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: Trousseau's sign is assessed by placing a blood pressure cuff on the arm and checking for carpopedal spasms when the cuff is inflated.

Step-by-step solution

Identify Trousseau's sign

Trousseau's sign is a medical sign that suggests latent tetany, usually associated with hypocalcemia, or low calcium levels in the blood. It is assessed by inflating a blood pressure cuff on the patient's arm, usually, for 3 minutes, and observing if there are any carpopedal spasms.

Review the answer choices

Now that we understand what Trousseau's sign is, we can review each of the answer choices: A. Tap cranial nerves 7 and cranial nerve 5 and check for grimacing of the face – This relates to facial nerve assessment, not Trousseau's sign. B. Place a blood pressure cuff on the arm and check for carpopedal spasms when the cuff is inflated – This is the correct method to assess Trousseau's sign. C. Check the deep tendon reflexes by tapping the knee – This evaluates patellar or knee-jerk reflex, not Trousseau's sign. D. Monitor the client for nausea when cold water is used to irrigate the ear canal – This assesses for the vestibular system, and is not related to Trousseau's sign.

Select the correct answer

Based on our understanding of Trousseau's sign and assessing the answer choices, the correct answer is: B. Place a blood pressure cuff on the arm and check for carpopedal spasms when the cuff is inflated.

Key concepts

Hypocalcemia

Hypocalcemia refers to a lower-than-normal level of calcium in the blood. This condition can have various causes, such as vitamin D deficiency, kidney disease, or parathyroid dysfunction.

Calcium plays a pivotal role in various bodily functions, including bone health, muscle contractions, and nerve signaling. Therefore, hypocalcemia can lead to symptoms like tingling in the lips, fingers, and feet, muscle cramps, seizures, and, as noted in the exercise, carpopedal spasms. These symptoms arise because low calcium levels increase neuronal excitability and muscular contractions.

For students and healthcare providers, understanding the clinical manifestations of hypocalcemia is essential. Recognizing these symptoms can significantly impact patient care, leading to prompt identification and treatment of the underlying condition. For those preparing for medical exams, like the NCLEX-RN, familiarity with conditions like hypocalcemia is a must.

Carpopedal Spasms

Carpopedal spasms are involuntary, painful contractions of the muscles in the hands and feet. They are often associated with hypocalcemia and can be precipitated by conditions that invoke hyperventilation, leading to a decrease in carbon dioxide levels, alkalosis, and subsequent reduction in the ionized fraction of serum calcium.

During a nursing assessment, observing for carpopedal spasms can be a significant indicator of hypocalcemia and other electrolyte imbalances. Nurses may need to assess for Trousseau's sign to help diagnose the presence of latent tetany, which can be elicited by inflating a blood pressure cuff on the patient’s arm. This maneuver may induce the spasms due to ischemia produced by the cuff. Understanding the link between these spasms and hypocalcemia is valuable for both clinical practice and exam preparation, including the NCLEX-RN.

Nursing Assessment

Nursing assessment is a fundamental aspect of patient care, involving a comprehensive and systematic evaluation of a patient's physiological, psychological, sociocultural, developmental, and spiritual needs.

Detecting Trousseau's sign is a specific aspect of a physical examination that nurses perform when hypocalcemia is suspected. It involves inflating a blood pressure cuff on the patient's arm above systolic pressure for several minutes and watching for signs of muscular spasm.

A thorough nursing assessment is critical as it forms the foundation for all subsequent decision-making and care planning. It enables the nurse to create a personalized care plan that addresses all identified issues, including electrolyte imbalances like hypocalcemia, and to monitor the patient's response to treatment.

NCLEX-RN Exam Preparation

Preparing for the National Council Licensure Examination for Registered Nurses (NCLEX-RN) is a step each nursing graduate must take to become a licensed nurse. This exam tests the knowledge, skills, and abilities essential for safe and effective entry-level nursing practice.

Students preparing for the NCLEX-RN should focus on mastering various content areas, including pathophysiology, pharmacology, and patient care management. Understanding how to assess for Trousseau's sign, recognizing symptoms of hypocalcemia, and knowing how to intervene are crucial aspects that might be tested on the exam.

Effective study strategies include repetitive learning, practice questions, simulation exams, and staying current with the latest evidence-based practice guidelines. Incorporating these strategies helps ensure that nursing graduates are well-prepared to pass the NCLEX-RN and deliver high-quality patient care.