The nurse is caring for a patient who is admitted to a surgical unit after a thyroidectomy.
The nurse takes and maintains the inflated blood pressure cuff on the patient and observes a carpopedal spasm.
What does this result indicate to the nurse?

Choice A rationale

For a client with severe malnutrition, immediate intervention is necessary to address nutritional deficiencies. Inserting a nasogastric tube and beginning enteral feeding is the first step to provide essential nutrients, stabilize the patient's condition, and prevent further complications from malnutrition.

Choice B rationale

Teaching the patient to increase protein intake and to eat more frequently is important but not the immediate priority in a case of severe malnutrition. This can be addressed after initial stabilization and nutritional support.

Choice C rationale

Total parenteral nutrition (TPN) is an option for patients who cannot tolerate enteral feeding, but initiating strict NPO status without first attempting enteral feeding is not the best initial approach. Enteral feeding is generally preferred if the gastrointestinal tract is functional.

Choice D rationale

Rinsing the mouth with alcohol-based mouthwash before meals is not a priority in managing severe malnutrition. It does not address the immediate need for nutritional support and could be harmful if ingested.

Choice A rationale

Pain from mucositis and oral tissue injury is a significant concern for patients undergoing chemotherapy. However, it is not typically life-threatening and can be managed with appropriate pain relief measures and oral care.

Choice B rationale

Weakness and fatigue with activity are common side effects of chemotherapy and the disease process itself. While these symptoms impact the patient's quality of life, they do not usually require urgent intervention.

Choice C rationale

Blood pressure of 90/64 mmHg, pulse of 102 beats per minute, and oral temperature of 38.5 degrees Celsius suggest possible sepsis or severe infection. These vital signs indicate an urgent need for intervention to prevent further deterioration and potentially life-threatening complications.

Choice D rationale

Scattered ecchymosis and petechiae are signs of thrombocytopenia (low platelet count), which is a common complication of leukemia and its treatment. While important to monitor and manage, these findings are not typically as urgent as signs of sepsis or severe infection.