The nurse is assessing a client with hypocalcemia.
What clinical manifestation would the nurse expect to note in this client?
A.
Positive Trousseau’s sign.
B.
Hyperactive deep tendon reflexes.
C.
Hyperactive bowel sounds.
D.
Muscle twitching.
The correct answer and Explanation is :
The correct answer is: A. Positive Trousseau’s sign.
Explanation:
Hypocalcemia, or low calcium levels in the blood, can manifest in various clinical signs and symptoms due to its effects on neuromuscular and cardiovascular functions. Calcium is crucial for maintaining proper neuromuscular excitability and muscle contraction, and its deficiency can lead to several specific manifestations.
- Positive Trousseau’s Sign: This is a classic clinical manifestation of hypocalcemia. To perform the Trousseau’s sign test, a sphygmomanometer cuff is inflated above the patient’s systolic blood pressure for several minutes. A positive sign is indicated by the development of carpal spasm, or involuntary contraction of the muscles of the hand and forearm. This response is due to increased neuromuscular excitability caused by low calcium levels, which affects the function of nerves and muscles.
- Hyperactive Deep Tendon Reflexes: While hyperactive deep tendon reflexes can be associated with hypocalcemia, they are not as specific as Trousseau’s sign. Increased neuromuscular excitability in hypocalcemia can lead to exaggerated reflexes, but this is a more general sign and not as definitive for hypocalcemia alone.
- Hyperactive Bowel Sounds: Hypocalcemia typically does not present with hyperactive bowel sounds. In fact, hypocalcemia is more commonly associated with decreased bowel motility or constipation. Hyperactive bowel sounds are more often linked to other conditions, such as hyperthyroidism or gastrointestinal disturbances.
- Muscle Twitching: Muscle twitching can occur with hypocalcemia due to increased neuromuscular excitability. However, this sign is less specific compared to Trousseau’s sign, and muscle twitching can also be associated with other conditions and imbalances.
In summary, a positive Trousseau’s sign is a hallmark of hypocalcemia, making it the most specific and reliable clinical manifestation among the options provided. It reflects the increased neuromuscular excitability due to low calcium levels, making it a key indicator for this electrolyte imbalance.