To test for a positive Trousseau's sign indicating hypocalcemia, the nurse would need which piece of equipment?
1. Percussion hammer
2. Penlight
3. Blood pressure cuff
4. Doppler
3
Rationale 1: A percussion hammer is used to elicit deep tendon reflexes. The hyperactive reflexes associated with hypocalcemia need very little stimulation to elicit a response.
Rationale 2: Motor reflexes are not stimulated by light. The penlight is used to assess papillary reflex and to illuminate areas for assessment.
Rationale 3: Manifestations of hypocalcemia may develop as soon as 48 hours after the onset of the oliguric phase of acute kidney injury because renal tubule disorders often result in excessive loss of calcium. Spasm of the hand and wrist, called Trousseau's sign, may become apparent when a blood pressure cuff placed on an arm is inflated to 20 mm Hg above the systolic pressure for at least 3 minutes.
Rationale 4: A Doppler is used to assess arterial flow such as hard-to-feel peripheral pulses.
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