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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is the correct answer because BUN and creatinine are the most important laboratory values to monitor for nephrotoxicity, which is the damage or injury to the kidneys caused by certain drugs or chemicals.
Nephrotoxicity can impair the kidneys' ability to filter waste products from the blood, resulting in elevated levels of BUN and creatinine. The normal range for BUN is 7 to 20 mg/dL, and for creatinine is 0.6 to 1.2 mg/dL. The practical nurse (PN) should review these values before administering an antibiotic that can cause nephrotoxicity, such as aminoglycosides, cephalosporins, vancomycin, or sulfonamides. The PN should also monitor the client for signs and symptoms of nephrotoxicity, such as decreased urine output, edema, hypertension, fatigue, nausea, and confusion.
a) Serum calcium
This is not the correct answer because serum calcium is not directly related to nephrotoxicity. Serum calcium is the amount of calcium in the blood, which is important for bone health, muscle contraction, nerve function, and blood clotting. The normal range for serum calcium is 8.5 to 10.2 mg/dL. Serum calcium may be affected by kidney disease, but it is not a reliable indicator of nephrotoxicity.
b) Hemoglobin and hematocrit
This is not the correct answer because hemoglobin and hematocrit are not directly related to nephrotoxicity. Hemoglobin is the protein in red blood cells that carries oxygen, and hematocrit is the percentage of red blood cells in the blood. The normal range for hemoglobin is 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women, and for hematocrit is 38.8 to 50% for men and 34.9 to 44.5% for women.
Hemoglobin and hematocrit may be affected by kidney disease, but they are not reliable indicators of
nephrotoxicity.
c) White blood cell count (WBC)
This is not the correct answer because WBC is not directly related to nephrotoxicity. WBC is the number of white blood cells in the blood, which are part of the immune system and fight infections. The normal range for WBC is 4,500 to 10,000 cells per microliter of blood. WBC may be elevated in response to an infection or inflammation, but it is not a reliable indicator of nephrotoxicity.
Correct Answer is A
Explanation
Choice A rationale:
Impaired physical mobility relative to muscle rigidity has the highest priority in the nursing care plan for a client diagnosed with Parkinson's disease. Parkinson's disease is characterized by motor symptoms such as muscle rigidity, bradykinesia, and postural instability. Impaired physical mobility can significantly impact a patient's ability to perform activities of daily living and maintain independence. Addressing this issue is crucial to enhance the patient's quality of life and prevent complications such as falls.
Choice B rationale:
While the risk for aspiration relative to muscle weakness is a valid concern in Parkinson's disease, impaired physical mobility takes precedence as it directly affects the patient's ability to move, ambulate, and perform daily activities. Addressing mobility issues is fundamental to maintaining overall functioning and independence.
Choice C rationale:
The risk for constipation relative to immobility is important to address, but it is not the highest priority. Impaired physical mobility can lead to multiple complications, including constipation. However, improving mobility should be the primary focus to prevent a wide range of issues associated with Parkinson's disease.
Choice D rationale:
Self-care deficit relative to motor disturbance is a concern in Parkinson's disease, but it is not the highest priority. Impaired physical mobility directly impacts a patient's ability to engage in self-care activities. By addressing mobility issues first, the nurse can facilitate the patient's ability to perform self-care tasks more independently in the long run.
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