A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). Which of the following medications should the nurse plan to administer after the initial acute phase to manage the client's pain and anxiety?

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.

Choice A: “I have a tight sensation in my lower leg when I forget to put my feet up.” This statement may indicate the presence of edema, which is common in cirrhosis due to hypoalbuminemia and sodium retention. However, it is not as immediately concerning as other symptoms because it can often be managed with diuretics and compression. It is important to monitor for worsening edema, as it can lead to increased discomfort and risk of skin breakdown.

Choice B: “I can’t button my pants anymore because my belly is so swollen.” This statement is concerning because it suggests the development of ascites, which is the accumulation of fluid in the peritoneal cavity, causing abdominal swelling. Ascites can lead to abdominal discomfort, difficulty breathing, and is a sign of advanced liver disease with significant portal hypertension. It requires medical evaluation and management, which may include paracentesis (removal of fluid), diuretics, and sodium restriction. Cirrhosis is a late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases and conditions, such as hepatitis and chronic alcoholism. Portal hypertension is an increase in the blood pressure within a system of veins called the portal venous system. Veins from the stomach, intestine, spleen, and pancreas merge into the portal vein, which then branches into smaller vessels and travels through the liver.

Choice C: “I’m very constipated and have been straining during bowel movements.” While constipation is uncomfortable and can indicate dietary issues or side effects from medication, it is not typically a direct complication of cirrhosis or portal hypertension. However, straining during bowel movements can increase the risk of bleeding from esophageal varices if they are present, so it is important to manage constipation to prevent potential complications.

Choice D: “When I sleep, I have to sit in a recliner so that I can breathe more easily.” This statement indicates orthopnea, which can be associated with ascites or pleural effusions (fluid in the lungs), both of which can occur in the setting of cirrhosis and portal hypertension. While this symptom is concerning and affects the client’s quality of life, it is generally less concerning than the development of ascites, as it can be managed with adjustments in sleeping position and medical management of the underlying fluid accumulation.