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 ["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.
Correct Answer is A
Explanation
Rationale:
A. Injecting insulin into the abdominal area is appropriate as it is one of the preferred sites for insulin administration due to its consistent absorption.
B. Blood sugar readings should be taken before meals, not after, to determine the need for insulin and to manage blood glucose levels effectively.
C. Insulin does not allow for unrestricted consumption of high-sugar foods like ice cream; instead, a balanced diet is important to maintain stable blood glucose levels.
D. While weight reduction can help manage diabetes, it does not inherently cause hypoglycemia unless the client is taking insulin or other medications that lower blood glucose.