Question 1 of 6
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Which laboratory test would the nurse anticipate for an alert patient who presents to the emergency department with severe bilateral lower extremity weakness, shallow respirations, and normal heart rate and rhythm?
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- Serum potassiumThe nurse would anticipate a serum potassium concentration test for this patient. Hypokalemia causes bilateral quadriceps muscle weakness that may also weaken the respiratory muscles.
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- Urine specific gravityA urine specific gravity is used to assess sodium imbalances.
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- Serum sodiumSerum sodium imbalances cause a decreased level of consciousness.
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- Serum calciumCalcium imbalances alter neuromuscular excitability and do not cause respiratory muscle weakness.
Question 2 of 6
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Which neurologic assessment, performed by tapping the side of the face, would the nurse perform for a patient with risk factors for hypocalcemia?
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- Level of consciousness examAlthough a level of consciousness exam is an appropriate neurologic assessment to conduct for a patient with documented hypocalcemia, this test is not administered by tapping on the side of the patient’s face.
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- Trousseau signTrousseau sign is a neurologic assessment used to monitor for hypocalcemia. However, the assessment is performed using a blood pressure cuff to assess for spasm of the hand and wrist muscles.
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- ElectrocardiogramAn electrocardiogram is a cardiovascular diagnostic tool, not a neurologic assessment.
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- Chvostek signChvostek sign is elicited by a neurologic assessment that is performed by tapping the side of the face over the facial nerve. A positive Chvostek sign, spasm of the facial muscle, indicates increased neuromuscular excitability, consistent with hypocalcemia.
Question 3 of 6
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Which specific questions would a nurse include in the assessment interview for a patient with hypermagnesemia?
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- “What type of laxatives do you use?”Some laxatives are high in magnesium; therefore, this question is appropriate for the nurse to include when conducting a health history interview assessment for a patient with hypermagnesemia.
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- “Have you had diarrhea recently?”Diarrhea increases potassium excretion and, if chronic, also increases calcium and magnesium excretion; asking about diarrhea is not an appropriate assessment question during the health history interview for a patient who presents with hypermagnesemia. This may, however, be an appropriate question for a patient with hypomagnesemia.
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- “Do you use over-the-counter antacids?”Some over-the-counter antacids are high in magnesium; therefore, this question is appropriate for the nurse to include when conducting a health history interview assessment for a patient with hypermagnesemia.
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- “Do you have lactose intolerance?”Asking the patient about lactose intolerance is not an appropriate assessment question during the health history interview for a patient who presents with hypermagnesemia.
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- “Do you take a prescribed diuretic?”Loop diuretics cause hypokalemia and sometimes hypomagnesemia, not hypermagnesemia; therefore, this is not an appropriate assessment question during the health history interview for a patient who presents with hypermagnesemia.
Question 4 of 6
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Which cues would a nurse assess a patient for based on a serum phosphate concentration of 3.1 mEq/L?
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- TetanyA serum phosphate concentration greater than 2.6 mEq/L indicates hyperphosphatemia. The nurse should assess for tetany, a clinical manifestation of hypocalcemia caused by hyperphosphatemia.
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- HyperreflexiaA serum phosphate concentration greater than 2.6 mEq/L indicates hyperphosphatemia. The nurse should assess for hyperreflexia, a clinical manifestation of hypocalcemia caused by hyperphosphatemia.
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- Decreased deep tendon reflexesA serum phosphate concentration greater than 2.6 mEq/L indicates hyperphosphatemia. Decreased deep tendon reflexes occur with hypercalcemia or hypermagnesemia, not hyperphosphatemia.
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- Muscle crampsA serum phosphate concentration greater than 2.6 mEq/L indicates hyperphosphatemia. The nurse should assess for muscle cramps, a clinical manifestation of hypocalcemia caused by hyperphosphatemia.
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- Shallow respirationsA serum phosphate concentration greater than 2.6 mEq/L indicates hyperphosphatemia. Shallow respirations occur with hypophosphatemia or hypermagnesemia, not hyperphosphatemia.
Question 5 of 6
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Which clinical manifestation would a nurse monitor for when providing care to a patient whose serum potassium level is 5.4 mEq/L?
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- BradycardiaA serum potassium concentration of 5.4 mEq/L indicates hyperkalemia. The nurse should monitor for bradycardia, a clinical manifestation associated with this electrolyte imbalance.
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- Hyperactive deep tendon reflexesA serum potassium concentration of 5.4 mEq/L indicates hyperkalemia. Hyperactive deep tendon reflexes are associated with hypocalcemia and hypomagnesemia, not hyperkalemia.
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- LethargyA serum potassium concentration of 5.4 mEq/L indicates hyperkalemia. Lethargy is a clinical manifestation associated with hyponatremia, hyponatremia, hypercalcemia, or hypermagnesemia, not hyperkalemia.
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- EmesisA serum potassium concentration of 5.4 mEq/L indicates hyperkalemia. Emesis is not a clinical manifestation associated with hyperkalemia.
Question 6 of 6
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Which cue in a patient with end-stage renal disease would a nurse recognize as an indication of hyperphosphatemia?
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- Decreased blood pressureDecreased blood pressure, or hypotension, is a clinical manifestation of hypophosphatemia, not hyperphosphatemia.
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- AnorexiaAnorexia is a clinical manifestation of hypophosphatemia, not hyperphosphatemia.
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- Irritated and itchy eyesIn patients who have end-stage renal disease, hyperphosphatemia will cause calcium phosphate crystals to form in soft tissues, causing itching or irritated eyes.
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- ConfusionConfusion is a clinical manifestation of hypophosphatemia, not hyperphosphatemia.