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 D

Choice A rationale: The normal liver span is 6-12 cm above the right coastal margin hence this finding is normal.

Choice B rationale: This finding is normal and does not indicate hepatomegaly.

Choice C rationale: Additional health history questions regarding alcohol intake may not be relevant in this case since the patient has a normal liver span.

Choice D rationale: The normal liver span in the midclavicular line is 6 to 12 cm, so an area of dullness of 11 cm above the right costal margin is within the normal range.

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Correct Answer is C

Explanation

Choice A rationale: Estimating the degree of flexion and extension in each joint is more related to joint range of motion, not muscle strength.

Choice B rationale: Measuring the degree of force that it takes to overcome joint flexion or extension is not a standard method for assessing muscle strength.

Choice C rationale: To assess muscle strength, the nurse should apply an opposing force when the individual puts a joint in flexion or extension. This helps evaluate the strength of the muscles and their ability to move the joint against resistance.

Choice D rationale: Observing muscles for the degree of contraction when lifting a heavy object may provide information on muscle function but is not a specific muscle strength assessment.

A. Vertebral column B. Intervertebral disks C. Vertebral foramen D. Nucleus pulposus

Correct Answer is B

Explanation

Choice A rationale: The vertebral column refers to the entire structure of the spine.

Choice B rationale: Intervertebral disks are the structures between the vertebrae that act as shock absorbers, providing cushioning and flexibility to the spine.

Choice C rationale: The vertebral foramen is an opening in each vertebra through which the spinal cord passes.

Choice D rationale: Nucleus pulposus is the soft, gel-like substance in the center of an intervertebral disk.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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