Question

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

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

Step-by-step solution

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.

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.

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.