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).

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Correct Answer is A

Explanation

A. Reduce the client's intake of protein: Protein metabolism produces ammonia, which worsens hepatic encephalopathy. Reducing dietary protein (especially red meat) helps lower ammonia levels. However, some protein is necessary, so a diet high in plant-based protein is preferred.

B. Administer vitamin K: Vitamin K is used to manage coagulopathy in liver disease but does not affect ammonia levels.

C. Restrict the client's intake of fluids: Fluid restriction is necessary for hyponatremia or ascites, but it does not help reduce ammonia levels.

D. Administer diuretics: Diuretics are used for ascites and edema, not ammonia reduction.

A. increased serum amylase B. Decreased serum lipase C. Increased serum calcium D. Decreased WBC

Correct Answer is A

Explanation

A. Increased serum amylase: Amylase, like lipase, is an enzyme produced by the pancreas. In acute pancreatitis, amylase levels rise significantly due to pancreatic inflammation.

B. Decreased serum lipase: Lipase is actually increased, not decreased, in pancreatitis. Elevated lipase is more specific than amylase for diagnosing pancreatitis.

C. Increased serum calcium: Hypocalcemia (low calcium) is more commonly seen in acute pancreatitis due to fat necrosis binding calcium in the pancreas.

D. Decreased WBC: WBC count is usually elevated in acute pancreatitis due to the body’s inflammatory response.

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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

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