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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Flexion refers to bending a joint, usually decreasing the angle between two body parts.
B. Extension refers to straightening or increasing the angle between two body parts.
C. Abduction involves moving a body part away from the midline or center of the body.
D. Adduction involves moving a body part toward the midline or center of the body.
Correct Answer is D
Explanation
A. The vas deferens is a duct that transports sperm from the epididymis to the ejaculatory duct.
B. The epididymis is where sperm is stored and matures but not produced.
C. The prostate gland produces a fluid that contributes to semen but not sperm production.
D. The testes are responsible for producing sperm through the process of spermatogenesis.
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