A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. How should the nurse proceed?
Consider this finding as normal, and proceed with the examination.
Describe this dullness as indicative of an enlarged liver, and refer him to a physician.
Document the presence of hepatomegaly.
Ask additional health history questions regarding his alcohol intake.
The Correct Answer is B
A. Normal finding: This is not a normal finding. Dullness in this area could indicate an enlarged liver (hepatomegaly), which requires further evaluation.
B. Enlarged liver: Dullness above the right costal margin, especially around 11 cm, is often associated with hepatomegaly. The nurse should refer the patient to a physician for further investigation.
C. Hepatomegaly: While the finding could suggest hepatomegaly, the diagnosis should be confirmed by a physician. The nurse should refer the patient for further evaluation.
D. Alcohol intake: While it is relevant to ask about alcohol intake in the context of liver health, the immediate action is to refer the patient for further examination by a physician.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Atrophy of calf veins: Vein atrophy is not a normal aging process, although venous insufficiency is common due to other causes.
B. Narrowing of the inferior vena cava: This is not a typical age-related change.
C. Peripheral blood vessels growing more rigid: Arteriosclerosis (hardening of the arteries) is common with aging and leads to increased systolic blood pressure.
D. Hormonal changes causing vasodilation: Aging tends to cause vascular rigidity, not vasodilation, and is more likely to lead to hypertension.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}
Explanation
|
New Nurse Statement |
Met |
Not Met |
|
I will confirm the patient's pupil size with the scale on the side of the penlight. |
✅ |
|
|
When putting the penlight at the bridge of the nose, the eyes converge and constrict |
✅ |
|
|
I will check the patient's pupillary reflex by shining a light into their eyes. |
✅ |
|
|
When shining the penlight into the patient's eyes, their pupils should dilate |
✅ |
Rationale:
"I will confirm the patient's pupil size with the scale on the side of the penlight" (Met):
This is a correct use of the penlight to assess pupil size and document findings accurately.
"When putting the penlight at the bridge of the nose, the eyes converge and constrict" (Met):
This statement describes the normal accommodation reflex, where the eyes converge and pupils constrict when focusing on a near object.
"I will check the patient's pupillary reflex by shining a light into their eyes" (Met):
This correctly describes testing for the pupillary light reflex, where the pupil constricts in response to light.
"When shining the penlight into the patient's eyes, their pupils should dilate" (Not Met):
This is incorrect. The pupils should constrict in response to light, not dilate. Dilation occurs in response to low light or sympathetic stimulation.
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