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 D

Choice A rationale: The normal liver span is 6-12 cm above the right coastal margin hence this finding is normal.

Choice B rationale: This finding is normal and does not indicate hepatomegaly.

Choice C rationale: Additional health history questions regarding alcohol intake may not be relevant in this case since the patient has a normal liver span.

Choice D rationale: The normal liver span in the midclavicular line is 6 to 12 cm, so an area of dullness of 11 cm above the right costal margin is within the normal range.

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Correct Answer is C

Explanation

Choice A rationale: Flexion involves decreasing the angle between two body parts, typically bending a joint.

Choice B rationale: Extension involves increasing the angle between two body parts, typically straightening a joint.

Choice C rationale: Moving the right arm away from the center of the body is an example of abduction, which is the movement of a body part away from the midline.

Choice D rationale: Adduction is the movement of a body part toward the midline.

A. Asymmetry with one side hanging lower than the other B. Marked tenderness on palpation C. Easy sliding of scrotal contents when palpated D. Presence of small, firm, nontender, yellowish nodules

Correct Answer is B

Explanation

Choice A rationale: Asymmetry with one side hanging lower than the other is a normal variation in scrotal anatomy.

Choice B rationale: Marked tenderness on palpation of the scrotum is abnormal and may indicate inflammation or infection.

Choice C rationale: Easy sliding of scrotal contents when palpated is a normal finding.

Choice D rationale: Small, firm, nontender, yellowish nodules may represent sebaceous cysts or Fordyce spots, which are typically benign and not a cause for concern.

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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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Explanation

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Correct Answer is B

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