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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Choice A rationale: The sensation of the room spinning is termed vertigo. It is often caused by problems in the inner ear or the brain.
Choice B rationale: Seizure activity involves abnormal electrical activity in the brain and is not characterized by a sensation of the room spinning.
Choice C rationale: Dizziness is a more general term that may include lightheadedness or unsteadiness but does not specifically describe the sensation of the room spinning.
Choice D rationale: Syncope refers to a temporary loss of consciousness, often described as fainting, and is not indicative of a sensation of the room spinning.
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