When taking the blood pressure of a very ill client, the nurse observes that the client's hand undergoes flexion contractions. Which intervention is most appropriate?
a. Administer isotonic intravenous fluids.
b. Remove the blood pressure cuff and give oxygen.
c. Ensure the client has a patent intravenous line.
d. Document the finding in the client's chart.
C
Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. Flexion contractions that occur during blood pressure measurement are indicative of hy-pocalcemia and are referred to as a positive Trousseau's sign. Client safety is a priority, and the nurse must ensure that the client has a working intravenous line. Seizure precautions and de-creasing environmental stimuli are also important.
You might also like to view...
The nurse should caution which of the following clients about use of antihistamines?
a. a female client with allergic rhinitis. c. an adolescent with asthma. b. a middle-aged man with hay fever. d. a 30-year-old with skin rashes.
Respiratory care after surgery includes which of the following performed by the nursing assistant?
A) respiratory treatments B) encouraging the patient to take deep breaths C) oxygen D) all of the above
Which of the following is NOT a way of spreading HIV?
A) sexual contact B) blood-to-blood contact C) intravenous needle sharing D) reusing clean silverware
A nurse conducting an eye examination notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. How should the nurse document this finding?
A. Ptosis B. Nystagmus C. Scleral icterus D. Exophthalmos