A client who has a recent closed head injury reports a severe headache and is restless. Which of the following is an appropriate nursing intervention?

Choice A: Instruct the client to lean forward This action is not related to the assessment of asterixis. Leaning forward can be part of the physical examination for other conditions, such as assessing for spinal issues or abdominal pain, but it does not provoke the characteristic flapping motion of the hands seen in asterixis.

Choice B: Ask the client to extend the arms This is the correct method to assess for asterixis. The patient is asked to extend their arms and dorsiflex their wrists. The nurse then observes for any involuntary flapping movements of the hands, which would indicate the presence of asterixis. This sign is indicative of a disturbance in the central nervous system’s regulation of muscle tone, often due to metabolic liver dysfunction. To assess for asterixis, the nurse should ask the client to extend their arms, which is the standard method for eliciting this sign. The presence of asterixis can help in the diagnosis of hepatic encephalopathy and other metabolic conditions affecting the brain’s control of muscle tone.

Choice C: Dorsiflex the client’s foot Dorsiflexion of the foot is not a method used to assess for asterixis. While changes in muscle tone can be assessed in the lower limbs, asterixis is specifically a hand tremor and is best observed in the upper extremities.

Choice D: Measure the abdominal girth Measuring abdominal girth is relevant in the assessment of ascites, which can occur in cirrhosis, but it is not a method for assessing asterixis. Ascites refers to the accumulation of fluid in the peritoneal cavity, leading to increased abdominal size, which is a common complication of cirrhosis.

- Step 1: Identify the required dose in grams. The client is scheduled to receive 30 grams of lactulose.

- Step 2: Identify the concentration of the available solution. The available solution contains 5 grams of lactulose per 10 mL.

- Step 3: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:

- 5 grams is to 10 mL as 30 grams is to X mL.

- In other words, 5 g : 10 mL = 30 g : X mL.

- Step 4: Solve for X using cross-multiplication and division:

- Cross-multiplication gives us: 5 g × X mL = 30 g × 10 mL.

- Simplifying this gives us: 5X = 300.

- Dividing both sides by 5 gives us: X = 300 ÷ 5.

- Calculating the division gives us: X = 60.

60 mL of the lactulose solution should be poured into the medication cup to administer the required dose of 30 grams.