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

Measure the abdominal girth

Have the client extend their arms

Have the client flex and extend their foot

Ask the client to walk heel to toe

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is A

Explanation

Choice A Reason: This is the correct choice because driving a motorcycle is a high-risk activity that can expose the client to head trauma, especially if they do not wear a helmet. Traumatic brain injury (TBI) is a condition where the brain is damaged by an external force, such as a collision, fall, or assault.

Choice B Reason: This is incorrect because having high blood pressure is not a direct risk factor for traumatic brain injury. High blood pressure can increase the risk of stroke, which is a condition where the brain is damaged by an internal cause, such as a blood clot or hemorrhage.

Choice C Reason: This is incorrect because smoking and having a family history of brain cancer are not risk factors for traumatic brain injury. Smoking and genetic factors can increase the risk of developing brain tumors, which are abnormal growths of cells in the brain.

Choice D Reason: This is incorrect because golfing and driving a golf cart are low-risk activities that do not pose a significant threat to the client's head. Golfing and driving a golf cart may cause minor injuries, such as sprains, strains, or bruises, but not traumatic brain injury.

A. The client's bladder becomes distended. B. The client states having a severe headache. C. The client's blood pressure becomes elevated. D. The client states having nasal congestion.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A Reason: A distended bladder is one of the most common triggers of autonomic dysreflexia, which is a life-threatening condition that occurs in clients with spinal cord injuries above T-6. The bladder becomes overfilled and stimulates the sympathetic nervous system, causing vasoconstriction and hypertension.

Choice B Reason: A severe headache is one of the most common symptoms of autonomic dysreflexia, caused by the increased blood pressure in the brain. The headache may be accompanied by blurred vision, sweating, flushing, or anxiety.

Choice C Reason: An elevated blood pressure is the hallmark sign of autonomic dysreflexia, which can reach dangerously high levels and cause stroke, seizure, or death. The blood pressure may rise up to 300/160 mmHg or higher.

Choice D Reason: Nasal congestion is another possible trigger of autonomic dysreflexia, as it stimulates the nasal mucosa and activates the sympathetic nervous system. Other potential triggers include bowel impaction, skin irritation, tight clothing, or temperature changes.

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The nurse is reviewing the record of a client with a diagnosis 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

Which of the following clients is most at risk for traumatic brain injury?

Correct Answer is A

Explanation

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?

The physician suspects a client has a dermatological infection. Which of the following diagnostics will be ordered to observe color changes to the skin using an ultraviolet light source?

The caregiver of an elderly client asks the nurse what can be done about the chronic bilateral inflammation of the eyelid margins that keeps recurring. Which of the following is the information that the nurse will provide?

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A client's chart indicates that they are legally blind. Which of the following is the definition of legally blind?

A nurse is planning to provide discharge teaching for a client who has hearing loss. Which of the following actions should the nurse plan to take?

A client arrives to the emergency department after falling from a ladder. The client has a loss of sensation and flaccid paralysis. Which of the following complications of an acute spinal cord injury does the nurse suspect?