A client arrives at the emergency room with symptoms of peptic ulcer disease. Which of these symptoms should the nurse identify as the priority?

Choice A reason: Instructing the client to perform range-of-motion exercises to his lower extremities immediately after cardiac catheterization is not recommended. The client should maintain bed rest with the affected leg straight to prevent bleeding from the catheter insertion site.

Choice B reason: Ambulating the client 1 hour following the procedure is not advised. After femoral artery access, the client is typically required to remain on bed rest with the affected leg straight for several hours to ensure hemostasis and prevent bleeding².

Choice C reason: Restricting the client's fluid intake is not a standard post-procedure action. Adequate hydration is important after cardiac catheterization to help flush the contrast dye used during the procedure from the body, unless contraindicated.

Choice D reason: Assessing the color, temperature, and pulse in the affected extremity is crucial for detecting signs of bleeding, hematoma formation, or arterial occlusion. These assessments should be performed regularly as part of post-cardiac catheterization care².

Choice A: Instruct the client to lean forward This action is not related to the assessment of asterixis. Leaning forward can be part of the physical examination for other conditions, such as assessing for spinal issues or abdominal pain, but it does not provoke the characteristic flapping motion of the hands seen in asterixis.

Choice B: Ask the client to extend the arms This is the correct method to assess for asterixis. The patient is asked to extend their arms and dorsiflex their wrists. The nurse then observes for any involuntary flapping movements of the hands, which would indicate the presence of asterixis. This sign is indicative of a disturbance in the central nervous system’s regulation of muscle tone, often due to metabolic liver dysfunction. To assess for asterixis, the nurse should ask the client to extend their arms, which is the standard method for eliciting this sign. The presence of asterixis can help in the diagnosis of hepatic encephalopathy and other metabolic conditions affecting the brain’s control of muscle tone.

Choice C: Dorsiflex the client’s foot Dorsiflexion of the foot is not a method used to assess for asterixis. While changes in muscle tone can be assessed in the lower limbs, asterixis is specifically a hand tremor and is best observed in the upper extremities.

Choice D: Measure the abdominal girth Measuring abdominal girth is relevant in the assessment of ascites, which can occur in cirrhosis, but it is not a method for assessing asterixis. Ascites refers to the accumulation of fluid in the peritoneal cavity, leading to increased abdominal size, which is a common complication of cirrhosis.