Nursing Prioritization Delegation Assignment Q 34
The assigned LPN of the unit reports to you that a client’s blood pressure and heart rate have decreased, and when her face is assessed, one side twitches. What is the most appropriate thing to do as a nurse?
A. Assess the client's pupillary reaction to light.
B. Obtain a neurologic exam request for the client.
C. Review the client's morning calcium level.
D. Retake the client's blood pressure and heart rate.
Correct Answer: C. Review the client’s morning calcium level.
Facial twitching of one side of the mouth, nose, and cheek in response to tapping the face just below and in front of the ear is a positive Chvostek sign. It is a neurologic manifestation of hypocalcemia.
Option A: Pupillary light reflex is used to assess the brain stem function. Abnormal pupillary light reflex can be found in optic nerve injury, oculomotor nerve damage, brain stem lesions, such as tumors, and medications like barbiturates.
Option B: The neurological examination is an assessment tool to determine a patient’s neurologic function. It is beneficial in a variety of ways as it allows the localization of neurologic diseases and helps in ruling in or ruling out differential diagnoses.
Option D: The LPN is experienced and holds the skills to carefully and accurately measure vital signs. The clinical manifestations of hypocalcemia can range from no symptoms if it is mild to life-threatening symptoms like seizures, heart failure, or laryngospasm if it is severe. Also, the clinical manifestation depends on the rate of development of hypocalcemia and its chronicity.