COMPREHENSIVE ASSESSMENT FORM
A QUESTIONS WITH CORRECT
ANSWERS
ElectrolytewlImbalances:wlIdentifyingwlManifestationswlofwlawlCalciumwlImbalancewl-
wlANS--Hypocalcemia:
-wlLevel:wl<9wlmg/dL
-wlRiskwlfactors:wlCalciumwldeficit,wldiarrhea,wlend-
stagewlkidneywldisease,wlwoundwldrainage;wlalkalosis,wlacutewlpancreatitis,wlimmobility,wl
parathyroidwlremoval/damage
-
wlS&S:wlTetanywl(mostwlcommonwlmanifestation),wlparesthesiawlofwlthewlfingerswlandwllips
,wlmusclewltwitches,wl
seizure,wlmusclewlspasms,wlhyperactivewlDTRs,wlpositivewlChvostek'swlsignwl(facialwltwitc
hing),wlpositivewlTrousseau'swlsignwl(hand/
fingerwlspasmswlwithwlBPwlcuffwlinflation),wlcardiovascularwlirregularities,wldiarrhea,wlabdo
minalwlcramps
-wlTx:wlVitaminwlDwlsupplements
-wlComplications:wlCardiacwlarrest
AssociatedwlmanifestationwlofwlHypocalcemiawl-wlANS--PositivewlTrousseau'swlsign
AssociatedwlmanifestationwlofwlHyperkalemiawl-wlANS--ECGwlwithwltall,wlpeakedwlt-waves
AssociatedwlmanifestationwlofwlHyponatremiawl-wlANS--Boundingwlpulse
AssociatedwlmanifestationwlofwlHypokalemiawl-wlANS--Hypoactivewlbowelwlsounds
ThewlnursewliswlassessingwlthewlclientwlforwlChvostek'swlsign.wlWhichwlofwlthewlfollowingwla
ctionswlshouldwlthewlnursewltake?
a.wlApplywlawlBPwlcuffwltowlthewlclient'swlarmwl
b.wlPlacewlawlstethoscopewlbellwloverwlthewlclient'swlcarotidwlarterywl
c.wlAskwlthewlclientwltowllowerwltheirwlchinwltowltheirwlchest
d.wlTapwllightlywlonwlthewlclient'swlcheekwl-wlANS--d.wlTapwllightlywlonwlthewlclient'swlcheek
TapwloverwlthewlfacialwlnervewljustwlbelowwlandwlanteriorwltowlthewlearwltowlelicitwlChvostek'
swlsign.wl
Awlpositivewlsignwl=wlFacialwltwitchingwlonwlthewlsidewlofwlthewlface
, Thewlnursewliswlassessingwlthewlclientwlwhowlreportswlnausea,wlvomiting,wlandwlweakness.
wlWhichwlofwlthewlfollowingwlfindingswlarewlmanifestationswlofwlhypocalcemia?wlSATA
a.wlTinglingwlinwlfingers
b.wlPoorwlskinwlturgorwl
c.wlAbdominalwlpainwl
d.wlElevatedwltemperaturewl
e.wlMusclewltwitchingwl-wlANS--a,wlc,wle
Numbnesswlandwltinglingwlinwlfingerswlandwltoes,wlabdominalwlcrampswlandwldiarrhea,wlan
dwlmusclewltwitchingwlarewlmanifestationswlofwlhypocalcemia.
RespiratorywlDiagnosticwlProcedures:wlPlanningwlCarewlforwlawlClientwlWhowlIswlSchedule
dwlforwlawlThoracentesiswl-wlANS--Preprocedure:
-
wlPercussion,wlauscultation,wlradiography,wlorwlsonographywliswlusedwltowllocatewlthewleffu
sionwlandwlneedlewlinsertionwlsite.
-wlAssistwlthewlolderwlclientwltowlmaintainwlstillwlforwlthewlprocedure
-
wlPositionwlthewlclientwlsittingwluprightwlwithwlarmswlandwlshoulderswlraisedwlandwlsupporte
dwlonwlpillowswland/orwlanwloverbedwltablewlandwlwithwlfeetwlandwllegswlwell-supported.
-wlRemainwlstills,wlnowlcoughingwlorwltalkingwl
Intraprocedure:
-wlAsepticwltechniquewl
-wlMonitorwlVS,wlskinwlcolor,wlandwloxwlsat
-wlAmountwlofwlfluidwlremovedwliswllimitedwltowl1Lwlatwlawltimewltowlpreventwlre-
expansionwlpulmonarywledemawl
Postprocedure:
-wlApplywldressingwloverwlpuncturewlsitewl
-wlAssesswlforwlbleedingwlorwldrainagewl
-wlMonitorwlVSwlandwlrespiratorywlstatuswlhourlywlforwlthewlfirstwlseveralwlhourswl
-wlEncouragewldeepwlbreathewltowlassistwlwithwllungwlexpansion
-wlObtainwlawlpostprocedurewlcxr
Thoracentesiswl-wlANS--
Thoracentesiswliswlthewlsurgicalwlperforationwlofwlthewlchestwlwallwlandwlpleuralwlspacewlwi
thwlawllarge-
borewlneedle.wlItwliswlperformedwltowlobtainwlspecimenswlforwldiagnosticwlevaluation,wlinstil
lwlmedicationwlintowlthewlpleuralwlspace,wlandwlremovewlfluidwlorwlairwlfromwlthewlpleuralwls
pacewlforwltherapeuticwlreliefwlofwlpleuralwlpressure.
Awlnursewliswlreviewingwlinformationwlwithwlawlclientwlwhowliswlscheduledwlforwlpulmonarywl
functionwltests.wlWhichwlofwlthewlfollowingwlstatementswlshouldwlthewlnursewlmake?
a.wl"Dowlnotwlusewlinhalerwlmedicationswlforwl6wlhrwlfollowingwlthewltest."
b.wl"Dowlnotwlsmokewltobaccowlforwl6-8wlhrwlpriorwltowlthewltest."