Genevieve is diagnosed with hypomagnesemia, which nursing intervention would be appropriate?
A. Instituting seizure precaution to prevent injury.
B. Instructing the client on the importance of preventing infection.
C. Avoiding the use of tight tourniquet when drawing blood.
D. Teaching the client the importance of early ambulation.
Correct Answer: A. Instituting seizure precaution to prevent injury.
Instituting seizure precaution is an appropriate intervention because the client with hypomagnesemia is at risk for seizures. Changes in mentation or the development of seizure activity in severe low magnesium increase the risk of client injury. Provide a quiet environment and subdued lighting. Reduces extraneous stimuli; promotes rest.
Option B: Hypophosphatemia may produce changes in granulocytes, which would require the nurse to instruct the client about measures to prevent infection. Mild hypophosphatemia will not be clinically apparent. Severe hypophosphatemia may have the clinical presence of altered mental status, neurological instability including seizures and focal neurologic findings such as numbness or reflexive weakness, a cardiac manifestation of possible heart failure, muscle pain, and muscular weakness.
Option C: Avoiding the use of a tight tourniquet when drawing blood helps prevent pseudohyperkalemia. Assess the level of consciousness and neuromuscular function, including sensation, strength, and movement. The client is usually conscious and alert; however, muscular paresthesia, weakness, and flaccid paralysis may occur.
Option D: Early ambulation is recommended to reduce calcium loss from bones during hospitalization. Encourage frequent repositioning and range-of-motion (ROM) and/or muscle-setting exercises with caution. Promote ambulation as tolerated. Muscle activity may reduce calcium shifting from the bones that occur during immobilization.
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