While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

Cardiac atrophy.

Cardiac enlargement.

Benign variation.

Expected finding.

Answer and Explanation

The Correct Answer is B

A. Cardiac atrophy would typically not present with an area of dullness upon percussion. Instead, you might expect a different set of findings related to the heart's size and function.
B. Cardiac enlargement is indicated by an area of dullness that extends beyond the normal borders of the heart. Dullness on percussion indicates the presence of solid or fluid-filled structures, such as an enlarged heart.
C. A benign variation in heart sounds or borders is usually within normal limits and does not typically show such pronounced changes in percussion notes.
D. This finding is not an expected normal finding. Normal heart borders are not usually marked by an area of dullness extending from the 5th to the 2nd intercostal space.

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Correct Answer is B

Explanation

A. Rebound tenderness is typically associated with peritoneal irritation and is not expected in pyelonephritis. It is more commonly observed in conditions like appendicitis or peritonitis.
B. Sharp, severe pain upon percussion of the costovertebral angle (CVA) is a hallmark sign of pyelonephritis, indicating inflammation or infection in the kidneys. This response, known as CVA tenderness, is a key diagnostic indicator of this condition.
C. An audible thud without pain would be considered a normal finding and does not suggest the presence of pyelonephritis or other kidney-related issues. The absence of pain would likely rule out significant kidney inflammation.
D. Rigidity and firmness are typically associated with muscle guarding or abdominal wall tension rather than kidney involvement. This finding would not be expected in the context of pyelonephritis.

A. Monitor urinary output B. Obtain an electrocardiogram C. Restrict activity to bed rest D. Initiate NPO status

Correct Answer is D

Explanation

A. Monitoring urinary output is important for assessing kidney function and hydration status, but it is not the immediate priority in this situation. The abrupt cessation of inhalation during palpation suggests acute abdominal pathology that requires immediate attention.
B. Obtaining an electrocardiogram (ECG) is necessary in cases of suspected cardiac issues, but the symptoms described are more indicative of an acute abdominal condition, such as peritonitis or cholecystitis, rather than a cardiac event.
C. Restricting activity to bed rest may help prevent further discomfort or complications, but it is not the most critical immediate action. The client’s acute symptoms suggest the need for more urgent interventions.
D. Initiating NPO (nothing by mouth) status is the most important action because the client may require surgical intervention or further diagnostic testing for an acute abdominal condition. NPO status is essential to prepare the client for potential surgery and to prevent further complications.

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While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

Correct Answer is B

Explanation

During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

Correct Answer is D

Explanation

A client reports experiencing stomach pain, and it is localized in the middle section of the abdomen below the xiphoid process. The nurse should describe the pain as occurring in which region of the abdomen?

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