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 C

Explanation

Choice A reason:

McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus

Choice B reason:

McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus

Choice C reason:

McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus

Choice D reason:

McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus

A. Keep the patient in a low Fowler's position when at rest. B. Connect the tube to continuous wall suction when not in use. C. Confirm placement of the tube prior to each medication administration. D. Have the patient sip cool water to stimulate saliva production.

Correct Answer is C

Explanation

Choice A reason:

Keeping the patient in a low Fowler's position may not directly address the management of the NG tube and dysphagia.

Choice B reason:

Connecting the tube to continuous wall suction when not in use is not a standard intervention for NG tube feeding.

Choice C reason:

This statement is correct. Confirming placement of the tube prior to each medication

administration is crucial to ensure safe and effective delivery of medications and nutrition.

Choice D reason:

Having the patient sip cool water, while a general recommendation for some patients, does not specifically address the care of the NG tube.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

Correct Answer is C

Explanation

A patient's new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patient's care plan accordingly. What intervention should the nurse include in the patient's plan of care?

Correct Answer is C

Explanation

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