Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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
Asterixis is a characteristic sign of hepatic encephalopathy, characterized by a flapping tremor of the hands. It is associated with liver dysfunction and is indicative of impaired ammonia metabolism in the brain.
B. Fetor hepaticus
Fetor hepaticus refers to a musty, sweet odor of the breath that is associated with severe liver disease. It is not related to the flapping tremor observed in this case.
C. Palmar erythema
Palmar erythema is a reddening of the palms and is associated with various conditions, including liver disease. However, it is not the sign described in the scenario.
D. Constructional apraxia
Constructional apraxia is a neurological deficit characterized by difficulty in copying or constructing simple drawings or designs. It is not related to the flapping tremor seen in hepatic encephalopathy.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Proctored Exam 6. Take the full exam now
Full Explanation
Choice A reason:
Asterixis is a characteristic sign of hepatic encephalopathy, characterized by a flapping tremor of the hands. It is associated with liver dysfunction and is indicative of impaired ammonia metabolism in the brain.
Choice B reason:
Fetor hepaticus refers to a musty, sweet odor of the breath that is associated with severe liver disease. It is not related to the flapping tremor observed in this case.
Choice C reason:
Palmar erythema is a reddening of the palms and is associated with various conditions, including liver disease. However, it is not the sign described in the scenario.
Choice D reason:
Constructional apraxia is a neurological deficit characterized by difficulty in copying or constructing simple drawings or designs. It is not related to the flapping tremor seen in hepatic encephalopathy.
Similar Questions
A nurse is teaching a client who has a hiatal hernia about dietary recommendations. Which of the following client s understanding of the teaching? (Select all that apply)
A. “I consume less caffeine and fewer spicy foods"
This statement demonstrates the client's understanding of the need to reduce intake of caffeine and spicy foods, which can exacerbate symptoms of hiatal hernia.
B. “ I will try not to gain weight"
This statement shows the client's awareness of the importance of maintaining a healthy weight, which can help manage hiatal hernia symptoms.
C. “ I will lie down for one half hour after meals
This statement is not related to the dietary recommendations for hiatal hernia.
D. “ I will drink less fluid
Limiting fluid intake can help prevent excessive stomach distension, which may aggravate hiatal hernia symptoms.
Full Explanation
Choice A reason:
This statement demonstrates the client's understanding of the need to reduce intake of caffeine and spicy foods, which can exacerbate symptoms of hiatal hernia.
Choice B reason:
This statement shows the client's awareness of the importance of maintaining a healthy weight, which can help manage hiatal hernia symptoms.
Choice C reason:
This statement is not related to the dietary recommendations for hiatal hernia.
Choice D reason:
Limiting fluid intake can help prevent excessive stomach distension, which may aggravate hiatal hernia symptoms.
The nurse is completing the intake and output record for a preschool-age client admitted for fluid volume deficit.
The client has had the following intake and output during the shift:
Intake:
- 4 oz of Pedialyte
- 1/2 of an 8-oz cup of clear orange Jell-O
- 2 graham crackers
- 200 mL of D 5-1/2 sodium chloride IV
Output:
- 345 mL of urine
- 50 mL of loose stool
The nurse documents the client's intake as milliliters. How much liquidintake did the client have in Milliliters?
Round the answer to the nearest whole number.
Full Explanation
- To convert ounces to milliliters, multiply by 29.57
- 4 oz of Pedialyte = 118.28 mL
- 1/2 of an 8-oz cup of clear orange Jell-O = 118.28 mL
- 2 graham crackers = no liquid intake
- 200 mL of D 5-1/2 sodium chloride IV = 200 mL
- Total intake = 118.28 + 118.28 + 200 = 436.56 mL
- Round to the nearest whole number = 437 mL
- The nurse documents the client's intake as 437 mL
A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis.
Which of the following instructions should the nurse include in the teaching plan?
A. Include foods high in fiber.
While foods high in fiber are generally healthy, they may not specifically address the issue of biliary colic related to cholecystitis.
B. Include foods high in starch and proteins.
Foods high in starch and proteins are important for overall nutrition, but they may not directly impact biliary colic.
C. Avoid foods high in fat.
This statement is correct. Avoiding foods high in fat is crucial for managing biliary colic in clients with chronic cholecystitis.
D. Avoid foods high in sodium.
Avoiding foods high in sodium is important for cardiovascular health, but it is not the primary dietary modification for cholecystitis.
Full Explanation
Choice A reason:
While foods high in fiber are generally healthy, they may not specifically address the issue of biliary colic related to cholecystitis.
Choice B reason:
Foods high in starch and proteins are important for overall nutrition, but they may not directly impact biliary colic.
Choice C reason:
This statement is correct. Avoiding foods high in fat is crucial for managing biliary colic in clients with chronic cholecystitis.
Choice D reason:
Avoiding foods high in sodium is important for cardiovascular health, but it is not the primary dietary modification for cholecystitis.