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 C

Explanation

Choice A rationale:

Avocados and cheese are not specifically recommended for a client with a postoperative wound infection. While a balanced diet is important for overall health, yogurt or buttermilk is a better choice due to their probiotic content, which may promote gut health and support the immune system.

Choice B rationale:

Fresh fruits are generally a healthy dietary choice, but they are not particularly relevant to the management of a postoperative wound infection. The emphasis for this client should be on foods that support wound healing and immune function, such as yogurt or buttermilk.

Choice D rationale:

Green leafy vegetables are rich in vitamins and minerals, but they are not a primary focus for a client with a postoperative wound infection. Again, the emphasis should be on foods that support the immune system and overall recovery, such as yogurt or buttermilk.

A. Assessment of tobacco use geared toward adolescents. B. Exploration of stress self-management techniques. C. Video with statistics showing trends in suicide rates. D. Handouts for local substance abuse treatment centers.

Correct Answer is B

Explanation

Choice A rationale:

Assessment of tobacco use geared toward adolescents. Rationale: While assessing tobacco use is essential for promoting health in adolescents, the question is about developing a class about mental health and addressing the increase in suicides in the community. Assessing tobacco use is not directly related to this topic. Stress self-management techniques are more relevant.

Choice B rationale:

Exploration of stress self-management techniques. Rationale: This is the correct answer. Addressing stress and teaching adolescents self-management techniques is crucial in the context of mental health promotion and suicide prevention. Adolescents often face stressors, and providing them with effective strategies to manage stress can contribute to their overall well-being.

Choice C rationale:

Video with statistics showing trends in suicide rates. Rationale: While providing statistics about suicide rates can be informative, it may not be the most engaging or effective method for teaching adolescents about mental health and stress management. Interactive activities and skill-building exercises are often more beneficial.

Choice D rationale:

Handouts for local substance abuse treatment centers. Rationale: Providing handouts for substance abuse treatment centers

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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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Correct Answer is C

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Correct Answer is B

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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?