The nurse is performing an assessment on a client experiencing hypoparathyroidism. While taking a blood pressure on this client, the nurse notes spasms of the hands. The nurse should document this clinical manifestation as:
1. Chvostek's sign.
2. Trousseau's sign.
3. Turner's sign.
4. Cullen's sign.
2. Trousseau's sign.
Rationale:
Trousseau's sign is elicited when placing a blood pressure cuff on the arm; when the cuff is inflated, the client experiences carpal spasms. Chvostek's sign is elicited by tapping on the face in front of the ear and observing for contractions of the muscle. Turner's sign indicates retroperitoneal bleeding. Cullen's sign is associated with retroperitoneal bleeding.
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a. Skin folds under the breasts b. Senile keratosis or senile lentigines skin lesion c. Thinning scalp hair d. Pressure ulceration over a bony prominence
A nurse in a long-term care facility is approached by an older resident who is crying and states: "You need to help me. The mean little men are in my room again. They are watching me from the corner and they are laughing at me
Make them go away." The nurse accompanies the resident to the room and there is no one in the corner of the room. What is the best response by the nurse? (Select all that apply.) a. "Yup, I see them. Let me call security to haul the men away." b. "Can you tell me what you are so fright-ened of?" c. "I will do my best to keep you safe." d. "I understand that you are very frightened and upset." e. "You know that there is no one there. Stop carrying on like this."
The nurse is planning to assess a client's pulse. What characteristics should the nurse include in this assessment?
1. Rate 2. Rhythm 3. Volume 4. Tone 5. Viscosity
A client is ordered heparin following open heart surgery. What method would the nurse use to administer this medication?
A) Intradermal B) Subcutaneous C) Intramuscular D) Intravenous