An adult male 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. Which action will the nurse perform next?
Describe the dullness as indicative of an enlarged liver and refer to a provider.
Ask additional health history questions regarding alcohol intake.
Document the presence of hepatomegaly.
Consider this finding as normal and proceed with the examination.
The Correct Answer is D
A. Describe the dullness as indicative of an enlarged liver and refer to a provider: Liver span is considered enlarged when it measures more than 12 cm at the midclavicular line. Since the measurement here is 11 cm, this does not indicate hepatomegaly.
B. Ask additional health history questions regarding alcohol intake: While alcohol use is important to assess in all patients, the finding of a liver span of 11 cm does not specifically suggest alcohol-related liver disease.
C. Document the presence of hepatomegaly: Hepatomegaly is defined by liver enlargement beyond the normal range. In adult males, the normal liver span is about 6–12 cm, so documenting hepatomegaly with an 11 cm span would be inaccurate.
D. Consider this finding as normal and proceed with the examination: A liver span of 11 cm lies within the expected normal range for an adult male. The nurse should therefore document the finding as normal and continue with the rest of the physical examination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Tragus: The temporomandibular joint (TMJ) is located just below the temporal artery and directly anterior to the tragus of the ear. Palpation at this point allows the nurse to assess for movement, tenderness, or crepitation during jaw opening and closing.
B. Vagus nerve: The vagus nerve runs through the neck and thorax, not near the TMJ. It is not a landmark used when assessing the joint.
C. Hyoid bone: The hyoid bone is situated in the anterior neck above the larynx and is unrelated to the location of the TMJ. It does not serve as a reference point in this assessment.
D. Mandible: The mandible forms part of the joint itself, but the landmark for palpation is anterior to the tragus, not simply the mandible. The tragus provides the specific external reference point used by clinicians.
Correct Answer is B
Explanation
A. Palpable central groove: The central groove is normally felt when palpating a healthy prostate gland. Its presence indicates a typical anatomical landmark and is not considered abnormal.
B. Tenderness to palpation: Tenderness suggests possible infection or inflammation of the prostate, such as in prostatitis. A healthy prostate is generally nontender, so pain on palpation is considered an abnormal finding.
C. Being heart shape: The normal prostate gland is heart-shaped with two lateral lobes separated by a central groove. This shape is expected and does not indicate pathology.
D. Elastic and rubbery consistency: A healthy prostate typically feels smooth, elastic, and rubbery. This consistency is a normal characteristic and only becomes abnormal if the gland feels hard, nodular, or irregular.
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