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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The urea breath test is typically used to diagnose Helicobacter pylori (H. pylori) infection in the stomach. H. pylori can lead to gastritis and ulcers, which can interfere with nutrient absorption and contribute to imbalanced nutrition.
Choice B reason:
Impaired dentition related to gingivitis is not directly related to the need for a urea breath test. This diagnosis pertains to dental health, not gastric health.
Choice C reason:
Diarrhea related to Clostridium difficile infection is not directly related to the need for a urea
breath test. This diagnosis pertains to a bacterial infection in the colon, not H. pylori infection in the stomach.
Choice D reason:
Risk for impaired skin integrity related to peptic ulcers is also not directly related to the need for a urea breath test. This diagnosis pertains to potential skin breakdown due to ulcers, not the
assessment of H. pylori infection.
Correct Answer is D
Explanation
Choice A reason:
Avoiding chemicals that are toxic to the liver is a valid recommendation for liver health, but it is not specific to preventing hepatitis E virus infection.
Choice B reason:
Limiting alcohol intake is an important measure for maintaining liver health, but it is not a specific prevention measure for hepatitis E virus.
Choice C reason:
Wearing a condom during sexual contact is an important measure to prevent the transmission of certain sexually transmitted infections (STIs), but hepatitis E is primarily transmitted through contaminated water and not through sexual contact.
Choice D reason:
Following proper hand-washing techniques is a crucial preventive measure for hepatitis E virus. This virus is primarily transmitted through the fecal-oral route, often via contaminated water or food. Proper hand hygiene can significantly reduce the risk of transmission.
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