Question

A client is suspected to have severe hypocalcemia secondary to chronic alcoholism. While waiting for the lab result, the nurse is completing a physical assessment. Which finding would the nurse anticipate during assessment?

Answer 1

Correct Answers:

Positive Trousseau's sign

Rationale :

❣️ Hypocalcemia increases neuromuscular excitability, which can produce characteristic signs of tetany such as Trousseau's and Chvostek's signs.

❣️ A positive Trousseau's sign occurs when inflation of a blood pressure cuff causes carpal spasm, including flexion of the wrist and metacarpophalangeal joints.

❣️ Chronic alcoholism can contribute to hypocalcemia through poor nutritional intake, vitamin D deficiency, hypomagnesemia, and impaired calcium metabolism.

❣️ Severe hypocalcemia can also cause muscle cramps, paresthesias, seizures, laryngospasm, and prolonged QT intervals, making prompt recognition important.

❣️ The presence of Trousseau's sign therefore strongly supports significant calcium deficiency and increased neuromuscular irritability.

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Answer 2

Correct Answers:

Change the semipermeable dressing every 7 days.
Use a back-and-forth motion when cleansing the access site.
Clean the access port on the CVAD line with chlorhexidine prior to use.

Rationale :

Change the semipermeable dressing every 7 days.

✳️ A transparent semipermeable dressing over a central venous catheter is generally changed at established intervals, commonly every 7 days, unless it becomes damp, loose, visibly soiled, or contaminated sooner.

✳️ Maintaining an intact dressing helps protect the insertion site from microbial contamination and moisture.

✳️ Dressing changes should be performed using aseptic technique to minimize introduction of microorganisms.

✳️ The insertion site should also be assessed for redness, drainage, tenderness, swelling, or other signs of infection whenever the dressing is changed.

✳️ Following scheduled dressing changes is therefore an important component of preventing CLABSI.

Use a back-and-forth motion when cleansing the access site.

✳️ Chlorhexidine skin preparation is commonly applied using friction with a back-and-forth motion over the catheter insertion site.

✳️ Friction helps mechanically reduce microorganisms present on the skin and improves the effectiveness of the antiseptic.

✳️ The antiseptic should be allowed to air-dry completely before applying a new dressing because drying contributes to antimicrobial activity.

✳️ The nurse should avoid touching the cleansed site afterward because this can reintroduce contamination.

✳️ Proper site antisepsis is one of the strongest measures for reducing catheter-related bloodstream infection.

Clean the access port on the CVAD line with chlorhexidine prior to use.

✳️ The access port or needleless connector should be vigorously disinfected before every access to reduce transmission of microorganisms into the bloodstream.

✳️ Appropriate antiseptic agents include chlorhexidine or another facility-approved disinfectant used according to policy.

✳️ The connector should be scrubbed for the recommended amount of time and allowed to dry before connection.

✳️ Failure to disinfect the hub can allow microorganisms to enter the catheter lumen and cause a central line-associated bloodstream infection.

✳️ Consistent hub disinfection is therefore essential whenever medications, fluids, or flushes are administered through the CVAD.

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Answer 3

Correct Answers:

Headache, mental confusion, and twitching

Rationale :

🧿 Dialysis disequilibrium syndrome occurs when solutes such as urea are removed from the blood too rapidly during hemodialysis, producing osmotic shifts into brain cells.

🧿 The resulting cerebral edema can cause neurologic manifestations such as headache, confusion, restlessness, nausea, muscle twitching, and seizures.

🧿 Symptoms often occur during or shortly after the first few dialysis treatments or when dialysis is especially aggressive.

🧿 Severe cases can progress to seizures, coma, increased intracranial pressure, and death, requiring rapid recognition and intervention.

🧿 Headache, mental confusion, and twitching are therefore classic findings indicating possible dialysis disequilibrium syndrome.

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Answer 4

Correct Answers:

Grilled shrimp, sliced cucumber, and fresh blueberries

Rationale :

♦️ This meal contains foods that are relatively lower in potassium compared with the other choices.

♦️ Cucumbers and blueberries are commonly included in renal diets because they provide nutrients without contributing excessive potassium.

♦️ Shrimp can provide protein while avoiding the particularly high potassium load found in foods such as potatoes, tomatoes, avocados, raisins, and many nuts.

♦️ Clients with stage 4 chronic kidney disease may have difficulty excreting potassium, placing them at risk for hyperkalemia and life-threatening cardiac dysrhythmias.

♦️ Selecting lower-potassium foods therefore helps reduce the risk for dangerous potassium accumulation as renal function declines.

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Answer 5

Correct Answers:

Use of sequential compression devices (SCDs)

Rationale :

🖍️ Total hip arthroplasty places the client at high risk for venous thromboembolism because surgery and reduced mobility promote venous stasis.

🖍️ Sequential compression devices intermittently compress the lower extremities and improve venous return to the heart.

🖍️ Improved blood flow decreases venous pooling and helps prevent formation of deep vein thromboses.

