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 C

Explanation

Choice A rationale:

A bottle is generally much better than using a pacifier. This statement is not accurate. Prolonged bottle use, especially with sugary liquids like milk, can have adverse effects on a child's dental health. It can lead to an increased risk of cavities, similar to prolonged pacifier use.

Choice B rationale:

The bottle will assist in preventing thumb sucking. This statement is incorrect. While a bottle may provide comfort to a child, it does not prevent thumb sucking. Thumb sucking is a separate behavior that may also have dental implications if it persists beyond a certain age.

Choice C rationale:

Prolonged bottle use can increase the risk for cavities. This response is correct. Prolonged bottle use, especially with milk or sugary beverages, can expose the child's teeth to prolonged contact with sugars, increasing the risk of cavities. It's important for the nurse to educate the mother about the potential dental risks associated with extended bottle use.

Choice D rationale:

Using milk rather than juice helps to avoid tooth decay. While milk is generally considered a healthier choice than juice, the key issue in this scenario is the prolonged use of the bottle, regardless of its content. Prolonged bottle use with any liquid, including milk, can still increase the risk of cavities.

A. Administer prescribed PRN sleep medications. B. Encourage use of prescribed analgesic perineal sprays. C. Administer prescribed stool softener. D. Encourage breastfeeding to promote uterine involution.

Correct Answer is C

Explanation

The correct answer is choice c. Administer prescribed stool softener.

Choice A rationale:

Administering prescribed PRN sleep medications is not the highest priority. While rest is important, managing pain and preventing complications from the laceration take precedence.

Choice B rationale:

Encouraging the use of prescribed analgesic perineal sprays is beneficial for pain management, but it is not the highest priority intervention.

Choice C rationale:

Administering a prescribed stool softener is crucial because it helps prevent constipation, which can cause significant pain and strain on the perineal area, potentially worsening the laceration.

Choice D rationale:

Encouraging breastfeeding to promote uterine involution is important for postpartum recovery, but it does not directly address the immediate needs related to the fourth-degree laceration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is planning care for a client who has a fourth-degree midline laceration that occurred during vaginal delivery of an 8-pound 10-ounce (3674 grams) infant. Which intervention has the highest priority for this client?

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?