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 involves cranial nerves related to speech production (e.g., CN V, CN VII, CN XII) but not specifically for CN V.
B. Reading a Snellen chart assesses visual acuity, primarily involving cranial nerve II (optic nerve).
C. Identifying scented aromas involves olfactory nerve (cranial nerve I) assessment.
D. Asking the client to clench their teeth evaluates the function of the muscles of mastication, which is controlled by cranial nerve V (trigeminal nerve).

A. Tell the adolescent everything will be fine and there's nothing to worry about. B. Complete an assessment and notify the emergency department physician immediately. C. Perform a focused assessment and document. D. Document pain assessment as normal.

Correct Answer is B

Explanation

A. Reassurance is important, but it should be given after a thorough assessment and appropriate actions have been taken.
B. Completing an assessment and promptly informing the physician allows for timely intervention in case of testicular torsion or other serious conditions causing severe testicular pain.
C. Performing a focused assessment is crucial but shouldn't delay immediate notification of the physician in such a critical situation.
D. Documenting pain assessment is important but not the priority when a client presents with severe, acute pain in a sensitive area like the testicles.

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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

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