As the nurse is shaving a patient who is 2 days postoperative from a thyroidectomy, the patient has a spasm of the facial muscles. What should the nurse recognize this as?
a. Chvostek sign
b. Montgomery sign
c. Trousseau sign
d. Homans sign
ANS: A
The spasm of facial muscles when stimulated is the Chvostek sign, an indication of hypocalcemic tetany.
You might also like to view...
A nurse reviews these laboratory values of a client who returned from kidney transplantation 12 hours ago:
Sodium 136 mEq/L Potassium 5 mEq/L Blood urea nitrogen (BUN) 44 mg/dL Serum creatinine 2.5 mg/dL What initial intervention would the nurse anticipate? a. Start hemodialysis immediately. b. Discuss the need for peritoneal dialysis. c. Increase the dose of immunosuppression. d. Return the client to surgery for exploration.
The patient has a platelet count of 9,000/microliter. The nurse realizes that:
a. this is a normal platelet level. b. spontaneous bleeding may occur. c. the patient is at great risk for fatal hemorrhage. d. this level is considered slightly low.
A patient is diagnosed with bilateral osteoarthritis of the knees. To best address the long-term risk for falls, the nurse encourages the patient to
a. use assistive mobility devises when ne-cessary. b. report exacerbation of symptoms promptly. c. add a daily walk to exercise the knees ap-propriately. d. take analgesic medication as prescribed to manage joint pain.
A psychiatric nurse is developing care plans for multiple inpatient clients. The nurse understands that nursing diagnoses and associated interventions should be prioritized. Nursing diagnoses are prioritized according to:
A) The established goal of care. B) The life-threatening potential. C) The nurse's priority of care. D) The client's preference.