The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows.

Which response provides the best explanation?

Choice B rationale:

Stroke is a condition that occurs when the blood supply to a part of the brain is interrupted, causing brain tissue damage. Facial drooping and garbled speech are common signs of stroke, especially if they occur suddenly and on one side of the face.Stroke is a medical emergency that requires immediate treatment to prevent further brain damage and complications

Choice C rationale:

An allergic reaction could cause various symptoms, but it typically does not result in facial drooping or garbled speech. Common signs of an allergic reaction include hives, itching, redness, and swelling of the skin, as well as difficulty breathing in severe cases (anaphylaxis). There is no mention of these symptoms in the client’s presentation.

Choice D rationale:

Malignant hypertension is a possibility given the client’s extremely high blood pressure reading. This condition refers to severe hypertension that can quickly lead to organ damage. However, while it can cause neurological symptoms if it leads to a hypertensive crisis, the specific symptoms of facial drooping and garbled speech are more indicative of a stroke. In conclusion, based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of a stroke as evidenced by neurological defects (facial drooping and garbled speech). The client’s high blood pressure and reported alcohol consumption are both risk factors for stroke. Immediate medical intervention is crucial to minimize brain damage and potential complications.

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.