Medical Surgical Fluid & Electrolyte Basics #4

Question

Upon assessment of a client in renal failure, the nurse observes a mental status change with hyperactive deep tendon reflexes. She inflates the blood pressure cuff to a level above his systolic pressure for 3 minutes and Trousseau’s sign is positive. The nurse recognizes this as which electrolyte imbalance?

Answers

  1. Hypermagnesemia
    • Rationale:

      This answer is not correct because skeletal muscle weakness, not hyperactive deep tendon reflexes is a sign of hypermagnesemia. Other signs include hypotension, lethargy, respiratory failure, and cardiac dysrhythmias.

  2. Hypomagnesemia
    • Rationale:

      This answer is not correct because symptoms are different in that the client will have muscle fasciculations, anorexia, nausea, vomiting, and lethargy. Hypomagnesemia can also be assessed with Trousseau’s sign.

  3. Hypercalcemia
    • Rationale:

      This answer is not correct because the client will experience an increased heart rate and blood pressure with decreased GI motility and skeletal muscle weakness. Hypercalcemia can also lead to dysrhythmias and heart failure.

  4. Hypocalcemia
    • Rationale:

      This answer is correct because these are the signs and symptoms of hypocalcemia. Hypocalcemia can cause mental status changes, hyperactive deep tendon reflexes, diarrhea, cardiac dysrhythmias, seizures, and pathological fractures. Interventions include treating the cause of the imbalance, increasing dietary calcium or calcium medication. Food sources for calcium include fortified cereals, canned salmon, spinach, yogurt, cheese, and milk.

Overview

Hypocalcemia can cause mental status changes, hyperactive deep tendon reflexes, diarrhea, cardiac dysrhythmias, seizures, and pathological fractures. It is assessed by Trousseau’s sign by inflating the blood pressure cuff to a level above systolic pressure for 3 minutes. If a carpopedal spasm is caused, then Trousseau’s sign is considered positive and the client is experiencing hypocalcemia.

Explanation

Learning Outcomes

Hypocalcemia can cause mental status changes, hyperactive deep tendon reflexes, diarrhea, cardiac dysrhythmias, seizures, and pathological fractures. It is assessed by Trousseau’s sign by inflating the blood pressure cuff to a level above systolic pressure for 3 minutes. If a carpopedal spasm is caused, then Trousseau’s sign is considered positive and the client is experiencing hypocalcemia. Interventions include treating the cause of the imbalance, increasing dietary calcium or calcium medication. Food sources for calcium include fortified cereals, canned salmon, spinach, yogurt, cheese, and milk. Medication used is IV calcium gluconate, p.o. calcium supplements, vitamin D supplements, and aluminum hydroxide to bind phosphate. Phosphorus and calcium have an inverse relationship.

Test Taking Tip

Make an educated guess. Educated guessing usually comes from previous knowledge so the chances of picking the correct choices(s) are improved.

Video Rationale