🖍️ SCDs are commonly combined with early ambulation and pharmacologic prophylaxis when prescribed to further reduce postoperative thromboembolic risk.

🖍️ Their use therefore directly addresses the major mechanism of postoperative DVT formation: venous stasis.

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Answer 6

Correct Answers:

A 69-year-old female client with a history of diabetes mellitus type 2

Rationale :

♠️ Advanced age and diabetes mellitus are both major risk factors for peripheral vascular disease, particularly peripheral arterial disease.

♠️ Chronic hyperglycemia damages vascular endothelium and accelerates atherosclerosis, narrowing arteries supplying the lower extremities.

♠️ Diabetes also contributes to inflammation, lipid abnormalities, and impaired circulation, which further increase vascular complications.

♠️ Older adults have accumulated vascular risk over time, making the combination of age 69 and diabetes more significant than the isolated risk factors in the other clients.

♠️ This client therefore has the greatest likelihood of developing manifestations such as intermittent claudication, diminished pulses, cool extremities, and poor wound healing.

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Answer 7

Correct Answers:

"I take my diuretic as needed, especially if I have plans to leave the house."

Rationale :

🧡 Diuretics prescribed for heart failure should generally be taken exactly as prescribed, not only when the client feels they are needed.

🧡 Skipping or delaying diuretic therapy can cause sodium and fluid retention, leading to edema, pulmonary congestion, weight gain, and worsening heart failure.

🧡 Clients may plan medication timing around daily activities when permitted, but they should not independently omit doses to avoid urinary frequency while outside the home.

🧡 The nurse should reinforce the importance of adherence and teach the client to monitor daily weight, edema, breathing difficulty, and other signs of fluid overload.

🧡 This statement therefore indicates a misunderstanding of medication management and requires additional teaching.

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Answer 8

Correct Answers:

Crackles during inspiration
Hacking cough
Frothy pink sputum

Rationale :

Crackles during inspiration

✍️ Left-sided heart failure causes blood to back up into the pulmonary circulation, increasing hydrostatic pressure in the lungs.

✍️ Fluid then moves into the pulmonary interstitial and alveolar spaces, producing pulmonary congestion.

✍️ Crackles are heard when air moves through fluid-filled or partially collapsed alveoli during inspiration.

✍️ Increasing crackles can indicate worsening pulmonary edema and impaired gas exchange.

✍️ Inspiratory crackles are therefore a classic respiratory manifestation of left ventricular failure.

Hacking cough

✍️ Pulmonary vascular congestion irritates the airways and can produce a persistent dry or hacking cough.

✍️ The cough may worsen when the client lies flat because venous return increases and pulmonary congestion becomes more pronounced.

✍️ Clients may also report orthopnea, paroxysmal nocturnal dyspnea, and activity intolerance.

✍️ A cough in the setting of left-sided failure should be evaluated alongside breath sounds and oxygenation.

✍️ The finding reflects the accumulation of fluid and pressure within the pulmonary circulation.

Frothy pink sputum

✍️ Pink, frothy sputum is a classic sign of pulmonary edema associated with severe left-sided heart failure.

✍️ Fluid leaking into the alveoli mixes with air and small amounts of blood, producing the characteristic frothy appearance.

✍️ This finding indicates significant pulmonary congestion and can be associated with severe respiratory distress.

✍️ The nurse should treat this as an urgent finding and assess oxygenation, respiratory effort, and other signs of decompensation.

✍️ Frothy pink sputum therefore strongly reflects acute left-sided cardiac failure with pulmonary edema.

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Answer 9

Correct Answers:

"The client should be reminded to use scanning technique when eating."

Rationale :

🔆 Homonymous hemianopsia causes loss of the same half of the visual field in both eyes, making it difficult for the client to see objects on the affected side.

🔆 Teaching a scanning technique encourages the client to consciously turn the head and eyes toward the impaired visual field.

🔆 During meals, scanning helps the client locate food, utensils, and beverages that might otherwise be missed.

🔆 Repeated practice improves safety and compensates for the visual-field deficit during activities of daily living.

🔆 Scanning is therefore a key rehabilitation strategy for improving independence in clients with post-stroke visual-field loss.

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Answer 10

Correct Answers:

" We will conduct active range of motion exercises on the unaffected arm and leg."

Rationale :

❣️ Clients with unilateral neglect require interventions that increase awareness and use of the affected side, rather than focusing primarily on the unaffected extremities.

❣️ Range-of-motion exercises should include the affected extremities, using active-assisted or passive exercises when the client cannot move them independently.

❣️ Ignoring the affected arm and leg can contribute to contractures, stiffness, impaired circulation, weakness, and further loss of function.

❣️ Rehabilitation should encourage the client to look toward, touch, move, and incorporate the neglected side into activities whenever safely possible.

❣️ Limiting active exercise to the unaffected extremities therefore demonstrates incomplete understanding and requires additional teaching.

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QLexNursing

1 :
A client is suspected to have severe hypocalcemia secondary to chronic alcoholism. While waiting for the lab result, the nurse is completing a physical assessment. Which finding would the nurse anticipate during assessment?

