A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?

A) Asterixis
B) Constructional apraxia
C) Fetor hepaticus
D) Palmar erythema


Ans: A
Feedback:
The nurse will document that a patient exhibiting a flapping tremor of the hands is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to the breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor.

Nursing

You might also like to view...

A patient with a primary diagnosis of colorectal cancer has developed bone metastases in recent weeks

When reviewing this patient's daily blood work, the nurse should be aware that secondary bone tumors create a significant risk of what electrolyte imbalance? A) Hypokalemia B) Hypercalcemia C) Hyponatremia D) Hyperchloremia

Nursing

The empowerment of staff is a hallmark of transformational leadership. What does empowerment mean?

1 . Allow 2 . Develop 3 . Enable 4 . Lead A) 1, 2, 3 B) 1, 2, 4 C) 1, 3, 4 D) 2, 3, 4

Nursing

The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

a. Urine output over 8 hours is 250 mL less than the fluid intake. b. The patient cannot move the left arm and leg when asked to do so. c. Tremors are noted in the fingers when the patient extends the arms. d. The patient complains of a headache with pain at level 8/10 (0 to 10 scale).

Nursing

Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia? Select all that apply

A. Group therapy B. Medication management C. Deterrent therapy D. Supportive family therapy E. Social skills training

Nursing