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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Bronchitis may cause wheezing, but it typically presents with a productive cough and can be associated with fever, which this client does not have. The absence of a productive cough and the degree of difficulty breathing suggest another condition.
B. Asthma is the most likely diagnosis. The client’s wheezing, decreased tactile fremitus, prolonged expirations, and history of exercise-induced symptoms are consistent with an asthma exacerbation. Asthma often presents with wheezing and difficulty breathing, especially during or after physical exertion.
C. Pneumonia typically presents with fever, chills, productive cough, and localized lung findings, which are not present in this client. The lack of fever and the presence of wheezing make pneumonia unlikely.
D. Pneumothorax may cause dyspnea and decreased breath sounds, but the wheezing, prolonged expirations, and history of exertion suggest asthma as the primary concern. A pneumothorax would typically present with more abrupt onset and significant breath sounds asymmetry, which is not seen in this case.

Correct Answer is []

Explanation

Condition: Pleural Effusion

Pleural effusion is an accumulation of fluid in the pleural space, leading to difficulty breathing, decreased lung sounds, and dullness upon percussion (as noted in the nurse's assessment).

Actions to Take:

Auscultate the lungs for adventitious breath sounds: Pleural effusion may result in decreased or absent breath sounds due to fluid in the pleural cavity. Adventitious sounds such as crackles or a pleural friction rub can sometimes be heard, but in this case, decreased sounds are noted.
Inspect the chest for lag on the affected side: In pleural effusion, there may be a delay in chest expansion on the affected side due to fluid buildup, which is consistent with the decreased expansion noted in the assessment.

Parameters to Monitor:

Cyanosis: Cyanosis may occur if the fluid accumulation severely impairs oxygenation.
Respiratory rate and pulse: Monitoring respiratory rate and pulse is critical to assess for signs of respiratory distress and hypoxia, which could result from the pleural effusion.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

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