The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?
Measure the abdominal girth
Have the client extend their arms
Have the client flex and extend their foot
Ask the client to walk heel to toe
The Correct Answer is B
Choice A Reason: Measuring the abdominal girth is not related to asterixis, which is a tremor of the hand when the wrist is extended. It may indicate ascites, which is a complication of cirrhosis, but not asterixis.
Choice B Reason: This is the correct choice. Asterixis is a flapping tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings. It is caused by abnormal function of the diencephalic motor centers that regulate the muscles involved in maintaining posture. It is a sign of hepatic encephalopathy, which is a neuropsychiatric disorder that occurs in patients with liver disease.
Choice C Reason: Having the client flex and extend their foot is not related to asterixis, which affects the hand and wrist. It may test for ankle clonus, which is a rhythmic contraction of the calf muscles when the foot is dorsiflexed. It indicates an upper motor neuron lesion, but not hepatic encephalopathy.
Choice D Reason: Asking the client to walk heel to toe is not related to asterixis, which affects the hand and wrist. It may test for balance and coordination, which can be impaired in patients with hepatic encephalopathy, but it is not a specific sign of asterixis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because full vision loss in one eye does not necessarily mean that the person is legally blind. Legal blindness depends on the visual acuity and visual field of both eyes.
Choice B Reason: This is correct because legal blindness is defined by the World Health Organization (WHO) as having a visual acuity of 20/200 or worse in the better eye with the best possible correction, such as glasses or contact lenses. This means that the person can see at 20 feet what a normal person can see at 200 feet.
Choice C Reason: This is incorrect because inability to see clearly from 200 feet away without corrective lenses may indicate nearsightedness or myopia, but not legal blindness. Nearsightedness can be corrected with lenses or surgery.
Choice D Reason: This is incorrect because bilateral visual impairment of 20/60 or greater does not meet the criteria for legal blindness. Visual impairment is defined by WHO as having a visual acuity of less than 20/60 but better than 20/200 in the better eye with the best possible correction.
Correct Answer is B
Explanation
Choice A reason: This is incorrect because loss of peripheral vision is not a manifestation of cataracts, but of glaucoma. Glaucoma is a condition that causes increased pressure inside the eye and damage to the optic nerve, which can lead to loss of vision in the outer edges of the visual field. The nurse should assess the client's intraocular pressure and visual field test results to rule out glaucoma.
Choice B reason: This is correct because a decreased ability to perceive colors is a manifestation of cataracts. Cataracts are a condition that causes clouding or opacity of the lens, which is the transparent structure behind the pupil that focuses light onto the retina. Cataracts can reduce the clarity and contrast of vision and make colors appear faded or yellowish. The nurse should ask the client about any changes in color perception or brightness of objects.
Choice C reason: This is incorrect because loss of central vision is not a manifestation of cataracts but of macular degeneration. Macular degeneration is a condition that affects the macula, which is the central part of the retina that is responsible for sharp and detailed vision. Macular degeneration can cause blurred or distorted central vision, difficulty reading or recognizing faces, or dark spots in the visual field. The nurse should assess the client's visual acuity and fundoscopic examination results to rule out macular degeneration.
Choice D reason: This is incorrect because seeing bright flashes of light and floaters is not a manifestation of cataracts but of retinal detachment. Retinal detachment is a condition that occurs when the retina, which is the layer of tissue at the back of the eye that converts light into nerve impulses, separates from its underlying support tissue. Retinal detachment can cause sudden flashes of light, floaters, or shadows in the visual field. The nurse should refer the client to an ophthalmologist immediately if retinal detachment is suspected.
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