During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes that this finding could indicate a problem with which organ?

Sigmoid

Liver

Appendix

Gallbladder

Answer and Explanation

The Correct Answer is C

A.   The sigmoid is a part of the large intestine located in the left lower quadrant, so tenderness in the right lower quadrant is unlikely to be related to the sigmoid.
B.   The liver is situated higher in the abdomen, typically more towards the right upper quadrant, and its tenderness wouldn't manifest in the right lower quadrant.
C.   Tenderness in the right lower quadrant is a classic sign of appendicitis, suggesting inflammation of the appendix.
D.   The gallbladder is positioned closer to the liver, in the right upper quadrant, and wouldn't typically cause tenderness in the right lower quadrant.

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Correct Answer is D

Explanation

A. Cranial Nerve XI (Accessory nerve) is not involved in tongue movement; it controls muscles involved in head and shoulder movement.
B. Eye movement and control relate more to Cranial Nerves III, IV, and VI, which control eye muscles.
C. Hearing is primarily assessed by Cranial Nerve VIII (Vestibulocochlear nerve).
D. Cranial Nerve XI innervates the sternocleidomastoid and trapezius muscles, enabling movements like head turning and shoulder shrugging against resistance.

A. Recognizes this dullness as indicative of an enlarged liver, and refers the client to a provider B. Document the presence of hepatomegaly C. Ask additional health history questions regarding alcohol intake D. Recognizes this finding as normal, and proceed with the examination

Correct Answer is A

Explanation

A. Dullness above the right costal margin could indicate an enlarged liver. Referring the client to a healthcare provider is crucial for further evaluation and diagnosis.
B. Documenting hepatomegaly without further investigation or confirmation by a healthcare provider could be premature.
C. While alcohol intake can be a factor in liver conditions, additional history alone may not confirm the cause of the dullness. Direct evaluation by a healthcare provider is necessary.
D. Finding an area of dullness above the right costal margin, particularly of such magnitude, should prompt further investigation rather than being considered normal.

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During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes that this finding could indicate a problem with which organ?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse tests the function of Cranial Nerve XI while performing a physical examination on a client. Which statement best describes the response the nurse should expect if Cranial Nerve XI is intact?

Correct Answer is D

Explanation

The nurse is percussing a client's abdomen during a physical assessment. The nurse observes an area of dullness above the right costal margin of approximately 11 cm. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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