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 B

Explanation

Choice A rationale:

Encouraging the client to exercise every day to eliminate bedtime wakefulness is not appropriate advice in this scenario. It oversimplifies the issue and may not address the underlying causes of the client's sleep difficulties. Additionally, excessive exercise close to bedtime may actually interfere with sleep.

Choice C rationale:

Asking the client for a description of the exercise schedule being followed is a reasonable action. It allows the nurse to gather information about the client's exercise routine and assess whether it might be contributing to the sleep difficulties. However, this alone may not fully address the client's concerns.

Choice D rationale:

Determining the amount of weight the client has lost since increasing activity is relevant to the client's overall health and progress toward weight loss goals, but it does not directly address the issue of sleep difficulties. Weight loss and improved sleep may not always have a direct cause-and-effect relationship.

A. Client's healthcare power of attorney. B. Fall at home as reason for admission. C. Currently prescribed medications. D. Increasing confusion of the client.

Correct Answer is D

Explanation

Choice A rationale:

Providing information about the client's healthcare power of attorney is not the most critical piece of information to report in this situation. The immediate concern is the client's change in mental status and potential medical emergency.

Choice B rationale:

While the reason for the client's admission is important background information, it is not the most urgent information to report in this situation. The priority is addressing the client's acute change in mental status.

Choice C rationale:

The nurse should be aware of the client's currently prescribed medications, but this information does not take precedence over the client's sudden onset of confusion and agitation. Immediate action is needed to address the client's altered mental status.

Choice D rationale:

Increasing confusion and agitation in a client who recently underwent ORIF of the right femur is a significant change in condition and may indicate a medical emergency such as infection, delirium, or other complications. This information should be provided first to alert the healthcare provider to the client's immediate needs.

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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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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?