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The nurse is assessing the client for Trousseau's sign. Which finding indicates a positive Trousseau sign? A. Tap cranial nerves 7 and cranial nerve 5 and check for grimacing of the face B. Place a blood pressure cuff on the arm and check for carpopedal spasms when the cuff is inflated C. Check the deep tendon reflexes by tapping the knee D. Monitor the client for nausea when cold water is used to irrigate the ear canal

Short Answer

Expert verified
Answer: Placing a blood pressure cuff on the arm and checking for carpopedal spasms when the cuff is inflated.

Step by step solution

01

Understand the Trousseau sign

The Trousseau sign is a clinical sign of hypocalcemia. When hypocalcemia is present, it causes an increased neuromuscular irritability. The Trousseau sign test is done by inflating a blood pressure cuff on a patient's arm, which can provoke carpopedal spasms (involuntary contractions) in the hand and wrist if hypocalcemia is present.
02

Evaluate each option

A. Tap cranial nerves 7 and cranial nerve 5 and check for grimacing of the face - This is not related to the Trousseau sign, as it involves tapping cranial nerves and observing the facial response. This is a test for facial nerve function. B. Place a blood pressure cuff on the arm and check for carpopedal spasms when the cuff is inflated - This correctly describes the Trousseau sign test, as the blood pressure cuff is used to provoke carpopedal spasms in positive cases. C. Check the deep tendon reflexes by tapping the knee - This is a test for the patellar reflex, not the Trousseau sign, as it involves tapping the knee to check deep tendon reflexes. D. Monitor the client for nausea when cold water is used to irrigate the ear canal - This is not related to the Trousseau sign, as it involves observing the patient's reaction to cold water in the ear canal, which is a test for the caloric reflex.
03

Select the correct option

The correct answer is option B, which states "Place a blood pressure cuff on the arm and check for carpopedal spasms when the cuff is inflated." It correctly describes a positive Trousseau sign.

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Key Concepts

These are the key concepts you need to understand to accurately answer the question.

Hypocalcemia
Hypocalcemia is a condition in which there are lower than normal levels of calcium in the blood. Calcium is vital for bone health and crucial for proper functioning of muscles and nerves. When calcium levels drop, it affects the body's ability to perform these functions effectively.

Some common symptoms of hypocalcemia include:
  • Muscle cramps
  • Fatigue
  • Numbness or tingling
  • Anxiety or depression
One of the key clinical signs of hypocalcemia is Trousseau's sign, which involves using a blood pressure cuff to detect carpopedal spasms. This is important as detecting hypocalcemia early can prevent more severe complications, such as cardiac issues and bone disturbances.
Healthcare professionals need to identify these symptoms promptly to provide necessary treatment, which might include dietary supplements or medications that increase calcium levels.
Carpopedal Spasms
Carpopedal spasms are involuntary muscle contractions that can affect the hands and feet. These spasms happen due to an imbalance in electrolytes, particularly involving calcium. When the levels of calcium in the blood are low (hypocalcemia), it can cause the muscles in the hands and feet to contract involuntarily.

During a Trousseau sign test, inflating a blood pressure cuff on the arm for a few minutes can trigger these spasms. This occurs because the temporary reduction in blood flow makes the existing low calcium levels even more noticeable, causing a neuromuscular reaction.

Recognizing carpopedal spasms is crucial in diagnosing hypocalcemia because it helps to avoid prolonged complications. Clinicians use this information to evaluate whether a patient's calcium metabolism needs correction and to ensure appropriate treatment is administered.
Nursing Assessment
Nursing assessments are fundamental in diagnosing and managing health conditions such as hypocalcemia. By regularly performing assessments, nurses can detect critical signs and symptoms, like Trousseau's sign, early on.

For Trousseau's sign, the nurse inflates a blood pressure cuff above the patient's systolic pressure and monitors for involuntary movements in the hand and wrist often indicative of carpopedal spasms. This is a proactive step in nursing care and is an essential skill for early detection of calcium imbalances.

Key factors included in a comprehensive nursing assessment for hypocalcemia may include:
  • Reviewing patient history for risk factors such as vitamin D deficiency or kidney disease
  • Physical assessment for muscle twitching or spasms
  • Order and interpret blood tests for calcium levels
With an accurate nursing assessment, timely intervention can be provided and can help mitigate the acute symptoms and underlying causes of hypocalcemia.

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