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    Ati Med Surg 2 Proctored Exam (Anderson)

    A nurse is assessing a patient with suspected hypocalcemia. How should the nurse use Chvostek's sign to guide further care?

    Explanation & Rationale

    A. Trousseau's sign, not Chvostek's sign, involves inflating a blood pressure cuff on the arm to induce carpal spasm, or other maneuvers that elicit muscle contractions. The Achilles tendon is not used to assess hypocalcemia via Chvostek's sign. B. Percussion of the lower leg is not related to detecting hypocalcemia. Muscle tenderness may occur in some electrolyte disturbances, but it does not specifically indicate low calcium levels. C. Chvostek’s sign is a clinical test for neuromuscular excitability associated with low calcium levels. When the facial nerve (just anterior to the ear at the cheekbone) is tapped, a twitch of the ipsilateral facial muscles (e.g., around the mouth, nose, or eye) indicates hypocalcemia. This finding guides the nurse to further assess calcium levels and prepare for interventions such as calcium supplementation or cardiac monitoring if levels are critically low. D. Pupil response assesses cranial nerve II and III function and neurological status, but it does not indicate hypocalcemia

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