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During an assessment, the nurse decides to assess a patient’s calcium level. Which action will the nurse take to identify a low calcium level?
- A. Palpate turgor of skin
- B. Observe the color of the skin
- C. Conduct a Trousseau’s sign test
- D. Save urine to measure 17-ketosteroids
Correct Answer: C
Rationale: The Trousseau’s sign test is used to identify low calcium levels in a patient. This test involves inflating a blood pressure cuff on the patient's arm above systolic pressure for a few minutes, which can trigger a carpal spasm (wrist and hand flexion) in patients with low calcium levels (hypocalcemia). This is due to increased neuromuscular irritability caused by low calcium levels. Therefore, conducting a Trousseau’s sign test is the appropriate action to identify a low calcium level in a patient. Palpating turgor of skin, observing the color of the skin, and saving urine to measure 17-ketosteroids are not relevant actions for assessing calcium levels.
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A client is prescribed enalapril (Vasotec) for treatment of heart failure. Which adverse effect should the nurse assess for following the initial administration of this drug?
- A. Jaundice
- B. Ototoxicity
- C. Low blood pressure
- D. Blurred vision
Correct Answer: C
Rationale: Enalapril is an angiotensin-converting enzyme (ACE) inhibitor commonly used in the treatment of heart failure. One of the potential adverse effects of ACE inhibitors, including enalapril, is hypotension or low blood pressure. This is especially a concern following the initial administration of the drug, as it can cause a significant drop in blood pressure. Nurses should assess the patient for signs and symptoms of hypotension, such as dizziness, light-headedness, weakness, or fainting, after starting enalapril therapy. Monitoring blood pressure regularly and educating the patient about the possibility of low blood pressure is important to ensure patient safety and optimal outcomes.
The nurse is providing care to a client who has experienced several episodes of angina. Which agent does the nurse anticipate being ordered to reduce the intensity and frequency of an angina episode?
- A. The client will experience relief of chest pain with therapeutic lifestyle changes.
- B. The client will experience relief of chest pain with statin therapy.
- C. The client will experience relief of chest pain with nitrate therapy.
- D. The client will experience relief of chest pain with anticoagulant therapy.
Correct Answer: C
Rationale: Nitrates are commonly prescribed for the management of angina. These agents work by dilating blood vessels, which leads to improved blood flow to the heart muscle and decreased workload on the heart. This results in reduced intensity and frequency of angina episodes by increasing oxygen supply to the heart and decreasing its demand. Nitrates can be administered sublingually, orally, or topically to provide prompt relief of chest pain during an angina episode. Thorough patient education should be provided regarding the proper use of nitrates and potential side effects.
The nurse is caring for a client admitted to the hospital with lower extremity edema and shortness of breath. Which electrocardiogram finding indicates the client is at risk for an alteration in perfusion?
- A. P wave smooth and round
- B. Absent U wave
- C. PR interval 0.30 seconds
- D. ST segment isoelectric
Correct Answer: D
Rationale: An isoelectric ST segment on an electrocardiogram can indicate myocardial ischemia or injury, which can lead to a decrease in perfusion to the heart muscle. This finding suggests an increased risk of inadequate blood flow to the heart, potentially resulting in further complications such as a myocardial infarction or altered perfusion to other organs. In a client with lower extremity edema and shortness of breath, identifying this ECG finding is crucial for early intervention and monitoring to prevent further deterioration in perfusion status.
The nurse is assessing a client who is in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse?
- A. Blood pressure of 142/92 mmHg
- B. Pulse of 92 beats per minute
- C. Respiratory rate of 24 per minute
- D. Weight gain of 16 oz per week
Correct Answer: A
Rationale: A blood pressure of 142/92 mmHg in a client in the third trimester of pregnancy is elevated and could indicate the development of preeclampsia, a serious hypertensive disorder that can have adverse effects on both the mother and the fetus. Preeclampsia is characterized by high blood pressure accompanied by signs of organ damage, such as proteinuria and changes in other laboratory values. Immediate intervention is required in this situation, as preeclampsia can lead to complications such as seizures (eclampsia), stroke, and placental abruption. It is essential for the nurse to further assess the client and notify the healthcare provider promptly for appropriate management.
After being diagnosed with polycystic kidney disease, an adult patient asks if current children are at risk for developing the disorder. How should the nurse respond?
- A. The adult form of this disorder is rare and should not affect grown children
- B. The children should undergo genetic testing and screening for evidence of the disease
- C. Because the condition was just diagnosed, there is no risk of passing the condition on to any children
- D. The children would have developed symptoms of the disorder in utero or shortly after birth if they had inherited the defective gene
Correct Answer: B
Rationale: Polycystic kidney disease (PKD) is a genetic disorder that can be inherited by children if one or both parents have the gene mutation responsible for the condition. In cases where a parent has been diagnosed with PKD, their children are at risk of inheriting the faulty gene. As such, it is recommended for the children to undergo genetic testing and screening to identify any evidence of the disease early on. By identifying the gene mutation in the children, appropriate monitoring and management can be initiated, potentially leading to better outcomes and quality of life for the affected individuals. Therefore, genetic testing and screening are crucial in cases where there is a known genetic component to a disorder like PKD.