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The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a
positive Chvosteks sign indicate?
- A. Hypermagnesemia
- B. Hyponatremia
- C. Hypocalcemia
- D. Hyperkalemia
Correct Answer: C
Rationale: Step 1: Chvostek's sign is a facial muscle spasm induced by tapping the facial nerve in hypocalcemia.
Step 2: Hypocalcemia causes increased neuromuscular excitability, leading to Chvostek's sign.
Step 3: Hyperkalemia (choice D) causes muscle weakness, not muscle spasm.
Step 4: Hyponatremia (choice B) affects osmolarity, not neuromuscular excitability.
Step 5: Hypermagnesemia (choice A) causes muscle weakness, not muscle spasm.
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A patient's most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the patient's dietary intake of potassium. Which of the following would be a good source of potassium?
- A. Apples
- B. Asparagus
- C. Carrots
- D. Bananas
Correct Answer: D
Rationale: The correct answer is D: Bananas. Bananas are a good source of potassium, with around 400-500 mg per banana. Potassium is essential for maintaining proper muscle function, nerve signaling, and fluid balance in the body. Increasing dietary intake of potassium can help address a slight decrease in potassium levels without the need for drug therapy. Apples, asparagus, and carrots are not as high in potassium as bananas, making them less effective choices for addressing a potassium deficiency.
. A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?
- A. The catheter has been in place for 20 hours.
- B. . The client has poor vascular access in the upper extremities.
- C. The catheter is placed in the proximal tibia.
- D. The clients left lower extremity is cool to the touch.
Correct Answer: D
Rationale: The correct answer is D. A cool lower extremity can indicate impaired circulation due to the intraosseous catheter placement, leading to compartment syndrome or tissue necrosis. This finding requires immediate intervention to prevent serious complications. Choices A, B, and C are incorrect because the duration of catheter placement, poor vascular access, and the specific location of the catheter do not directly impact circulation and tissue perfusion as significantly as a cool lower extremity.
After teaching a client who was malnourished and is being discharged, a nurse assesses the clients understanding. Which statement indicates the client correctly understood teaching to decrease risk for the development of metabolic acidosis?
- A. I will drink at least three glasses of milk each day.
- B. . I will eat three well-balanced meals and a snack daily.
- C. . I will not take pain medication and antihistamines together.
- D. I will avoid salting my food when cooking or during meals.
Correct Answer: A
Rationale: The correct answer is A: "I will drink at least three glasses of milk each day." Milk is a good source of calcium and bicarbonate, which can help buffer excess acids in the body and prevent metabolic acidosis. Calcium also plays a role in maintaining the acid-base balance.
Option B is incorrect because while eating well-balanced meals is important for overall health, it does not specifically address the prevention of metabolic acidosis. Option C is irrelevant to the prevention of metabolic acidosis. Option D is incorrect because avoiding salting food does not directly address the underlying issue of metabolic acidosis related to malnutrition.
A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?
- A. Ask family members to speak quietly to keep the client calm.
- B. Assess urine color, amount, and specific gravity each day.
- C. Encourage the client to drink at least 1 liter of fluids each shift.
- D. Dangle the client on the bedside before ambulating.
Correct Answer: D
Rationale: The correct answer is D because dangling the client on the bedside before ambulating helps prevent orthostatic hypotension and potential falls. This step allows the nurse to assess the client's tolerance to changes in position and reduces the risk of injury.
A: Asking family members to speak quietly does not directly address the prevention of injury related to dehydration.
B: Assessing urine parameters is important for monitoring hydration status but does not directly prevent injury.
C: Encouraging fluid intake is important for rehydration but does not directly address the risk of injury during ambulation.
You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone
metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain.
Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient
may be experiencing what electrolyte imbalance?
- A. Hypernatremia
- B. Hypomagnesemia
- C. Hypophosphatemia
- D. Hypercalcemia
Correct Answer: D
Rationale: The correct answer is D: Hypercalcemia. Bone metastases in lung cancer can lead to increased release of calcium into the blood, causing hypercalcemia. The patient's symptoms of weakness and abdominal pain are consistent with hypercalcemia. Hypernatremia (choice A) is unlikely as the symptoms do not align with high sodium levels. Hypomagnesemia (choice B) and hypophosphatemia (choice C) are less likely as they are not typically associated with bone metastases in lung cancer. In summary, the patient's presentation of weakness and abdominal pain in the setting of lung cancer with bone metastases points to hypercalcemia as the most likely electrolyte imbalance.