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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is c. Recommend using a breast shield.
Choice A reason: Offering supplemental formula feedings is not the first-line action for inverted nipples as it does not address the issue and may lead to nipple confusion, potentially complicating future breastfeeding attempts.
Choice B reason: Teaching about the use of a breast pump is beneficial for milk expression but does not directly assist with the immediate concern of latching issues due to inverted nipples.
Choice C reason: Using a breast shield can be helpful for mothers with inverted nipples. It can temporarily draw out the nipple, allowing the baby to latch on more easily. This tool acts as a bridge between the breast and the baby's mouth, facilitating breastfeeding while the mother works on long-term solutions for her inverted nipples.
Choice D reason: Encouraging the use of ice on the areola may temporarily stiffen the nipple, but it is not a recommended practice for addressing inverted nipples as it can cause discomfort and may not be effective in promoting a successful latch.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A rationale:
The nurse should consider the patient's physical abilities and limitations when planning recreational activities because this information is crucial for ensuring the safety and appropriateness of the activities. For example, a patient with limited mobility may benefit from activities that can be done in a seated position, while a patient with greater physical abilities may be able to engage in more active pursuits.
Choice B rationale:
The patient's cognitive abilities and limitations should also be taken into account when planning activities. Some patients may have cognitive impairments that require simpler, more straightforward activities, while others may be able to participate in more complex or intellectually stimulating options. This ensures that the activities are enjoyable and suitable for the individual's cognitive capacity.
Choice C rationale:
Considering the patient's interests and preferences is essential to make the recreational activities meaningful and enjoyable. It is important to involve patients in activities they find interesting and pleasurable, as this can have a positive impact on their emotional and psychological well-being during the rehabilitation process.
Choice E rationale:
The patient's cultural and religious background is an important consideration when planning activities. Some activities may be more or less acceptable to individuals from different cultural or religious backgrounds. It's essential to respect cultural and religious preferences to ensure that the activities do not cause discomfort or offense to the patients.
Choice D rationale:
The patient's age and gender are not the primary factors to consider when selecting appropriate activities for individuals in a rehabilitation and restorative care setting. Age and gender do not necessarily determine a person's interests, physical abilities, or cognitive limitations. Therefore, they are not as relevant as the other factors listed in this context.
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