The nurse is percussing a client's abdomen during a physical assessment. The nurse observes an area of dullness above the right costal margin of approximately 11 cm. Which of the following actions should the nurse take?

Recognizes this dullness as indicative of an enlarged liver, and refers the client to a provider

Document the presence of hepatomegaly

Ask additional health history questions regarding alcohol intake

Recognizes this finding as normal, and proceed with the examination

Answer and Explanation

The Correct Answer is A

A.   Dullness above the right costal margin could indicate an enlarged liver. Referring the client to a healthcare provider is crucial for further evaluation and diagnosis.
B.   Documenting hepatomegaly without further investigation or confirmation by a healthcare provider could be premature.
C.   While alcohol intake can be a factor in liver conditions, additional history alone may not confirm the cause of the dullness. Direct evaluation by a healthcare provider is necessary.
D.   Finding an area of dullness above the right costal margin, particularly of such magnitude, should prompt further investigation rather than being considered normal.

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Correct Answer is C

Explanation

A. Estimating the degree of flexion and extension in each joint primarily assesses the range of motion, not specifically muscle strength.
B. Measuring the degree of force required to overcome joint flexion or extension may assess resistance but doesn't directly evaluate muscle strength.
C. Applying an opposing force when the individual puts a joint in flexion or extension is an accurate method to assess muscle strength, as it evaluates the force the muscle can generate against resistance.
D. Observing muscles for contraction while lifting a heavy object evaluates muscle usage but doesn’t offer a standardized way to assess muscle strength.

A. "A good time to examine your testicles is just before you take a shower." B. "If you notice an enlarged testicle or a painless lump, call your health care provider." C. "Perform a testicular examination at least once a week to detect the early stages of testicular cancer." D. "The testicle is egg-shaped and movable. It feels firm and has a lumpy consistency."

Correct Answer is B

Explanation

A. Timing for testicular examination isn't as crucial as recognizing changes in the testicles. While showering might facilitate the exam, it's not the only appropriate time.
B. Noticing an enlargement or painless lump is a crucial sign that requires immediate medical attention for evaluation.
C. Performing a testicular examination once a week might not be necessary for most individuals. Monthly self-examination is often recommended.
D. Describing the testicle's normal characteristics is helpful, but recognizing changes such as lumps or enlargements is more critical for self-examination.

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The nurse is percussing a client's abdomen during a physical assessment. The nurse observes an area of dullness above the right costal margin of approximately 11 cm. Which of the following actions should the nurse take?

Nursing Test Bank

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