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 B

Explanation

A. HPV vaccination is recommended for both sexually active and non-sexually active individuals for preventive purposes. This statement restricts the vaccine unnecessarily.
B. This statement is correct. The HPV vaccine works best if administered before exposure to the virus, so it is not effective in treating existing HPV infections or genital warts.
C. While true that the HPV vaccine is typically recommended for individuals within a certain age range, this statement doesn't address the client's specific query about getting rid of existing genital warts.
D. Involving the physician in vaccine candidacy is a good step but doesn't directly address the client's query about HPV infection and genital warts.

A. The central nervous system consists of the brain and electrical impulse stimulators. B. The central nervous system is made up of the hypothalamus and cerebral nerves. C. The central nervous system is made up of the brain and spinal cord. D. The central nervous system includes the peripheral and autonomic components.

Correct Answer is C

Explanation

A. This option inaccurately includes "electrical impulse stimulators," which is not a recognized component of the central nervous system. The central nervous system comprises the brain and spinal cord.
B. The hypothalamus and cerebral nerves are parts of the nervous system but do not represent the entirety of the central nervous system.
C. The central nervous system consists specifically of the brain and spinal cord, responsible for coordinating and processing sensory information.
D. The peripheral and autonomic components belong to the broader nervous system but are not part of the central nervous system.

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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

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