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 ["B"]
Explanation
A. Stress can affect sexual performance, but it's not exclusively an internal factor. Stress can be caused by both internal and external factors.
B. Low testosterone levels are an internal factor that can significantly impact sexual performance in aging males. Testosterone decline is a natural part of aging and can affect libido and sexual function.
C. Substance use can affect sexual performance, but it's not solely an internal cause as it often involves external factors related to the intake of substances.
D. Lack of sleep affects overall health, but it can also be influenced by external factors and is not strictly an internal cause.
E. Chronic diseases such as diabetes, cardiovascular diseases, and others can have internal physiological effects that impact blood flow, nerve function, and overall health, contributing to declines in sexual performance later in life.
Correct Answer is B
Explanation
A. A bone spur is a bony projection often caused by joint damage, but it does not typically produce audible crunching or grating sounds.
B. Crepitation refers to a crunching, grating, or popping sound or sensation that occurs with movement of a joint. It's often associated with conditions like osteoarthritis.
C. Tendonitis involves inflammation of a tendon and may cause pain or tenderness, but it does not typically produce audible sounds like crepitation.
D. Fluid in the knee joint might cause swelling and limited movement, but it does not usually produce audible crunching or grating sounds.
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