Answer is B
A. Assessing blood pressure with a sphygmomanometer is unrelated to Chvostek's sign, which specifically evaluates neuromuscular excitability.
B. Chvostek's sign is assessed by tapping the facial nerve near the cheekbone. A positive response, such as twitching of the facial muscles, indicates hypocalcemia or neuromuscular irritability.
C. Assessing heart rate with a stethoscope does not involve evaluating neuromuscular function or calcium levels.
D. Monitoring respiratory rate with a pulse oximeter is unrelated to Chvostek's sign and does not assess neuromuscular excitability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Advising the client to add citrus juices and bananas is inappropriate because these are high in potassium and would further increase the already elevated potassium level, potentially worsening hyperkalemia.
B. Obtaining a 12-lead ECG is the correct action. A potassium level of 6.8 mEq/L is critically high and can cause life-threatening cardiac arrhythmias. An ECG can help identify hyperkalemia-related changes, such as peaked T waves, widened QRS complexes, or arrhythmias.
C. While obtaining a serum sodium level might provide additional information, it does not address the immediate risk posed by the elevated potassium level. The priority is assessing the cardiac effects of hyperkalemia.
D. Suggesting that the client use a salt substitute is incorrect, as many salt substitutes contain potassium chloride, which could worsen hyperkalemia.
Correct Answer is B
Explanation
A. Removing and applying the fixator for showers is not appropriate. The external fixator should not be removed by the nurse without proper medical guidance. Showers should be managed in a way that prevents the fixator from becoming wet or contaminated.
B. Documenting pin site assessment and care is essential for clients with external fixation. The nurse should regularly assess pin sites for signs of infection (e.g., redness, swelling, drainage) and ensure proper care is provided to prevent complications.
C. Encouraging the patient to lie prone several times per day may not be necessary or appropriate unless specifically ordered by the provider. The patient’s positioning should be based on comfort and the provider’s instructions to avoid strain on the injured limb.
D. Turning the patient every 3 hours is a general nursing practice for preventing pressure ulcers, but it is not specific to the care of a client with external fixation. The focus should be on protecting the fixator and ensuring the limb is properly supported.
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