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 A

Explanation

Choice A rationale: Finding a firm, irregularly shaped mass during a rectal examination raises concerns about the possibility of colorectal pathology, including cancer. The nurse should report the finding and refer the client to a specialist for further examination and diagnostic testing.

Choice B rationale: Dismissing the mass without further investigation may lead to a delay in diagnosis and appropriate treatment.

Choice C rationale: Instructing the client to return for a repeat assessment in 1 month is not appropriate when a potentially serious finding is present. Immediate referral for further evaluation is necessary.

Choice D rationale: Continuing the examination without addressing the finding and obtaining appropriate follow-up could compromise the client's health and delay necessary interventions.

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

Choice A rationale: While performing a testicular self-examination before taking a shower may be convenient, it is not the most critical instruction regarding the detection of abnormalities.

Choice B rationale: The appropriate statement is to instruct the client that if they notice an enlarged testicle or a painless lump, they should contact their health care provider for further evaluation.

Choice C rationale: Performing a testicular examination once a week may be excessive, and the frequency is not universally recommended. Monthly self-examinations are often suggested.

Choice D rationale: Describing the testicle as egg-shaped, movable, firm, and having a lumpy consistency provides general information about the normal characteristics of the testicle.

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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

The nurse is performing a rectal examination on a client and finds a firm, irregularly shaped mass. Which of the following is the next action the nurse should take?

Correct Answer is A

Explanation

The nurse is describing how to perform a testicular self-examination to a client. Which of the following should be the appropriate statement by the nurse?

Correct Answer is B

Explanation

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