Regulating Body Fluids
Regulating Body Fluids ( 5 Questions)
A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect?
A positive Chvostek's sign is a facial twitch that occurs when the facial nerve is tapped. This is a sign of hypocalcemia, which causes increased neuromuscular excitability. According to index 2, a nurse can assess for Chvostek's sign by tapping the cheek just below the temple. If the facial muscles contract, the sign is positive.
Decreased deep tendon reflexes are not a sign of hypocalcemia, but rather of hypercalcemia, which causes decreased neuromuscular excitability. According to index 5, symptoms of hypercalcemia include muscle weakness, fatigue, constipation, nausea, vomiting, and confusion.
Muscle weakness is also not a sign of hypocalcemia, but rather of hyperkalemia, which causes impaired muscle contraction. According to index 1, a nurse can assess for muscle weakness by testing the client's grip strength and ability to lift the legs against resistance. If the client has difficulty performing these tasks, they may have hyperkalemia.
Hypoactive bowel sounds are not a sign of hypocalcemia, but rather of ileus, which is a paralysis of the intestinal muscles that causes obstruction. Ileus can be caused by various factors, such as surgery, infection, medication, or electrolyte imbalance. According to index 6, symptoms of ileus include abdominal pain, distension, nausea, vomiting, and constipation.
Choice A reason:
A positive Chvostek's sign is a facial twitch that occurs when the facial nerve is tapped. This is a sign of hypocalcemia, which causes increased neuromuscular excitability. According to index 2, a nurse can assess for Chvostek's sign by tapping the cheek just below the temple. If the facial muscles contract, the sign is positive.
Choice B reason:
Decreased deep tendon reflexes are not a sign of hypocalcemia, but rather of hypercalcemia, which causes decreased neuromuscular excitability. According to index 5, symptoms of hypercalcemia include muscle weakness, fatigue, constipation, nausea, vomiting, and confusion.
Choice C reason:
Muscle weakness is also not a sign of hypocalcemia, but rather of hyperkalemia, which causes impaired muscle contraction. According to index 1, a nurse can assess for muscle weakness by testing the client's grip strength and ability to lift the legs against resistance. If the client has difficulty performing these tasks, they may have hyperkalemia.
Choice D reason:
Hypoactive bowel sounds are not a sign of hypocalcemia, but rather of ileus, which is a paralysis of the intestinal muscles that causes obstruction. Ileus can be caused by various factors, such as surgery, infection, medication, or electrolyte imbalance. According to index 6, symptoms of ileus include abdominal pain, distension, nausea, vomiting, and constipation.