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 D
Explanation
A. Change in cilia: This is not the cause of dry, flaky cerumen. It would not be typical to assess hearing loss based on this observation alone.
B. Poor hygiene: Dry, flaky cerumen is not indicative of poor hygiene. Hygiene-related cerumen would more likely be wet and impacted.
C. Lesions from eczema: While eczema can affect the ear canal, the dry cerumen itself is more likely to be a normal characteristic for some individuals, particularly in people of Asian descent.
D. Normal finding: The presence of dry, flaky cerumen is normal in certain ethnic groups, including East Asians, and usually requires no follow-up.
Correct Answer is D
Explanation
A. Constipation: This involves hardened stool in the colon, causing localized distention but no free fluid.
B. Splenomegaly: Enlargement of the spleen causes a palpable mass in the left upper quadrant but no free fluid.
C. Distended bladder: This causes suprapubic distension but does not produce a fluid wave.
D. Ascites: A positive fluid wave test indicates free fluid in the abdominal cavity, a hallmark sign of ascites. The test is performed by tapping one side of the abdomen and observing for a wave-like transmission of fluid to the opposite side.
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