While completing an admission assessment for a client with fatigue, weakness, and unexplained weight loss, the nurse notes scleral jaundice. Which finding during percussion of the abdomen should the nurse document indicating hepatomegaly?
Areas of tympany within the liver region.
Tympany noted boarding the margins of the liver. C. A hollow sound over the lower abdomen.
A dull percussion tone outside the costal margins.
The Correct Answer is D
A. Tympany indicates the presence of gas within the intestines. This would not be expected over the liver area if there is hepatomegaly.
B. This is not an expected finding in hepatomegaly. Tympany is associated with air-filled structures, which would not be present over an enlarged liver.
C. A hollow sound is also indicative of air-filled organs like the intestines. It is not a sign of hepatomegaly, which would be characterized by dullness on percussion.
D. Dullness upon percussion outside the costal margins suggests an enlarged liver (hepatomegaly). This is due to the liver becoming larger and filling the space that normally contains air-filled organs like the intestines.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Longitudinal ridges on the fingernails are a common finding in older adults and often do not indicate any underlying health problems. These ridges may develop due to normal aging processes as the rate of nail growth slows.
B. While COPD can cause changes in the nails, such as clubbing, longitudinal ridges are not typically associated with this condition. COPD is more likely to cause cyanosis and other signs related to poor oxygenation.
C. A fungal infection usually causes discoloration, thickening, or brittleness in nails, but not longitudinal ridges. Fungal infections would likely affect the overall appearance of the nail rather than causing isolated ridges.
D. Psoriasis can cause pitting, scaling, or thickening of the nails, but longitudinal ridges are not characteristic of this condition. Psoriasis typically affects the skin more than the nails, though it can lead to changes in nail structure.
Correct Answer is D
Explanation
A. This is not specific for egophony. While lung auscultation is part of a thorough assessment, egophony is assessed when the patient vocalizes a specific sound, not just breathing in and out.
B. This is a technique used to assess for whispered pectoriloquy, not egophony. The nurse would be looking for clarity of the whispered words, which is different from assessing for egophony.
C. This test is used to assess for bronchophony, where the nurse listens for clarity or increased volume of spoken words over the lungs. It is not related to egophony, which is a change in the sound when the client says "E."
D. This is the correct method for assessing egophony. In this test, the client is asked to say "E," and the nurse listens for any change in the sound. Normally, the "E" should sound like "E." If it sounds like "A," it indicates egophony, which can suggest a lung consolidation, such as might occur with a lung abscess.
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