ATI Capstone Proctored Comprehensive
Assessment Form A
Electrolyte Imbalances: Identifying Manifestations of a Calcium Imbalance - ANSWER -
Hypocalcemia:
- Level: <9 mg/dL
- Risk factors: Calcium deficit, diarrhea, end-stage kidney disease, wound drainage; alkalosis,
acute pancreatitis, immobility, parathyroid removal/damage
- S&S: Tetany (most common manifestation), paresthesia of the fingers and lips, muscle
twitches,
seizure, muscle spasms, hyperactive DTRs, positive Chvostek's sign (facial twitching), positive
Trousseau's sign (hand/finger spasms with BP cuff inflation), cardiovascular irregularities,
diarrhea, abdominal cramps
- Tx: Vitamin D supplements
- Complications: Cardiac arrest
Associated manifestation of Hypocalcemia - ANSWER - Positive Trousseau's sign
Associated manifestation of Hyperkalemia - ANSWER - ECG with tall, peaked t-waves
Associated manifestation of Hyponatremia - ANSWER - Bounding pulse
,Associated manifestation of Hypokalemia - ANSWER - Hypoactive bowel sounds
The nurse is assessing the client for Chvostek's sign. Which of the following actions should the
nurse take?
a. Apply a BP cuff to the client's arm
b. Place a stethoscope bell over the client's carotid artery
c. Ask the client to lower their chin to their chest
d. Tap lightly on the client's cheek - ANSWER - d. Tap lightly on the client's cheek
Tap over the facial nerve just below and anterior to the ear to elicit Chvostek's sign.
A positive sign = Facial twitching on the side of the face
The nurse is assessing the client who reports nausea, vomiting, and weakness. Which of the
following findings are manifestations of hypocalcemia? SATA
a. Tingling in fingers
b. Poor skin turgor
c. Abdominal pain
d. Elevated temperature
e. Muscle twitching - ANSWER - a, c, e
, Numbness and tingling in fingers and toes, abdominal cramps and diarrhea, and muscle
twitching are manifestations of hypocalcemia.
Respiratory Diagnostic Procedures: Planning Care for a Client Who Is Scheduled for a
Thoracentesis - ANSWER - Preprocedure:
- Percussion, auscultation, radiography, or sonography is used to locate the effusion and needle
insertion site.
- Assist the older client to maintain still for the procedure
- Position the client sitting upright with arms and shoulders raised and supported on pillows
and/or an overbed table and with feet and legs well-supported.
- Remain stills, no coughing or talking
Intraprocedure:
- Aseptic technique
- Monitor VS, skin color, and ox sat
- Amount of fluid removed is limited to 1L at a time to prevent re-expansion pulmonary edema
Postprocedure:
- Apply dressing over puncture site
- Assess for bleeding or drainage
- Monitor VS and respiratory status hourly for the first several hours
- Encourage deep breathe to assist with lung expansion
- Obtain a postprocedure cxr
Assessment Form A
Electrolyte Imbalances: Identifying Manifestations of a Calcium Imbalance - ANSWER -
Hypocalcemia:
- Level: <9 mg/dL
- Risk factors: Calcium deficit, diarrhea, end-stage kidney disease, wound drainage; alkalosis,
acute pancreatitis, immobility, parathyroid removal/damage
- S&S: Tetany (most common manifestation), paresthesia of the fingers and lips, muscle
twitches,
seizure, muscle spasms, hyperactive DTRs, positive Chvostek's sign (facial twitching), positive
Trousseau's sign (hand/finger spasms with BP cuff inflation), cardiovascular irregularities,
diarrhea, abdominal cramps
- Tx: Vitamin D supplements
- Complications: Cardiac arrest
Associated manifestation of Hypocalcemia - ANSWER - Positive Trousseau's sign
Associated manifestation of Hyperkalemia - ANSWER - ECG with tall, peaked t-waves
Associated manifestation of Hyponatremia - ANSWER - Bounding pulse
,Associated manifestation of Hypokalemia - ANSWER - Hypoactive bowel sounds
The nurse is assessing the client for Chvostek's sign. Which of the following actions should the
nurse take?
a. Apply a BP cuff to the client's arm
b. Place a stethoscope bell over the client's carotid artery
c. Ask the client to lower their chin to their chest
d. Tap lightly on the client's cheek - ANSWER - d. Tap lightly on the client's cheek
Tap over the facial nerve just below and anterior to the ear to elicit Chvostek's sign.
A positive sign = Facial twitching on the side of the face
The nurse is assessing the client who reports nausea, vomiting, and weakness. Which of the
following findings are manifestations of hypocalcemia? SATA
a. Tingling in fingers
b. Poor skin turgor
c. Abdominal pain
d. Elevated temperature
e. Muscle twitching - ANSWER - a, c, e
, Numbness and tingling in fingers and toes, abdominal cramps and diarrhea, and muscle
twitching are manifestations of hypocalcemia.
Respiratory Diagnostic Procedures: Planning Care for a Client Who Is Scheduled for a
Thoracentesis - ANSWER - Preprocedure:
- Percussion, auscultation, radiography, or sonography is used to locate the effusion and needle
insertion site.
- Assist the older client to maintain still for the procedure
- Position the client sitting upright with arms and shoulders raised and supported on pillows
and/or an overbed table and with feet and legs well-supported.
- Remain stills, no coughing or talking
Intraprocedure:
- Aseptic technique
- Monitor VS, skin color, and ox sat
- Amount of fluid removed is limited to 1L at a time to prevent re-expansion pulmonary edema
Postprocedure:
- Apply dressing over puncture site
- Assess for bleeding or drainage
- Monitor VS and respiratory status hourly for the first several hours
- Encourage deep breathe to assist with lung expansion
- Obtain a postprocedure cxr
