While completing an admission assessment for a client with fatigue, weakness, and unexplained weight loss, the nurse notes scleral jaundice. Which finding during percussion of the abdomen should the nurse document indicating hepatomegaly?

Areas of tympany within the liver region.

Tympany noted boarding the margins of the liver. C. A hollow sound over the lower abdomen.

A dull percussion tone outside the costal margins.

Answer and Explanation

The Correct Answer is D

A.   Tympany indicates the presence of gas within the intestines. This would not be expected over the liver area if there is hepatomegaly.
B.   This is not an expected finding in hepatomegaly. Tympany is associated with air-filled structures, which would not be present over an enlarged liver.
C.   A hollow sound is also indicative of air-filled organs like the intestines. It is not a sign of hepatomegaly, which would be characterized by dullness on percussion.
D.   Dullness upon percussion outside the costal margins suggests an enlarged liver (hepatomegaly). This is due to the liver becoming larger and filling the space that normally contains air-filled organs like the intestines.

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Correct Answer is C

Explanation

A. Alcohol or drug abuse screening may be important but does not directly assess functional ability.
B. Medication side effects can impact functionality, but ADLs are a direct measure of independence.
C. Assessing a client's ability to perform activities of daily living (ADLs) is crucial for determining their functional status and whether they can live independently or need assistance.
D. Long-term memory evaluation is less important than assessing the client's ability to perform daily tasks.

A. Enter subjective data in the note section of the client's electronic medical record. B. Document the client's history that is directly related to current admission diagnoses. C. Enter the information in the electronic medical record at the client's bedside. D. Document the assessment findings on the computer at the nursing station.

Correct Answer is B

Explanation

A. While subjective data is important, it should be categorized appropriately based on relevance to the diagnosis, not just placed in the notes section without context.
B. