An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm.

After confirming the presence of the spasms, which action should the nurse take?

Review the client's serum calcium level.

Administer an as-needed (PRN) antianxiety medication.

Ask the UAP to take the blood pressure in the other arm.

Tell the UAP to use a different sphygmomanometer.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Review the client's serum calcium level. Rationale: Checking the client's serum calcium level is not the most appropriate action in this situation. Hand and finger spasms during blood pressure measurement are more likely due to discomfort or muscle tension than a calcium deficiency. There is no immediate indication that the client's calcium level needs to be assessed urgently.

Choice B rationale:

Administer an as-needed (PRN) antianxiety medication. Rationale: Administering an antianxiety medication is not indicated in this situation. The client's symptoms of hand and finger spasms during blood pressure measurement are not likely related to anxiety. It is essential to address the immediate issue of obtaining an accurate blood pressure reading.

Choice C rationale:

Ask the UAP to take the blood pressure in the other arm. Rationale: This is the correct answer. When the UAP reports spasms in the client's right hand and fingers while taking blood pressure using the same arm, the nurse should prioritize obtaining an accurate blood pressure measurement. Asking the UAP to use the other arm can help ensure a more reliable reading. Muscle spasms in the arm being used for blood pressure measurement can lead to inaccurate results.

Choice D rationale:

Tell the UAP to use a different sphygmomanometer. Rationale: In this scenario, the issue appears to be related to muscle spasms in the client's hand and fingers rather than the sphygmomanometer itself. Changing the sphygmomanometer is unlikely to resolve the problem. The priority is to obtain an accurate blood pressure reading by addressing the spasms in the arm being used.

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Correct Answer is D

Explanation

Choice A rationale:

Assigning the newly hired unlicensed assistive personnel (UAP) to clients who require the least complex level of care is not the best approach to ensure adequate care for all clients. It may limit the UAP's opportunities for learning and growth and may not fully utilize their skills.

Choice B rationale:

Asking the most experienced UAP to partner with the newly hired UAP is a reasonable approach, but it may not provide a comprehensive solution. It can be beneficial for mentorship and guidance, but it may not address all the clients' needs efficiently.

Choice C rationale:

Reviewing the UAP's skills checklist and experience with the person who hired the UAP is an important step in assessing competency. However, it alone may not ensure adequate care for all clients. Competency assessment should be ongoing and include direct observation of care delivery.

A. CP is one of the most common permanent physical disabilities in children. B. Brain damage with CP is not progressive but does have a variable course. C. Severe motor dysfunction determines the extent of successful habilitation. D. Continued development of the brain lesion determines the child's outcome.

Correct Answer is B

Explanation

Choice A rationale:

CP being one of the most common permanent physical disabilities in children is a general statement but does not directly address the mother's question about the progression of her child's impaired movements. It does not provide an explanation for the potential course of CP.

Choice B rationale:

Brain damage with CP is not progressive but does have a variable course. This response provides the best explanation to the mother's question. CP is a static neurological condition, which means that the initial brain injury that led to CP does not worsen over time. However, the functional abilities and impairments of a child with CP can vary widely and may change as the child grows and develops. Some children may improve with therapy and interventions, while others may have relatively stable impairments.

Choice C rationale:

Severe motor dysfunction determines the extent of successful habilitation is not entirely accurate. While the severity of motor dysfunction does play a role in the challenges a child with CP may face, it does not solely determine the extent of successful habilitation. Many factors, including early intervention, therapy, and individualized care, can influence a child's progress and potential for improvement.

Choice D rationale:

Continued development of the brain lesion determines the child's outcome is not an accurate statement. CP is primarily caused by non-pro

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An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm.

After confirming the presence of the spasms, which action should the nurse take?