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 D

Explanation

Choice A rationale: CN X (vagus nerve) and CN VII (facial nerve) are separate cranial nerves, and the described findings are more indicative of dysfunction in the motor component of CN VII.

Choice B rationale: CN XI (accessory nerve) is primarily involved in motor function related to the sternocleidomastoid and trapezius muscles. It is not likely to cause the described facial asymmetry.

Choice C rationale: CN IV (trochlear nerve) is responsible for eye movement and would not be directly related to the described facial findings.

Choice D rationale: The described findings, such as asymmetry when smiling or frowning, uneven lifting of the eyebrows, and escape of air when pressing against a puffed cheek, indicate dysfunction of the motor component of cranial nerve VII (facial nerve).

A. The central nervous system consists of the brain and electrical impulse stimulators B. The central nervous system is made up of the hypothalamus and cerebral nerves C. The central nervous system is made up of the brain and spinal cord D. The central nervous system includes the peripheral and autonomic components

Correct Answer is C

Explanation

Choice A rationale: The central nervous system consists of the brain and spinal cord, not "electrical impulse stimulators."

Choice B rationale: The hypothalamus is a part of the brain, but the central nervous system encompasses both the brain and the spinal cord.

Choice C rationale: The central nervous system (CNS) is made up of the brain and spinal cord. The CNS processes and interprets sensory information and sends motor commands to effectors.

Choice D rationale: The peripheral nervous system and autonomic nervous system are distinct from the central nervous system and are not part of the CNS.

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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?

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Correct Answer is D

Explanation

The student nurse is studying the functioning of the nervous system. Which of the following descriptions of the central nervous system is accurate?

Correct Answer is C

Explanation

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