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.
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. Tenting of the skin is a classic sign of dehydration. When the skin is pinched and does not return quickly to its normal position, it indicates a lack of fluid in the body. This is a common finding in dehydration, particularly in older adults.
B. Loss of skin elasticity is a natural part of the aging process and may not be directly related to dehydration. It is common in older adults and is not necessarily an indicator of fluid status.
C. Warm and dry skin can be a sign of dehydration, particularly if accompanied by other symptoms such as a dry mouth or increased heart rate. Dry skin occurs when there is insufficient moisture in the body, which is common in dehydration.
D. Thinning hair in the lower extremities is more often associated with circulation issues or aging. It is not a typical sign of dehydration and would not be used as a primary indicator for assessing hydration status.
Correct Answer is C
Explanation
A. Alcohol or drug abuse screening may be important but does not directly assess functional ability.
B. Medication side effects can impact functionality, but ADLs are a direct measure of independence.
C. Assessing a client's ability to perform activities of daily living (ADLs) is crucial for determining their functional status and whether they can live independently or need assistance.
D. Long-term memory evaluation is less important than assessing the client's ability to perform daily tasks.
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