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 B

Explanation

Choice A rationale: Telling the adolescent that everything will be fine without a thorough assessment may delay necessary interventions.
Choice B rationale: Excruciating pain in the testicle requires immediate attention since it could be an indication of testicular torsion. The nurse should complete an assessment and notify the emergency department physician promptly.
Choice C rationale: While documentation is important, the priority is to address the immediate needs of the adolescent in severe pain.
Choice D rationale: Documenting pain assessment as normal is not appropriate when the client is experiencing excruciating pain.

A. Observing for facial symmetry B. Checking the pupillary response to light C. Testing visual acuity D. Eliciting the gag reflex

Correct Answer is B

Explanation

Choice A rationale: Observing for facial symmetry is more relevant to Cranial Nerve VII (facial nerve).

Choice B rationale: Cranial nerve III (oculomotor nerve) is responsible for pupillary constriction. The nurse should check the pupillary response to light to assess the function of this cranial nerve.

Choice C rationale: Testing visual acuity is not specific to Cranial Nerve III but is more associated with Cranial Nerve II (optic nerve).

Choice D rationale: Eliciting the gag reflex is related to Cranial Nerve IX (glossopharyngeal nerve) and X (vagus nerve), not Cranial Nerve III.

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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

An adolescent male is brought to the emergency department with complaints of excruciating pain in his left testicle. Which of the following should be the priority action by the nurse?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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