The nurse is meeting a client post-liver transplantation for the first time and notices a tremor as they shake hands. The client states this has not happened before. Which action by the nurse is most appropriate?
a. Conduct a thorough assessment, then no-tify the surgeon of the findings.
b. Review today's laboratory work, includ-ing liver function studies.
c. Assess the client's vital signs, and offer acetaminophen if the client is febrile.
d. Perform an assessment of the client's gross and fine motor skills.
A
The client may be exhibiting asterixis. Any sign of deteriorating neurologic function could indi-cate that the new liver is not working properly. The surgeon must be notified, but first the nurse should conduct a thorough assessment of the client. Reviewing today's laboratory work is im-portant, but this is not the best option because the client's liver could have deteriorated after the laboratory work was drawn. Clients with any type of liver problem should not take acetamino-phen. Assessing the client's fine and gross motor skills is part of an assessment.
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