{"id":141258,"date":"2024-09-20T14:57:50","date_gmt":"2024-09-20T14:57:50","guid":{"rendered":"https:\/\/learnexams.com\/blog\/?p=141258"},"modified":"2024-09-20T14:57:52","modified_gmt":"2024-09-20T14:57:52","slug":"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","status":"publish","type":"post","link":"https:\/\/www.learnexams.com\/blog\/2024\/09\/20\/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\/","title":{"rendered":"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."},"content":{"rendered":"\n

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?<\/p>\n\n\n\n

A.
Measure the abdominal girth<\/p>\n\n\n\n

B.
Have the client extend their arms<\/p>\n\n\n\n

C.
Have the client flex and extend their foot<\/p>\n\n\n\n

D.
Ask the client to walk heel to toe<\/p>\n\n\n\n

The Correct Answer and Explanation is:<\/mark><\/strong><\/p>\n\n\n\n

The correct answer is B. Have the client extend their arms<\/strong>.<\/p>\n\n\n\n

Explanation:<\/h3>\n\n\n\n

Asterixis is a clinical sign often associated with metabolic encephalopathies, particularly hepatic encephalopathy in clients with advanced liver disease such as cirrhosis. It is characterized by a tremor of the hands when the wrist is extended, resembling a “flapping” motion. This occurs due to an inability to maintain sustained muscle contraction, a condition known as a negative myoclonus.<\/p>\n\n\n\n

Assessment of asterixis:<\/strong> To assess for the presence of asterixis, the nurse should ask the client to extend their arms with wrists dorsiflexed (the hands bent backward) and fingers spread apart. If asterixis is present, the client’s hands will show a jerking or flapping motion, which is a positive sign of this condition. This is caused by impaired function of the brain due to the accumulation of toxins, particularly ammonia, that the liver is unable to process effectively in cases of liver dysfunction.<\/p>\n\n\n\n

Link to cirrhosis:<\/strong> In clients with cirrhosis, the liver’s ability to detoxify harmful substances diminishes. One of the critical substances that accumulates is ammonia, which affects the central nervous system, leading to hepatic encephalopathy. Asterixis is an important clinical indicator of this neurological complication.<\/p>\n\n\n\n

Why other options are incorrect:<\/strong><\/p>\n\n\n\n

    \n
  • A. Measure the abdominal girth<\/strong>: This action assesses for ascites, the accumulation of fluid in the peritoneal cavity, which is common in cirrhosis. However, it is not related to asterixis.<\/li>\n\n\n\n
  • C. Have the client flex and extend their foot<\/strong>: This movement assesses for peripheral motor function and balance, but it is not specific for asterixis.<\/li>\n\n\n\n
  • D. Ask the client to walk heel to toe<\/strong>: This assesses for coordination and balance, but it is more related to neurological exams for gait disturbances rather than for detecting asterixis.<\/li>\n<\/ul>\n\n\n\n

    Asterixis is a critical sign for recognizing worsening hepatic encephalopathy, which requires timely intervention to prevent further neurological deterioration.<\/p>\n","protected":false},"excerpt":{"rendered":"

    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? A.Measure the abdominal girth B.Have the client extend their arms C.Have the client flex and extend their foot D.Ask the client to […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-141258","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/141258","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=141258"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/141258\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=141258"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=141258"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=141258"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}