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 A

Explanation

Choice A reason:

This presentation of hepatic encephalopathy includes severe manifestations, such as profound confusion, difficulty in arousal, and the presence of rigidity, indicating advanced neurological impairment. This places the patient in Stage 4, which is the most severe stage of hepatic encephalopathy.

Choice B reason:

Stage 3 is characterized by severe symptoms, such as drowsiness, anxiety, seizures, severe personality changes, confused speech, and shaky hands.

Choice C reason:

Stage 1 is characterized by mild symptoms, such as difficulty thinking, personality changes, poor concentration, and problems with handwriting.

Choice D reason

Stage 2 is characterized moderate symptoms, such as confusion, forgetfulness, poor judgment, and a musty or sweet breath odor.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

-blood glucose level of 250 mg/dL, which indicates hyperglycemia and can worsen the inflammation of the pancreas

- hemoglobin level of 8 g/dL and hematocrit of 24%, which indicate anemia and can impair oxygen delivery to the tissues

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient with hepatic encephalopathy. The nurse's assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy?

Correct Answer is A

Explanation

A nurse is caring for a client who has acute pancreatitis. Exhibits Complete the following sentence. When prioritizing client needs, the nurse should first address the dropdown followed by dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

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