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 A
Choice A rationale: The spasm described is Trousseau's sign, a classic indicator of hypocalcemia. Inflating a blood pressure cuff above systolic pressure causes carpal spasm due to increased neuromuscular irritability, requiring immediate assessment of serum calcium levels.
Choice B rationale: Carpal spasms during blood pressure measurement are a physiological manifestation of electrolyte imbalance, not psychological distress. Administering antianxiety medication would delay necessary treatment for a potentially life-threatening calcium deficiency.
Choice C rationale: Moving the cuff to the other arm would likely produce the same result because hypocalcemia is a systemic condition. This action ignores the underlying physiological cause and fails to address the client's safety.
Choice D rationale: The spasms are a physical reaction from the client, not a malfunction of the equipment. Replacing the sphygmomanometer would be an ineffective intervention that misses the clinical significance of the sign.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale:
Verapamil is a calcium channel blocker and is expected to decrease heart rate by inhibiting calcium influx into cardiac cells, particularly in the SA (sinoatrial) node, where it can slow down the heart's electrical impulses.
Choice B rationale:
Increased contractility is not an expected outcome of verapamil use. In fact, verapamil's main action is to decrease myocardial contractility, making it useful for treating conditions like angina and atrial fibrillation.
Choice C rationale:
Verapamil is known to dilate coronary arteries, which can improve blood flow to the heart muscle and relieve symptoms of angina.
Choice D rationale:
Reduced blood pressure is an expected outcome of verapamil use due to its vasodilatory effects on peripheral blood vessels. This can be beneficial in treating hypertension and angina.
Choice E rationale:
Relieved chest pain is an expected outcome of verapamil use, particularly in the case of variant angina (Prinzmetal's angina), as it helps to relax coronary arteries and reduce coronary artery spasm, which is a common cause of chest pain in this condition.
Correct Answer is ["30"]
Explanation
The correct answer is 30 mL/hour.
Step 1 is to calculate the total amount of norepinephrine in the IV bag: 4 mg norepinephrine ÷ 1000 mL = 0.004 mg/mL
Step 2 is to convert the patient's weight from pounds to kilograms: 176 pounds ÷ 2.2 = 80 kilograms
Step 3 is to calculate the total amount of norepinephrine the patient will receive per minute: 2 mcg/min × 60 min = 120 mcg/min
Step 4 is to convert micrograms (mcg) to milligrams (mg): 120 mcg ÷ 1000 = 0.12 mg
Step 5 is to calculate the total volume of norepinephrine needed per hour: 0.12 mg ÷ 0.004 mg/mL = 30 mL/hour
Therefore, the nurse should program the infusion pump to deliver 30 mL/hour.
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