A nurse is teaching a client about the Rinne test. Which of the following client statements indicates an understanding of the teaching?

Choice A Reason: This is incorrect because standing directly in front of the client is not the priority action by the nurse when admitting a client who has a partial hearing loss. Standing directly in front of the client can enhance communication, but it is not as important as assessing the client's hearing status and needs.

Choice B Reason: This is incorrect because rephrasing statements the client does not hear is not the priority action by the nurse when admitting a client who has a partial hearing loss. Rephrasing statements can improve understanding, but it is not as essential as evaluating the client's hearing level and preferences.

Choice C Reason: This is incorrect because speaking using his usual tone of voice is not the priority action by the nurse when admitting a client who has a partial hearing loss. Speaking using his usual tone of voice may or may not be appropriate, depending on the client's hearing ability and comfort. The nurse should adjust his tone of voice based on the client's feedback and response.

Choice D Reason: This is the correct choice because determining if the client uses hearing aids is the priority action by the nurse when admitting a client who has a partial hearing loss. Hearing aids are devices that amplify sound and improve hearing for people with hearing loss. The nurse should determine if the client uses hearing aids, and if so, check their function, fit, and battery life. The nurse should also ask about any other assistive devices or strategies that the client uses to communicate effectively.

Choice A Reason: Measuring the abdominal girth is not related to asterixis, which is a tremor of the hand when the wrist is extended. It may indicate ascites, which is a complication of cirrhosis, but not asterixis.

Choice B Reason: This is the correct choice. Asterixis is a flapping tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings. It is caused by abnormal function of the diencephalic motor centers that regulate the muscles involved in maintaining posture. It is a sign of hepatic encephalopathy, which is a neuropsychiatric disorder that occurs in patients with liver disease.

Choice C Reason: Having the client flex and extend their foot is not related to asterixis, which affects the hand and wrist. It may test for ankle clonus, which is a rhythmic contraction of the calf muscles when the foot is dorsiflexed. It indicates an upper motor neuron lesion, but not hepatic encephalopathy.

Choice D Reason: Asking the client to walk heel to toe is not related to asterixis, which affects the hand and wrist. It may test for balance and coordination, which can be impaired in patients with hepatic encephalopathy, but it is not a specific sign of asterixis.