Marie Joy’s lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated?
A. Positive Trousseau's sign
B. Positive Chvostek's sign
C. Tetany
D. Paresthesia
Correct Answer: A. Positive Trousseau’s sign
In a client with hypocalcemia, a positive Trousseau’s sign refers to carpopedal spasm that develops usually within 2 to 5 minutes after applying and inflating a blood pressure cuff to about 20 mm Hg higher than systolic pressure on the upper arm. This spasm occurs as the blood supply to the ulnar nerve is obstructed.
Option B: Chvostek’s sign refers to twitching of the facial nerve when tapping below the earlobe. In the late 1800s, Dr. Chvostek noticed that mechanical stimulation of the facial nerve (as with the fingertip of the examiner, for example) could lead to twitching of the ipsilateral facial muscles. The long-accepted explanation is that this resulted from hypocalcemia, and this relationship became known as the Chvostek sign.
Option C: Tetany is a clinical manifestation of hypocalcemia denoted by tingling in the tips of the fingers around the mouth and muscle spasms in the extremities and face. Tetany is generally induced by a rapid decline in serum ionized calcium. Tetany is usually most dangerous and most commonly seen in the presence of respiratory alkalosis causing hypocalcemia.
Option D: Paresthesia refers to numbness or tingling. Paresthesia is an abnormal sensation of the skin (tingling, pricking, chilling, burning, numbness) with no apparent physical cause. Paresthesia may be transient or chronic and may have any of dozens of possible underlying causes.
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