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:
A painless sore with raised edges is a characteristic early sign of oral cancer. It may appear as a small, painless lump or sore in the mouth, often with raised edges. This finding should raise suspicion and prompt further evaluation.
Choice B reason:
Diffuse inflammation of the buccal mucosa is a non-specific finding and can be caused by various factors, including infection or irritation. While it's important to assess the oral mucosa for any abnormalities, it is not specific to oral cancer.
Choice C reason:
Dull pain radiating to the ears and teeth is not a characteristic early sign of oral cancer. Pain associated with oral cancer may occur in later stages or if there is local invasion of nerves.
Choice D reason:
Areas of tenderness that make chewing difficult may occur for various reasons, including dental issues or other oral health problems. While this can be distressing for the patient, it is not specific to oral cancer.
Correct Answer is ["B","C","E"]
Explanation
Choice A reason:
Chronic gastritis is not a common immediate postoperative complication of gastric surgery. It is more related to long-term gastric health.
Choice B reason:
Correct. Atelectasis, or partial lung collapse, is a potential complication postoperatively, especially in abdominal surgery. The nurse should assess for signs such as decreased breath sounds and reduced oxygen saturation.
Choice C reason:
Correct. Pneumonia is a potential complication due to reduced lung function and shallow breathing after surgery. The nurse should monitor for signs like fever, increased respiratory rate, and abnormal breath sounds.
Choice D reason:
Malignant hyperthermia is a rare complication related to certain types of anesthesia agents. It is not a common complication after gastric surgery.
Choice E reason:
Correct. Metabolic imbalances, such as electrolyte disturbances or changes in blood glucose levels, can occur after gastric surgery. The nurse should monitor for signs like weakness, confusion, and abnormal laboratory values.
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