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?

Choice A Reason:
Performing passive range of motion and compare the findings is inappropriate. While assessing passive range of motion can provide information about joint mobility and flexibility, it may not directly address the asymmetry observed in the legs. Range of motion assessment is more relevant for evaluating joint function and flexibility rather than leg length asymmetry.
Choice B Reason:
Comparing measured circumferences of each extremity joint is inappropriate. Measuring circumferences of extremity joints may help identify differences in muscle mass or swelling, but it may not directly address the asymmetrical leg length observed. Circumference measurements are more relevant for assessing muscle bulk or detecting signs of edema rather than leg length asymmetry.
Choice C Reason:
Instructing client to walk across the room and observe the gait is inappropriate. Observing the client's gait can provide valuable information about their walking pattern and any abnormalities in movement. While an abnormal gait may be associated with leg length asymmetry, directly measuring leg length would provide more precise data for evaluation.
Choice D Reason:
Measuring the length of each leg and document the findings is appropriate. Measuring the length of each leg can help identify any significant differences in leg length, which could be contributing to the asymmetry observed. Leg length discrepancy can result from various musculoskeletal conditions such as scoliosis, hip dysplasia, or unequal growth rates. Documenting the findings allows for accurate tracking of changes over time and provides important information for healthcare providers to determine appropriate interventions, such as orthotic devices or physical therapy.

Choice A Reason:
Expected finding is incorrect. While some degree of dullness is expected during percussion of the heart borders due to the presence of solid cardiac tissue, the specific pattern described in the scenario, extending from the 5th left intercostal space to the 2nd left intercostal space at the sternal border, suggests an abnormality rather than an expected finding.
Choice B Reason:
Cardiac atrophy is incorrect. Cardiac atrophy refers to a decrease in the size or mass of the heart muscle, resulting in a smaller than normal heart. However, the described findings indicate dullness extending upward, suggesting an enlargement rather than atrophy of the heart.
Choice C Reason:
Benign variation is incorrect. Benign variations in cardiac percussion findings are less likely to produce a pattern of dullness extending from the 5th left intercostal space to the 2nd left intercostal space at the sternal border. This pattern is more indicative of cardiac enlargement or pathology rather than a benign variation.
Choice D Reason:
Cardiac enlargement is correct. During percussion of the heart borders, dullness indicates solid tissue, such as the heart. The area of dullness extending from the 5th left intercostal space to the 2nd left intercostal space at the sternal border suggests an enlargement of the cardiac silhouette. This enlargement could be due to various cardiac conditions, such as cardiomegaly (enlarged heart), left ventricular hypertrophy, or other structural abnormalities affecting the heart.