During an abdominal assessment, the nurse considers which finding normal?
Palpable spleen between the ninth and eleventh ribs in the left midaxillary line
Presence of bruit in the femoral area
Tympanic percussion notes in the umbilical region
Dull percussion notes in the left upper quadrant at the midclavicular line
The Correct Answer is C
A. Palpable spleen between the ninth and eleventh ribs in the left midaxillary line: The spleen is not normally palpable in a healthy adult. If it can be felt, it usually indicates splenomegaly, which may result from infection, hematologic disorders, or liver disease.
B. Presence of bruit in the femoral area: A bruit represents turbulent blood flow, which may indicate vascular narrowing or aneurysm. It is not considered a normal finding in any vascular region, including the femoral arteries.
C. Tympanic percussion notes in the umbilical region: Tympany is the expected percussion note over the abdomen due to the presence of air in the intestines. Hearing tympany in the umbilical region is a normal finding during abdominal assessment.
D. Dull percussion notes in the left upper quadrant at the midclavicular line: Dullness in this area suggests splenic enlargement. Under normal conditions, the percussion note over the spleen is not broadly dull unless there is splenomegaly.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Fine hair is present: Hair is not normally found on the glans penis. Hair growth is typically limited to the pubic area and the base of the penis, so its presence on the glans would be abnormal.
B. The dorsal vein may be visible: The dorsal vein is located along the shaft of the penis, not on the glans. Its visibility is a normal finding on the shaft but not specifically on the glans itself.
C. The skin is wrinkled and without lesions: The skin of the glans penis is typically smooth and soft, not wrinkled. Wrinkled skin is characteristic of the scrotum, not the glans. The glans should be without lesions, but the skin texture is wrong.
D. Smegma may be present under the foreskin of an uncircumcised male: Smegma, a whitish secretion composed of dead skin cells and oils, is a normal finding beneath the foreskin in uncircumcised males and can be gently cleaned during hygiene.
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.
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