Medical Surgical Pancreatitis #1

Question

The nurse caring for a client with acute pancreatitis notices a carpal spasm while assessing blood pressure. Which action will the nurse perform next?

Answers

  1. Call the health care provider for a blood glucose level STAT.
    • Rationale:

      This answer is not correct because a positive Trousseau sign is not indicative of alterations in serum glucose levels; therefore, this is not the next action by the nurse based on the current data.

  2. Call the health care provider for amylase and lipase levels.
    • Rationale:

      This answer is not correct because alterations in amylase and lipase levels will not cause a positive Trousseau sign; therefore, this is not the next action by the nurse based on the current data.

  3. Call the health care provider for a calcium level STAT.
    • Rationale:

      This answer is correct because this finding indicates hypocalcemia and requires the nurse to call the healthcare provider STAT for serum calcium levels.

  4. Call the health care provider for a potassium level STAT.
    • Rationale:

      This answer is not correct because a positive Trousseau sign is not indicative of alterations in serum potassium levels; therefore, this is not the next action by the nurse based on the current data.

Overview

Trousseau sign is carpopedal spasm caused by inflating the blood-pressure cuff. A positive Trousseau sign is elicited when a client is experiencing low serum calcium levels (i.e., hypocalcemia).

Explanation

Learning Outcomes

A positive Trousseau sign is elicited when a client is experiencing low serum calcium levels (i.e., hypocalcemia). Hypocalcemia is prevalent in acute pancreatitis since 40-75% occur in acute pancreatitis. When this sign occurs with blood pressure assessment, it indicates significant hypocalcemia requiring immediate intervention by the nurse. Based on the data, the next action from the nurse is to call the healthcare provider for a STAT serum calcium level. Blood glucose, potassium, and amylase/lipase levels will not cause a positive Trousseau’s sign.

Test Taking Tip

Consider the client’s diagnosis and the implications of a positive Trousseau sign to answer this question correctly.

Video Rationale