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 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 C

Explanation

A. Battle sign refers to bruising behind the ears and is a sign of head trauma, not intoxication.
B. Chvostek's sign is related to hypocalcemia, not intoxication.
C. Romberg sign assesses for balance issues when standing with eyes closed and is commonly positive in clients with neurological impairment, including intoxication.
D. Babinski sign is related to neurological disorders and would not be directly associated with intoxication.

A. Flexion B. Adduction C. Abduction D. Extension

Correct Answer is ["A","C"]

Explanation

WRIST - ABLE TO BEND WRIST BACK TOWARD FOREARM:

Abduction

Abduction refers to the movement of a body part away from the body's midline. This movement is typically used for fingers, arms, or legs, but not for the wrist. Therefore, this choice is incorrect for the wrist's range of motion.

Flexion

Flexion refers to the bending of a joint that reduces the angle between two body parts. For the wrist, flexion would involve bending the wrist forward, toward the palm of the hand. Since the patient is able to bend the wrist backward (toward the forearm), this is not the correct choice.

Extension

Extension refers to straightening a joint, which increases the angle between the body parts. For the wrist, extension is the movement where the hand moves away from the palm (backward toward the forearm). This is the correct choice because the patient is able to bend the wrist back toward the forearm, which is extension.

Adduction

Adduction refers to the movement of a body part toward the body's midline. This is not relevant to the wrist, so it is an incorrect option.

SHOULDER - UNABLE TO MOVE THE ARM AWAY FROM THE BODY:

Extension

Extension refers to the movement that straightens a joint, increasing the angle between two parts of the body. For the shoulder, this would involve moving the arm behind the body, and it's not the movement of the arm away from the body, so this is not the correct choice.

Adduction

Adduction refers to moving a body part toward the midline of the body. For the shoulder, this would involve moving the arm closer to the body. This does not correspond to the action of moving the arm away from the body, so this is not the correct choice either.

Flexion

Flexion refers to the bending of a joint that decreases the angle between two body parts. For the shoulder, this would involve raising the arm forward, not moving it away from the body. This is not the correct choice for the described movement.

Abduction

Abduction refers to the movement of a body part away from the midline of the body. In this case, the shoulder movement of moving the arm away from the body is abduction. Since the client is unable to move the arm away from the body (i.e., is experiencing weakness or limited ROM), the shoulder’s range of motion has a restriction in abduction.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes that a client who is intoxicated has an ataxic gait. Which finding does the nurse expect to be positive upon further assessment of the client?

Correct Answer is C

Explanation

Correct Answer is ["A","C"]

Explanation

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