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 D

Explanation

Choice A Reason: This is incorrect because dimming the lights in the client's room is not a helpful action for providing discharge teaching for a client who has hearing loss. Dimming the lights can reduce the visibility and clarity of the nurse's facial expressions, gestures, and lip movements, which can aid in communication.

Choice B Reason: This is incorrect because increasing the rate of speech when talking with the client is not an effective action for providing discharge teaching for a client who has hearing loss. Increasing the rate of speech can make it harder for the client to follow and understand what the nurse is saying.

Choice C Reason: This is incorrect because answering client's questions using medical terminology is not an appropriate action for providing discharge teaching for a client who has hearing loss. Medical terminology can be confusing and unfamiliar to the client, which can impair comprehension and learning.

Choice D Reason: This is the correct choice because facing the client while talking is an important action for providing discharge teaching for a client who has hearing loss. Facing the client can enhance eye contact, attention, and rapport. It can also allow the client to see the nurse's facial expressions, gestures, and lip movements, which can facilitate communication.

A. Culture B. KOH C. Diascopy D. Wood's

Correct Answer is D

Explanation

Choice A Reason: Culture is not a diagnostic test that uses an ultraviolet light source, but a laboratory test that involves growing microorganisms from a sample of body fluid or tissue. Culture can help identify the type and sensitivity of the infection-causing agent.

Choice B Reason: KOH is not a diagnostic test that uses an ultraviolet light source, but a chemical test that involves applying potassium hydroxide to a sample of skin, hair, or nail. KOH can help diagnose fungal infections by dissolving the keratin and revealing the fungal elements under a microscope.

Choice C Reason: Diascopy is not a diagnostic test that uses an ultraviolet light source, but a physical test that involves applying pressure to a lesion with a glass slide or lens. Diascopy can help differentiate between blanchable and non-blanchable lesions, such as erythema or petechiae.

Choice D Reason: Wood's is a diagnostic test that uses an ultraviolet light source, also known as a Wood's lamp or black light. Wood's can help observe color changes to the skin that are not visible under normal light, such as fluorescence or hypopigmentation. Wood's can help diagnose conditions such as tinea capitis, vitiligo, or erythrasma.

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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

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?

Correct Answer is D

Explanation

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?

Correct Answer is D

Explanation

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