2 :
The nurse is assisting with catheter care for a client with a central venous access device (CVAD) to prevent a central line-associated bloodstream infection (CLABSI). Which action would the nurse take? Select all that apply.

3 :
The nurse is monitoring a client with chronic renal failure who has returned to the unit following hemodialysis. The nurse will monitor for disequilibrium syndrome in the client's plan of care. Which symptoms observed in the client would be indicative of disequilibrium syndrome?

4 :
The nurse is preparing discharge teaching for a client with stage 4 chronic kidney disease. Which meal selection would let the nurse know the client understands how to select potassium-restricted foods?

5 :
The nurse is planning care for a client admitted to the post-surgical unit following a total hip arthroplasty. Which order would the nurse anticipate implementing to prevent deep vein thrombosis (DVT)?

6 :
A nurse is assisting with community health screening. Which client is at greatest risk of developing peripheral vascular disease (PVD)?

7 :
The nurse is reinforcing teaching of disease management with a client who has congestive heart failure. Which statement made by the client indicates a need for further teaching?

8 :
A nurse is preparing to assess a client diagnosed with left sided heart failure. Which finding would the nurse expect while performing the client's assessment? Select 3 correct responses.

9 :
The nurse educator is teaching a group of new nurses about stroke care. Which statement indicates an understanding of care for a client experiencing homonymous hemianopsia?

10 :
A nurse is teaching a client and their caregivers about self care following a stroke with unilateral neglect. Which statement about client self care made by the caregiver indicates a need for further teaching?

QLexNursing

1 : A client is suspected to have severe hypocalcemia secondary to chronic alcoholism. While waiting for the lab result, the nurse is completing a physical assessment. Which finding would the nurse anticipate during assessment?

2 : The nurse is assisting with catheter care for a client with a central venous access device (CVAD) to prevent a central line-associated bloodstream infection (CLABSI). Which action would the nurse take? Select all that apply.

3 : The nurse is monitoring a client with chronic renal failure who has returned to the unit following hemodialysis. The nurse will monitor for disequilibrium syndrome in the client's plan of care. Which symptoms observed in the client would be indicative of disequilibrium syndrome?

4 : The nurse is preparing discharge teaching for a client with stage 4 chronic kidney disease. Which meal selection would let the nurse know the client understands how to select potassium-restricted foods?

5 : The nurse is planning care for a client admitted to the post-surgical unit following a total hip arthroplasty. Which order would the nurse anticipate implementing to prevent deep vein thrombosis (DVT)?

6 : A nurse is assisting with community health screening. Which client is at greatest risk of developing peripheral vascular disease (PVD)?

7 : The nurse is reinforcing teaching of disease management with a client who has congestive heart failure. Which statement made by the client indicates a need for further teaching?

8 : A nurse is preparing to assess a client diagnosed with left sided heart failure. Which finding would the nurse expect while performing the client's assessment? Select 3 correct responses.

9 : The nurse educator is teaching a group of new nurses about stroke care. Which statement indicates an understanding of care for a client experiencing homonymous hemianopsia?

10 : A nurse is teaching a client and their caregivers about self care following a stroke with unilateral neglect. Which statement about client self care made by the caregiver indicates a need for further teaching?

1 :
A client is suspected to have severe hypocalcemia secondary to chronic alcoholism. While waiting for the lab result, the nurse is completing a physical assessment. Which finding would the nurse anticipate during assessment?

2 :
The nurse is assisting with catheter care for a client with a central venous access device (CVAD) to prevent a central line-associated bloodstream infection (CLABSI). Which action would the nurse take? Select all that apply.

3 :
The nurse is monitoring a client with chronic renal failure who has returned to the unit following hemodialysis. The nurse will monitor for disequilibrium syndrome in the client's plan of care. Which symptoms observed in the client would be indicative of disequilibrium syndrome?

4 :
The nurse is preparing discharge teaching for a client with stage 4 chronic kidney disease. Which meal selection would let the nurse know the client understands how to select potassium-restricted foods?

5 :
The nurse is planning care for a client admitted to the post-surgical unit following a total hip arthroplasty. Which order would the nurse anticipate implementing to prevent deep vein thrombosis (DVT)?

6 :
A nurse is assisting with community health screening. Which client is at greatest risk of developing peripheral vascular disease (PVD)?

7 :
The nurse is reinforcing teaching of disease management with a client who has congestive heart failure. Which statement made by the client indicates a need for further teaching?

8 :
A nurse is preparing to assess a client diagnosed with left sided heart failure. Which finding would the nurse expect while performing the client's assessment? Select 3 correct responses.

9 :
The nurse educator is teaching a group of new nurses about stroke care. Which statement indicates an understanding of care for a client experiencing homonymous hemianopsia?

10 :
A nurse is teaching a client and their caregivers about self care following a stroke with unilateral neglect. Which statement about client self care made by the caregiver indicates a need for further teaching?