A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?

Asterixis

Fetor hepaticus

Palmar erythema

Constructional apraxia

Answer and Explanation

The Correct Answer is A

Choice A reason:

Asterixis is a characteristic sign of hepatic encephalopathy, characterized by a flapping tremor of the hands. It is associated with liver dysfunction and is indicative of impaired ammonia metabolism in the brain.

Choice B reason:

Fetor hepaticus refers to a musty, sweet odor of the breath that is associated with severe liver disease. It is not related to the flapping tremor observed in this case.

Choice C reason:

Palmar erythema is a reddening of the palms and is associated with various conditions, including liver disease. However, it is not the sign described in the scenario.

Choice D reason:

Constructional apraxia is a neurological deficit characterized by difficulty in copying or constructing simple drawings or designs. It is not related to the flapping tremor seen in hepatic encephalopathy.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

-blood glucose level of 250 mg/dL, which indicates hyperglycemia and can worsen the inflammation of the pancreas

- hemoglobin level of 8 g/dL and hematocrit of 24%, which indicate anemia and can impair oxygen delivery to the tissues

A. Assess for signs of infection. B. Assess for a patent airway. C. Assess ability to clear oral secretions. D. Assess for ability to communicate.

Correct Answer is B

Explanation

Choice A reason:

While assessing for signs of infection is important, ensuring a patent airway takes precedence immediately following surgery.

Choice B reason:

This statement is correct. Assessing for a patent airway is the top priority in postoperative care to ensure the patient can breathe effectively.

Choice C reason:

Assessing the ability to clear oral secretions is important, but it is secondary to ensuring a patent airway.

Choice D reason:

Assessing the ability to communicate is important, but it is not the immediate priority after surgical resection for oropharyngeal cancer.

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A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has acute pancreatitis. Exhibits Complete the following sentence. When prioritizing client needs, the nurse should first address the dropdown followed by dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?

Correct Answer is B

Explanation

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