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. The Glasgow Coma Scale assesses a patient's level of consciousness, not specifically limb weakness.
B. A complete neurological examination would involve assessing cranial nerves, motor and sensory functions, reflexes, coordination, and gait, which are essential when a client presents with unilateral weakness in the arm and leg.
C. A muscular examination might focus more on muscle strength and tone but might not cover the breadth of neurological assessment needed in this scenario.
D. Neurologic recheck examination suggests a reassessment after an initial neurological exam but doesn’t specify the need for a comprehensive evaluation.

A. Vertebral column B. Intervertebral disks C. Vertebral foramen D. Nucleus pulposus

Correct Answer is B

Explanation

A. The vertebral column refers to the series of vertebrae forming the backbone, not specifically the shock absorbers.
B. Intervertebral disks are the fibrocartilage pads between vertebrae that act as shock absorbers, allowing movement and cushioning the spine.
C. The vertebral foramen is the opening in the vertebrae through which the spinal cord passes.
D. The nucleus pulposus is the gel-like inner core of the intervertebral disk, contributing to its flexibility and shock-absorbing properties.

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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

A client comes to the clinic and reports having weakness in the left arm and leg for the past week. The nurse should perform which type of neurological exam?

Correct Answer is B

Explanation

The nurse teaches a client that there are shock absorbers in the back to cushion the spine and to help it move. The client understands that which of the following is another name for shock absorbers:

Correct Answer is B

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?

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