When taking the blood pressure of a very ill client, the nurse observes that the client's hand undergoes flexion contractions. What is the nurse's best first action?
A. Place the client in the high-Fowler's position and increase the IV flow rate.
B. Deflate the blood pressure cuff and give the client oxygen.
C. Document the finding as the only action.
D. Notify the emergency team.
B
Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. This effect of hypocalcemia is enhanced in the presence of tissue hypoxia. The flexion contractions occurring during blood pressure measurement are indicative of hypocalcemia and are referred to as a positive Trousseau's sign.
You might also like to view...
An elderly client says, "I can't seem to hear as well as I could when I was younger.". The nurse suspects this client is experiencing which of the following disorders?
1. Presbycusis 2. Mastoiditis 3. Otitis media 4. Otitis externa
A client scheduled for an electromyography (EMG) study asks the nurse what the purpose of the test is. The nurse explains that it:
A) measures brain electrical activity. B) will identify velocity of blood flow in a vessel. C) records electrical activity of muscles. D) stimulates contraction of muscle fibers.
A nurse in the emergency department cares for an 82-year-old man. The man was found wandering the streets looking for his dog in a snowstorm. Which of the following conditions is the highest priority for the nurse to monitor?
A) Altered mental status B) Fluid volume overload C) Hyperglycemia D) Urinary tract infection
What should the nurse explain to a client with Addison disease as the reason for needing mineralocorticoid replacement therapy?
1. Mineralocorticoids will reduce excessive serum glucose levels. 2. Mineralocorticoids will mimic the action of cortisol. 3. Mineralocorticoids will mimic the action of aldosterone. 4. Mineralocorticoids will reduce harmful bronzing of the skin.