An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm.

After confirming the presence of the spasms, which action should the nurse take?

Review the client's serum calcium level.

Administer an as-needed (PRN) antianxiety medication.

Ask the UAP to take the blood pressure in the other arm.

Tell the UAP to use a different sphygmomanometer.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Review the client's serum calcium level. Rationale: Checking the client's serum calcium level is not the most appropriate action in this situation. Hand and finger spasms during blood pressure measurement are more likely due to discomfort or muscle tension than a calcium deficiency. There is no immediate indication that the client's calcium level needs to be assessed urgently.

Choice B rationale:

Administer an as-needed (PRN) antianxiety medication. Rationale: Administering an antianxiety medication is not indicated in this situation. The client's symptoms of hand and finger spasms during blood pressure measurement are not likely related to anxiety. It is essential to address the immediate issue of obtaining an accurate blood pressure reading.

Choice C rationale:

Ask the UAP to take the blood pressure in the other arm. Rationale: This is the correct answer. When the UAP reports spasms in the client's right hand and fingers while taking blood pressure using the same arm, the nurse should prioritize obtaining an accurate blood pressure measurement. Asking the UAP to use the other arm can help ensure a more reliable reading. Muscle spasms in the arm being used for blood pressure measurement can lead to inaccurate results.

Choice D rationale:

Tell the UAP to use a different sphygmomanometer. Rationale: In this scenario, the issue appears to be related to muscle spasms in the client's hand and fingers rather than the sphygmomanometer itself. Changing the sphygmomanometer is unlikely to resolve the problem. The priority is to obtain an accurate blood pressure reading by addressing the spasms in the arm being used.

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Correct Answer is ["A","B","E"]

Explanation

Choice A rationale:

The client will have no signs of infection in the wound by day 7. Rationale: This outcome is appropriate because it sets a specific timeframe (day 7) for assessing the absence of infection in the wound. It provides a clear and measurable criterion for evaluating the effectiveness of the wound care plan.

Choice B rationale:

The client will report a pain level of 4/10 or less during dressing changes. Rationale: Pain management is an essential aspect of wound care. Setting a target pain level (4/10 or less) during dressing changes allows for monitoring and adjustment of pain management strategies, making it an appropriate outcome.

Choice C rationale:

The client will consume at least 75% of meals and snacks daily. Rationale: While nutrition is important for wound healing, this outcome is less directly related to the wound itself. Monitoring meal consumption is a valuable goal for overall health but may not be as closely tied to wound improvement as infection control, pain management, or wound care technique.

Choice D rationale:

The client will reposition self in bed every 2 hours with assistance. Rationale: Repositioning every 2 hours is an important preventive measure for pressure ulcer development. However, this choice may not be appropriate for this particular client if they are unable to reposition themselves, even with assistance. This outcome may not be achievable for all clients, and a more individualized goal may be necessary.

Choice E rationale:

The client will demonstrate proper wound care technique before discharge. Rationale: Ensuring that the client can perform proper wound care techniques independently or with minimal assistance is a crucial outcome. This ensures that the client can maintain wound hygiene and prevent complications after discharge.

A. Explain to the family that they must accept their mother's decision. B. Discuss success of clinical trials and ask the client to consider participating for one month. C. Explore the client's decision to refuse treatment and offer support. D. Ask the client with her children present if she fully understands the decision she has made.

Correct Answer is C

Explanation

Choice A rationale:

The nurse should respect the client's autonomy and right to make decisions about her own care. It is essential to honor the client's refusal of further treatment, and the nurse should communicate this to the family. In this situation, the client has the capacity to make her own decisions, and her wishes should be respected.

Choice B rationale:

Attempting to persuade the client to participate in the clinical trial for one month is not an appropriate approach. It disregards the client's autonomy and her right to refuse treatment. It's essential to respect the client's decision, and trying to convince her against her will is ethically and legally inappropriate.

Choice D rationale:

While it's important to ensure that the client fully understands the implications of her decision, doing so in front of her children may create additional pressure or discomfort for the client. The best approach is to have a private conversation with the client to assess her understanding and provide information or support as needed.

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An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

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A nurse is updating the plan of care for a client who has a pressure ulcer on the sacrum. Which of the following outcomes are appropriate for this client? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

Correct Answer is C

Explanation

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An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm.

After confirming the presence of the spasms, which action should the nurse take?