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?

Recognizes this dullness as indicative of an enlarged liver, and refers the client to a provider

Document the presence of hepatomegaly

Ask additional health history questions regarding alcohol intake

Recognizes this finding as normal, and proceed with the examination

Answer and Explanation

The Correct Answer is A

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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Correct Answer is D

Explanation

A. The basal ganglia are involved in motor control and learning but not specifically in controlling voluntary movement.
B. Motor pathways do not directly synapse in the thalamus; the thalamus serves as a relay station for sensory information.
C. The cerebellum is primarily involved in coordination, balance, and muscle control, not in speech and emotions.
D. The hypothalamus plays a crucial role in regulating body temperature, controlling hunger, thirst, fatigue, and regulating sleep cycles.

A. vas deferens B. Epididymis C. Prostate D. Testes

Correct Answer is D

Explanation

A. The vas deferens is a duct that transports sperm from the epididymis to the ejaculatory duct.
B. The epididymis is where sperm is stored and matures but not produced.
C. The prostate gland produces a fluid that contributes to semen but not sperm production.
D. The testes are responsible for producing sperm through the process of spermatogenesis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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