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. Listening to speech primarily assesses cranial nerves related to speech and articulation, not cranial nerve II.
B. Identifying scented aromas assesses the olfactory nerve.
C. Clenching teeth primarily assess cranial nerve V (trigeminal nerve).
D. Cranial nerve II is the optic nerve responsible for vision. Testing visual acuity using a Snellen chart assesses this nerve's function.

A. Motor component of CN X and sensory component of CN VII B. Motor and sensory component of CN XI C. Motor component of CN IV D. Motor component of CN VII

Correct Answer is D

Explanation

A. Dysfunction of the motor component of CN X (vagus nerve) and sensory component of CN VII (facial nerve) would present with different symptoms, such as difficulty swallowing and impaired taste sensation, not the observed facial asymmetry and puffing of cheeks.
B. CN XI (accessory nerve) dysfunction primarily affects the sternocleidomastoid and trapezius muscles and wouldn't cause the observed facial asymmetry.
C. Dysfunction of CN IV (trochlear nerve) leads to issues with downward and inward eye movement, not the facial asymmetry described.
D. Dysfunction of the motor component of CN VII (facial nerve) leads to facial asymmetry during expressions and difficulty controlling facial muscles, which matches the observed findings.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve II?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve V?

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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?

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