The client post-thyroidectomy complains of numbness and tingling around the mouth and the tips of the fingers. Which intervention should be implemented first?
Tap the cheek about two (2) centimeters anterior to the ear lobe.
A. (incorrect) The health care provider may need to be notified, but the nurse should perform assessment first.
B. (correct) These are signs and symptoms of hypocalcemia, and the nurse can confirm this by tapping the cheek to elicit the Chvosteks sign. If the muscles of the cheek begin to twitch, then the health care provider should be notified immediately because hypocalcemia is a medical emergency.
C. (incorrect) A positive Chvosteks sign can indicate a low calcium or magnesium level, but serum lab levels may have been drawn hours previously or may not be available.
D. (incorrect) If the client does have hypocalcemia, this may be ordered, but it is not implemented prior to assessment.
TEST-TAKING HINT: Assessment is the first step in the nursing process and is an appropriate option to select if the test taker has difficulty when trying to decide between two options.