The nurse assessing a client hospitalized with a diagnosis of hypoparathyroidism notes positive Trousseau's and Chvostek's signs. The nurse determines that these findings most indicate which electrolyte imbalance?
Hypernatremia
Hypermagnesemia
Hypocalcemia
Hypokalemia
The Correct Answer is C
Rationale:
A. Hypernatremia, an elevated sodium level, does not cause Trousseau's or Chvostek's signs.
B. Hypermagnesemia, an elevated magnesium level, is not associated with positive Trousseau's and Chvostek's signs.
C. Hypocalcemia, a low calcium level, is commonly associated with positive Trousseau's and Chvostek's signs. Trousseau's sign is a carpopedal spasm induced by inflating a blood pressure cuff, while Chvostek's sign is facial twitching in response to tapping over the facial nerve. Both are indicative of neuromuscular irritability due to low calcium levels.
D. Hypokalemia, a low potassium level, does not cause these specific signs and is associated with different clinical manifestations.
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Correct Answer is C
Explanation
Rationale:
A. Examining feet daily is important for preventing foot complications, such as ulcers, in diabetics but is not directly related to preventing retinopathy and nephropathy.
B. Wearing compression stockings is not specifically recommended for preventing retinopathy or nephropathy in diabetes.
C. Maintaining stable blood glucose levels is crucial for preventing or slowing the progression of diabetic complications such as retinopathy and nephropathy. Good glycemic control minimizes the damage to blood vessels in the eyes and kidneys.
D. While regular eye exams are important for detecting retinopathy early, maintaining stable blood glucose levels is key to preventing the development of complications in the first place.
Correct Answer is ["B","E","F"]
Explanation
Rationale:
A. The vital signs are stable and within normal limits. The slight drop in blood pressure post-dialysis is expected and not immediately concerning.
B. The client's weight decreased from 90 kg (198 lb) to 86.4 kg (190 lb) after dialysis. While weight loss is expected due to fluid removal during dialysis, this significant decrease (3.6 kg or approximately 8 lb) may need closer monitoring to ensure the client is not becoming dehydrated or losing more fluid than is safe.
C. The blood glucose levels are within an acceptable range for a client with type 2 diabetes mellitus. The slight decrease from 134 mg/dL to 75 mg/dL is not unusual given the time between measurements and the client's food intake.
D. The presence of a bruit and thrill at the AV fistula site indicates that it is functioning correctly, which is an expected finding.
E. The presence of crackles in the left lower lobe and an unproductive cough on the morning of Day 2 is concerning. These symptoms could indicate fluid overload or early signs of pulmonary edema, which require further evaluation and possible intervention.
F. The AV fistula site is noted to be ecchymotic and warm, with a bruit and thrill still present. While a bruit and thrill are expected findings, the ecchymosis and warmth could indicate a developing infection or trauma at the site, which necessitates further follow-up to prevent complications.