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: A peritoneal friction rub is a grating sound caused by the movement of inflamed peritoneal surfaces and is not associated with bowel sounds.

Choice B rationale: Loud continual humming bowel sounds do not accurately describe borborygmi and are not a common term used to describe bowel sounds.

Choice C rationale: Hypoactive bowel sounds indicate decreased bowel motility and are not associated with borborygmi.

Choice D rationale: Borborygmi refers to loud, gurgling bowel sounds that are audible without the use of a stethoscope. It is a normal sound associated with the movement of gas and fluid through the intestines.

A. Plantarflex the foot B. Dorsiflex the foot C. Hold both hands back to back while flexing the wrists 90 degrees for 60 seconds D. Hyperextend the wrists with the palmar surface of both hands touching, and wait for 60 seconds

Correct Answer is C

Explanation

Choice A rationale: Plantarflexion of the foot is not part of the Phalen test. Choice B rationale: Dorsiflexion of the foot is not part of the Phalen test.

Choice C rationale: To perform the Phalen test, the client should hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. This test helps assess for symptoms of carpal tunnel syndrome.

Choice D rationale: Hyperextension of the wrists with the palmar surface of both hands touching is not the correct position for the Phalen test.

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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 physician comments that the client has abdominal borborygmi. The nurse recognizes that which of the following is the best description of borborygmi?

Correct Answer is D

Explanation

The nurse suspects that a client has carpal tunnel syndrome and prepares to conduct the Phalen test. What instructions should the nurse give the client to perform the Phalen test?

Correct Answer is C

Explanation

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