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 B

Explanation

Choice A Reason: Hemorrhage is not a complication of an acute spinal cord injury, but rather a possible cause of it. Hemorrhage can occur due to trauma or rupture of blood vessels in or around the spinal cord, leading to compression and damage of the nerve tissue.

Choice B Reason: This is the correct choice. Spinal shock is a complication of an acute spinal cord injury that occurs within minutes to hours after the injury. It is characterized by loss of sensation, motor function, reflexes, and autonomic function below the level of injury. It is caused by transient disruption of nerve conduction and synaptic transmission in the spinal cord.

Choice C Reason: Apoptosis is not a complication of an acute spinal cord injury, but rather a cellular process that occurs after it. Apoptosis is programmed cell death that occurs in response to injury or stress. It can lead to further loss of neurons and glial cells in the spinal cord over time.

Choice D Reason: Neurogenic shock is a complication of an acute spinal cord injury that occurs within hours to days after the injury. It is characterized by hypotension, bradycardia, and peripheral vasodilation due to loss of sympathetic tone and unopposed parasympathetic activity. It is caused by disruption of autonomic pathways in the spinal cord.

A. "I ate shellfish about 2 weeks ago at a local restaurant." B. "I was an intravenous drug abuser in the past and shared needles." C. "I had a blood transfusion in 1980 after major abdominal surgery." D. "I have had unprotected sex with multiple partners."

Correct Answer is A

Explanation

Choice A Reason: "I ate shellfish about 2 weeks ago at a local restaurant." supports the medical diagnosis of hepatitis A, which is an infection of the liver caused by the hepatitis A virus (HAV). HAV is transmitted by fecal-oral route, meaning that it can be contracted by ingesting contaminated food or water, such as raw or undercooked shellfish from polluted waters. The incubation period for hepatitis A is about two to six weeks.

Choice B Reason: "I was an intravenous drug abuser in the past and shared needles." does not support the medical diagnosis of hepatitis A, but may indicate exposure to hepatitis B or C, which are infections of the liver caused by the hepatitis B virus (HBV) or hepatitis C virus (HCV). HBV and HCV are transmitted by blood or body fluids, meaning that they can be contracted by sharing needles, syringes, or other injection equipment with infected people.

Choice C Reason: "I had a blood transfusion in 1980 after major abdominal surgery." does not support the medical diagnosis of hepatitis A, but may indicate exposure to hepatitis B or C, which are infections of the liver caused by the hepatitis B virus (HBV) or hepatitis C virus (HCV). HBV and HCV are transmitted by blood or body fluids, meaning that they can be contracted by receiving blood transfusions or organ transplants from infected donors. However, since 1992, all donated blood in the United States has been screened for HBV and HCV.

Choice D Reason: "I have had unprotected sex with multiple partners." does not support the medical diagnosis of hepatitis A, but may indicate exposure to hepatitis B or C, which are infections of the liver caused by the hepatitis B virus (HBV) or hepatitis C virus (HCV). HBV and HCV are transmitted by blood or body fluids, meaning that they can be contracted by having unprotected sex with infected people. However, sexual transmission of HAV is rare, unless there is contact with fecal matter.

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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 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?

Correct Answer is B

Explanation

The primary health care provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis?

Correct Answer is A

Explanation

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