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 C

Explanation

Choice A reason:

While foods high in fiber are generally healthy, they may not specifically address the issue of biliary colic related to cholecystitis.

Choice B reason:

Foods high in starch and proteins are important for overall nutrition, but they may not directly impact biliary colic.

Choice C reason:

This statement is correct. Avoiding foods high in fat is crucial for managing biliary colic in clients with chronic cholecystitis.

Choice D reason:

Avoiding foods high in sodium is important for cardiovascular health, but it is not the primary dietary modification for cholecystitis.

A. "The only time I flush my tube is when I'm putting in medications." B. "I clean my stoma twice a day with alcohol." C. "I try to stay still most of the time to avoid dislodging my tube." D. "I flush my tube with water before and after each of my medications."

Correct Answer is D

Explanation

Choice A reason:

Flushing the tube only when administering medications is not sufficient for proper maintenance. Regular flushing with water helps prevent clogs and ensures tube patency.

Choice B reason:

Cleaning the stoma with alcohol is not necessary and can be irritating to the skin. Mild soap and water are typically recommended for stoma care.

Choice C reason:

While being cautious to avoid dislodging the tube is important, it is not the primary indicator of correct tube management. Proper flushing and care are essential components of tube

maintenance.

Choice D reason:

Flushing the tube with water before and after each medication administration is a crucial step in maintaining tube patency and preventing clogs. This indicates that the patient is managing the

tube correctly.

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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 preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?

Correct Answer is C

Explanation

The management of the patient's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the patient is managing the tube correctly?

Correct Answer is D

Explanation

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