the nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy which assessment by the nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy which assessment by
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Kaplan NCLEX Question of The Day

1. The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessment by the nurse suggests that the client is developing this complication?

Correct answer: Asterixis

Rationale: Asterixis, also known as flapping tremors, is a characteristic sign of hepatic encephalopathy. It is a flapping tremor of the hands when the wrists are extended, indicating neurological impairment. Hypertension and Kussmaul respirations are not directly associated with hepatic encephalopathy. Lethargy is a common symptom but not a specific sign that suggests the development of hepatic encephalopathy.

2. Which of the following represents a normal serum potassium level?

Correct answer: 4.0 mEq/L

Rationale: The correct answer is 4.0 mEq/L. Normal serum potassium levels typically range from 3.5–5.5 mEq/L. Choice A (1.5 mEq/L) is below the normal range, Choice B (3.0 mEq/L) is also below the normal range, and Choice D (6.0 mEq/L) is above the normal range. Therefore, the only option within the normal range is Choice C (4.0 mEq/L).

3. A nurse working in a surgical unit notices a patient experiencing SOB, calf pain, and warmth over the posterior calf. All of these symptoms may indicate which of the following medical conditions?

Correct answer: Patient may have a DVT.

Rationale: The correct answer is that the patient may have a DVT (Deep Vein Thrombosis). SOB (Shortness of Breath), calf pain, and warmth over the posterior calf are classic signs and symptoms of DVT. DVT is a serious condition where a blood clot forms in a deep vein, commonly in the legs. Choices B, C, and D are incorrect because dermatitis does not typically present with these symptoms, late stages of CHF would manifest with other signs, and anxiety after surgery usually does not produce these specific symptoms.

4. While assisting with data collection on a client, a nurse hears a bruit over the abdominal aorta. What action should the nurse prioritize based on this finding?

Correct answer: Notify the healthcare provider

Rationale: Detection of a bruit over the aorta during abdominal assessment may indicate the presence of an aneurysm. The nurse's priority action should be to notify the healthcare provider to further evaluate the situation. Palpating the area or percussing the abdomen could potentially increase the risk of an aneurysm rupture. While documenting the finding is important, the priority is to ensure timely intervention by involving the healthcare provider.

5. A client complains that her skin is redder than normal. The nurse notes the client’s skin, documents hyperemia, and explains to the client that this condition is caused by which factor?

Correct answer: Excess blood in the dilated superficial capillaries

Rationale: Hyperemia is an excess of blood in a part of the body. The skin over a hyperemic area usually becomes reddened or warm. The condition is caused by increased blood flow, local relaxation of arterioles, or obstruction of the outflow of blood from an area. Choice A is incorrect because constriction of blood vessels would lead to decreased blood flow, not excess blood. Choice B is incorrect as an increased amount of bilirubin in the blood is related to jaundice, not hyperemia. Choice C is incorrect because increased perfusion of the surrounding tissues would cause redness, not hyperemia.

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