Question

The nurse is checking the client for a positive Trousseau's sign. Which finding indicates a positive Trousseau's sign? A. Facial grimacing B. Carpopedal spasms C. Nuchal rigidity D. Abdominal tenderness

Short answer

Answer: B. Carpopedal spasms

Step-by-step solution

Understand the terms in all options

In this step, let's make sure that we understand what each option represents: A. Facial grimacing - The action of making a distorted face, typically expressing pain, disgust, or disapproval. B. Carpopedal spasms - Involuntary contractions of the muscles in the wrist and fingers. C. Nuchal rigidity - Neck stiffness, often associated with meningitis. D. Abdominal tenderness - Pain or discomfort in the abdomen when it is touched or pressed.

Identify the finding indicative of a positive Trousseau's sign

Given the definitions in Step 1, we can see that Option B. Carpopedal spasms directly describe the positive Trousseau's sign - involuntary contractions of the muscles in the wrist and fingers.

Conclusion

A positive Trousseau's sign is indicated by the presence of carpopedal spasms (Option B). This is the correct answer, as Trousseau's sign is a test for latent tetany, and carpopedal spasms are the key symptom of a positive result.

Key concepts

Trousseau's Sign

Trousseau's sign is a clinical test used to detect latent tetany in patients. It's an important indicator, particularly for identifying calcium imbalances, such as hypocalcemia. When performing this test, a healthcare provider applies a blood pressure cuff to the patient's arm and inflates it above the systolic blood pressure. The cuff is kept inflated for about three to five minutes.

A positive Trousseau's sign is characterized by the appearance of carpopedal spasms. This reaction indicates neuromuscular irritation due to low calcium levels. As a nursing student preparing for the NCLEX-RN exam, understanding Trousseau's sign ensures you can correctly assess these critical bodily responses, which can be crucial in patient evaluations.

Carpopedal Spasms

Carpopedal spasms are involuntary muscle contractions that occur in the fingers, wrists, and sometimes in the toes and feet. They are a classic sign associated with conditions like hypocalcemia and can be a result of a positive Trousseau's sign.

These spasms are typically caused by low calcium levels in the blood, which leads to increased excitability of nerves and muscles. Recognizing carpopedal spasms is important when conducting assessments, as they could signal underlying biochemical imbalances.

• Common in Trousseau's sign
• Results from low calcium during hypocalcemia
• Seen as the fingers curl into a claw-like shape

Recognizing these spasms helps nurses determine the need for further evaluation and intervention.

Nursing Assessment

Nursing assessment is the first step in the nursing process, crucial for identifying health problems and implementing interventions. When testing for Trousseau's sign, assessment skills are vital for correct identification.

A comprehensive nursing assessment involves collecting data through patient observation, physical examinations, and history taking. For Trousseau's sign, the nurse will observe the patient’s response to the blood pressure cuff application. A thorough assessment ensures holistic care and may involve:

• Checking vitals
• Performing physical exams like the Trousseau's test
• Documenting clinical findings accurately

Competence in assessment enhances patient care and enables timely intervention.

Latent Tetany

Latent tetany is a condition that arises due to low serum calcium levels, yet it doesn’t show obvious spasms or convulsions until provoked by certain tests, like Trousseau's or Chvostek's signs.

It's characterized by increased neural excitability and may be indicative of electrolyte imbalances like hypocalcemia. Recognizing latent tetany in a nursing context means looking for subtle signs and knowing when to conduct specific tests:

• Increased irritability in muscles
• Positive results in Trousseau's or Chvostek's tests
• Underlying causes like vitamin D deficiency or hypoparathyroidism

Understanding latent tetany equips nurses with the knowledge to manage and prevent potential complications.

Clinical Skills

Developing strong clinical skills is fundamental for nursing practice and ensures safe, effective patient care. When assessing signs like Trousseau's, it's important that clinical skills are sharp and precise.

Clinical skills cover a broad range of practices, from assessment to intervention and patient communication. Performing the Trousseau's test accurately requires:

• Competence with equipment, like a blood pressure cuff
• Observation skills to identify subtle signs like carpopedal spasms
• Communication skills to explain procedures to patients

Improving clinical skills through practice and study is vital preparation for the NCLEX-RN exam and professional practice.