The nurse is reviewing the record of a client with a diagnoses of Cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?

Dorsiflex the client's foot

Ask the client to extend the arms

Measure the abdominal girth

Instruct the client to lean forward

Answer and Explanation

The Correct Answer is B

A. Dorsiflex the client’s foot: Foot dorsiflexion does not assess asterixis; it is used in neurologic tests (e.g., clonus assessment).

B. Ask the client to extend the arms: Asterixis ("liver flap") is a flapping tremor seen in hepatic encephalopathy due to high ammonia levels. The nurse assesses for asterixis by asking the client to extend their arms and dorsiflex their wrists—a positive sign is a flapping movement of the hands.

C. Measure the abdominal girth: Abdominal girth measurement is used to assess ascites, not asterixis.

D. Instruct the client to lean forward: Leaning forward does not help in assessing asterixis; it is more relevant in pericarditis (relieves chest pain).

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Correct Answer is B

Explanation

A. "This condition is correlated to chronic blood loss.” : Chronic inflammation and ulceration in Crohn’s disease can cause occult GI bleeding, leading to iron-deficiency anemia.

B. "Villi within my intestine are damaged.”: Crohn’s disease affects the entire intestinal wall, but it does not damage villi specifically. Villi damage occurs in celiac disease, not Crohn’s disease.

C. "Poor nutrition is a causative factor.": Malabsorption of iron, vitamin B12, and folate due to inflammation contributes to anemia in Crohn’s disease.

D. "The ferrous sulfate prescribed will replace the lost iron.": Iron supplements (ferrous sulfate) are commonly prescribed for anemia in Crohn’s disease due to chronic blood loss.

A. Lower left quadrant B. Upper left quadrant C. Upper right quadrant D. Lower right quadrant

Correct Answer is A

Explanation

A. Lower left quadrant: Most diverticula occur in the sigmoid colon, causing LLQ pain.

B. Upper left quadrant: The upper left quadrant is not a common location for diverticular disease pain.

C. Upper right quadrant: URQ pain is more associated with gallbladder disease.

D. Lower right quadrant: LRQ pain is more common in appendicitis.

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The nurse is reviewing the record of a client with a diagnoses of Cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing education to a client with a history of Crohn's Disease and a new diagnosis of anemia. Which of the following statements by the client would require farther teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who has diverticular disease. When palpating the client's abdomen, in which of the following locations should the nurse expect the client to report abdominal pain?

Correct Answer is A

Explanation

A nurse is assessing clients in a health clinic for risk factors for contracting hepatitis. Which of the following clients is at risk for developing hepatitis C

The nurse is caring for a client diagnosed with Crohn's Disease who is crying. The client tells the nurse, am so frustrated. I never know when I will get sick and end up in the hospital" which statement would be the nurse's best response?

The nurse is caring for a client who asks why blood levels of Carcinoembryonic Antigen (CEA) is drawn at periodic intervals. Which of the following responses describes the correct rationale?

The nurse is caring for a client with End Stage Renal Disease has a mature Arteriovenous Fistula. Which of the following interventions would the nurse include in the client's plan of care? Select All that Apply

Which statement by a client indicates an understanding of the spread of Hepatitis C?

The nurse is caring for a client with acute pancreatitis. Which of the following would the nurse anticipate seeing in the client's history?

A nurse is providing discharge instructors to a client with hepatitis B. Which of the following statements should be included in the teaching?

A client with end stage liver disease, cirrhosis, and ascites is scheduled for a paracentesis. Which of the following interventions can be anticipated related to care of this patient?