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Zorluk: Çok zorReduction of Risk Potential

A 45-year-old client with acute necrotizing pancreatitis is being monitored in the high-acuity unit. Over a four-hour observation period, the client's serum calcium drops dramatically from 8.8 mg/dL to 6.5 mg/dL, accompanied by a rising heart rate of 118 bpm. The client reports a progressive 'pins and needles' sensation around the mouth and in the fingertips. As an unlicensed assistive personnel (UAP) approaches the bedside and begins wrapping a sphygmomanometer cuff around the client's upper arm, what represents the paramount risk reduction action?

  1. Stop the cuff inflation immediately, as inducing ischemia in the arm will precipitate Trousseau's sign and indicates an impending risk of airway obstruction from laryngospasm.Cevap
  2. B
    Permit the blood pressure measurement to finish to ascertain if the tachycardia is an early indicator of hypovolemic shock from pancreatic fluid shifts.
  3. C
    Instruct the UAP to defer vital signs and assist the nurse in palpating the abdomen prior to auscultating bowel sounds to assess for paralytic ileus.
  4. D
    Delegate the UAP to secure the blood pressure reading and then immediately perform a targeted cranial nerve evaluation to determine the cause of the facial paresthesia.

Cevap

The clinician must immediately stop the UAP from inflating the blood pressure cuff, as it will induce ischemia and provoke a severe carpopedal spasm (Trousseau's sign), signaling high risk for fatal laryngospasm.
The correct answer accurately identifies that a serum calcium level of 6.5 mg/dL is critically low. In this state of severe neuromuscular excitability, inflating a blood pressure cuff induces local tissue ischemia, which triggers Trousseau's sign (a painful carpopedal spasm). Eliciting this sign indicates the client is at extreme risk for widespread tetany, including life-threatening laryngospasm. The nurse must prioritize preventing this iatrogenic trigger over routine data collection.

Adım Adım Çözüm

1
Analyze the laboratory and clinical trends.
Serum calcium has plummeted to 6.5 mg/dL (severe hypocalcemia), and the client is exhibiting circumoral and peripheral paresthesia.
Hypocalcemia increases neuromuscular excitability, leading to tetany, arrhythmias, and potentially fatal laryngospasm.
2
Evaluate the UAP's impending action.
The UAP is about to inflate a blood pressure cuff on the client's arm.
Understanding how routine procedures interact with severe electrolyte imbalances is critical for risk reduction.
3
Synthesize the physiological risk associated with the UAP's action.
Inflating the cuff above systolic pressure induces localized ischemia, which triggers Trousseau's sign (carpopedal spasm) in hypocalcemic clients.
Triggering this reflex can cause severe pain, exacerbate tetany, and indicates an extreme risk for sudden airway obstruction via laryngospasm.
4
Determine the highest priority intervention.
Halting the blood pressure measurement is the absolute priority to prevent an iatrogenic crisis.
Risk reduction mandates preventing predictable, life-threatening complications before they occur.

Anahtar Kavram

Severe Hypocalcemia and Risk of Iatrogenic Tetany/Laryngospasm
Tahmini Süre:1m 30s
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Konular

Reduction of Risk Potential

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