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    HESI RN EXIT 3 PROCTORED EXAM

    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?

    Explanation & Rationale

    A: Using a different sphygmomanometer would not address the underlying cause of the spasms, which is likely not related to the equipment itself. B: Taking the blood pressure in the other arm may avoid the spasms temporarily, but it does not address the potential underlying medical issue causing the spasms. C: Administering an antianxiety medication is not indicated as the spasms are not necessarily related to anxiety; they could be a sign of a physiological condition. D: Reviewing the client's serum calcium level is the most appropriate action. The spasms described are indicative of Trousseau's sign, which is associated with hypocalcemia. Hypocalcemia can cause increased neuromuscular excitability, leading to spasms. It is important to identify and treat the underlying cause of the spasms, which in this case could be a calcium deficiency.

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