The nurse is reviewing the record of a client with a diagnoses of Cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?

Dorsiflex the client's foot

Ask the client to extend the arms

Measure the abdominal girth

Instruct the client to lean forward

Answer and Explanation

The Correct Answer is B

A. Dorsiflex the client’s foot: Foot dorsiflexion does not assess asterixis; it is used in neurologic tests (e.g., clonus assessment).

B. Ask the client to extend the arms: Asterixis ("liver flap") is a flapping tremor seen in hepatic encephalopathy due to high ammonia levels. The nurse assesses for asterixis by asking the client to extend their arms and dorsiflex their wrists—a positive sign is a flapping movement of the hands.

C. Measure the abdominal girth: Abdominal girth measurement is used to assess ascites, not asterixis.

D. Instruct the client to lean forward: Leaning forward does not help in assessing asterixis; it is more relevant in pericarditis (relieves chest pain).

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Hang IV fluids of CSNS with 20 mEq of potassium chloride at 125 ml/hr: Fluid resuscitation is important, but potassium should not be administered until electrolyte levels are assessed. Also, potassium administration in a client with a bowel obstruction requires caution due to the risk of hyperkalemia if renal function is impaired.

B. Insert a nasogastric tube: A nasogastric (NG) tube is essential in managing bowel obstruction as it helps decompress the stomach, relieve pressure, and prevent aspiration. This should be done first to stabilize the client.

C. Draw a basic metabolic panel: Checking electrolyte imbalances is important but should be done after stabilizing the client with NG tube insertion.

D. Ambulate in the hallway: Ambulation is contraindicated in acute bowel obstruction due to the risk of worsening symptoms such as nausea, vomiting, and severe pain.

A. “I understand how frustrating this must be for you, just be strong.” B. "Are you thinking about not continuing treatment.” C. "You must keep thinking about the good things in your life." D. “I can see that you are upset. I can sit down and we can talk.”

Correct Answer is D

Explanation

A. "I understand how frustrating this must be for you, just be strong." : While it acknowledges frustration, it dismisses the client’s emotions and offers an unrealistic solution ("just be strong").

B. "Are you thinking about not continuing treatment?" : This response is inappropriate because the client has not indicated nonadherence. It may also make the client feel defensive rather than supported.

C. "You must keep thinking about the good things in your life." : While positive thinking is beneficial, this statement invalidates the client's distress rather than addressing their concerns.

D. "I can see that you are upset. I can sit down and we can talk.": This is a therapeutic response that acknowledges the client’s feelings and provides an opportunity for open discussion, which is key in supporting clients with chronic illnesses.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is reviewing the record of a client with a diagnoses of Cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The emergency room nurse is caring for a client just diagnosed with a bowel obstruction secondary to adhesions. Which of the following orders should the nurse complete first?

Correct Answer is B

Explanation

The nurse is caring for a client diagnosed with Crohn's Disease who is crying. The client tells the nurse, am so frustrated. I never know when I will get sick and end up in the hospital" which statement would be the nurse's best response?

Correct Answer is D

Explanation

The nurse is caring for a client diagnosed with cancer of the pancreas head who is complaining of nausea, severe epigastric pain, and jaundice. Which of the following stool characteristics can the nurse anticipate?

Which of the following is a characteristic feature of irritable bowel syndrome?

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

A client with end stage liver disease, cirrhosis, and ascites is scheduled for a paracentesis. Which of the following interventions can be anticipated related to care of this patient?

The nurse is teaching a newly diagnosed client with celiac disease. Which of the following statements made by the client indicate understanding on the teaching?

A nurse is caring for a client who has ulcerative colitis and is teaching the client about the common link with Crohn's disease. Which of the following information should the nurse include?

The nurse is providing education to a client with a history of Crohn's Disease and a new diagnosis of anemia. Which of the following statements by the client would require farther teaching?

A client admitted with liver cancer and jaundice. Which of the following skin deposits are related to jaundice and cause itching?