A client is 12 hours postoperative following a total thyroidectomy. While inflating the blood pressure cuff to measure the client's vital signs, the practical nurse observes that the client's hand and fingers suddenly curl inward in a spasm. Which action should the nurse take first?
- Notify the registered nurse immediately to report the observation.Answer
- BMassage the client's hand and fingers to relieve the muscle cramping.
- CPrepare to administer a prescribed dose of intravenous calcium gluconate.
- DEvaluate the client's most recent serum potassium level to determine the cause.
Answer
Notify the registered nurse immediately to report the observation.
The correct answer is to notify the registered nurse immediately. The client is exhibiting Trousseau's sign, which is an early clinical indication of hypocalcemia (low serum calcium). Because the parathyroid glands are located on the posterior surface of the thyroid, they can be inadvertently damaged or removed during a thyroidectomy. Hypocalcemia can quickly escalate to severe tetany and laryngospasm, which compromises the client's airway. Immediate escalation is required for patient safety.
Step-by-Step Solution
Key Concept
Recognizing post-thyroidectomy complications (hypocalcemia) and escalating care