A patient comes into the clinic demonstrating symptoms of hypocalcemic tetany. What assessment should the nurse conduct to determine the patient's condition?
1. Tap a finger in front of the patient's ear at the angle of the jaw.
2. Place a tuning fork over one of the patient's fingers.
3. Measure the patient's blood pressure.
4. Measure capillary blood.
Correct Answer: 1
The nurse should assess the patient for Chvostek sign by tapping a finger in front of the patient's ear at the angle of the jaw. Decreased calcium levels will cause the patient's lateral facial muscles to contract. This demonstrates tetany. Placing a tuning fork over the patient's finger evaluates the patient's ability to perceive vibrations, but it does not evaluate the muscle response of tetany. Blood pressure measurement may give the nurse valuable information about the patient's fluid and electrolyte status, but it does not evaluate tetany. A capillary blood level for serum calcium would give a measurement, but it does not assess for the clinical symptoms of tetany.
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