Practice question F&E

Which nerve is implicated in the Chvostek's sign? -Facial -Hypoglossal -Optic -Spinal accessory

-Facial Chvostek's sign consists of twitching of muscles supplied by the facial nerve when the nerve is tapped about 2 cm anterior to the earlobe, just below the zygomatic arch.

Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate? -Give medications that promote fluid retention. -Limit sodium and water intake. -Assess for dehydration. -Teach client behaviors that decrease urination.

-Limit sodium and water intake. Implement prescribed interventions such as limiting sodium and water intake and administering ordered medications that promote fluid elimination.

The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system assessment would the nurse ask detailed questions? -Endocrine system -Gastrointestinal system -Neurological system -Musculoskeletal system

-Neurological system The nurse closely monitors the client with hypocalcemia for neurological manifestations such as tetany, seizures, and spasms. If the calcium level continues to decrease, seizure precautions are necessary. Cardiac dysrhythmias and airway obstruction may also occur.

A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. -sodium 137 mEq/L -potassium 4.6 mEq/L -chloride 94 mEq/L -calcium 12.9 mg/dL What laboratory value is of highest concern to the nurse?

-calcium 12.9 mg/dL Hypercalcemia, or calcium levels exceeding 10.2 mg/dL (2.5 mmol/L), can be a dangerous imbalance.

A client is diagnosed with hypocalcemia and the nurse is teaching the client about symptoms. What symptom would the nurse include in the teaching? -tingling sensation in the fingers -polyuria -flank pain -hypertension

-tingling sensation in the fingers

A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance? -Hyperkalemia -Hypocalcemia -Hypokalemia -Hypercalcemia

The normal reference range for serum calcium is 8.6 to 10.2 mg/dl. A serum calcium level of 12 mg/dl clearly indicates hypercalcemia.

Early signs of hypervolemia include: -a decrease in blood pressure. -thirst. -moist breath sounds. -increased breathing effort and weight gain.

-increased breathing effort and weight gain. Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort. Eventually, fluid congestion in the lungs leads to moist breath sounds.

A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition? -dehydration -hypervolemia -hypercalcemia -hyperkalemia

-dehydration Dehydration results when the volume of body fluid is significantly reduced in both extracellular and intracellular compartments. In dehydration, all fluid compartments have decreased volumes; in hypovolemia, only blood volume is low. The most common fluid imbalance in older adults is dehydration.

The nurse is caring for a 72-year-old client who has been admitted to the unit for a fluid volume imbalance. The nurse knows which of the following is the most common fluid imbalance in older adults? -Hypovolemia -Dehydration -Hypervolemia -Fluid volume excess

-Dehydration The most common fluid imbalance in older adults is dehydration. Because of reduced thirst sensation that often accompanies aging, older adults tend to drink less water. Use of diuretic medications, laxatives, or enemas may also deplete fluid volume in older adults.

The nurse is caring for a client in the intensive care unit (ICU) following a near-drowning event in saltwater. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen and dry tongue, flushed skin, and peripheral edema. The nurse anticipates that the client's serum sodium value would be: -155 mEq/L -145 mEq/L -135 mEq/L -125 mEq/L

-155 mEq/L The client is experiencing signs and symptoms (S/S) of hypernatremia. Hypernatremia is a serum sodium concentration >145 mEq/L (>145 mmol/L).

The nurse is caring for a client with a serum sodium concentration of 113 mEq/L. The nurse should monitor the client for the development of which condition? -Confusion -Headache -Nausea -Hallucinations

-Confusion

A client is taking spironolactone to control hypertension. The client's serum potassium level is 6 mEq/L. What is the nurse's priority during assessment? -neuromuscular function -bowel sounds -respiratory rate -electrocardiogram (ECG) results

-electrocardiogram (ECG) results Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can indicate potentially lethal arrhythmias such as ventricular fibrillation.

An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use? -Hyperkalemia -Hypokalemia -Hypernatremia -Hypophosphatemia

Hypokalemia (potassium level below 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium-losing diuretics, such as furosemide, can induce hypokalemia.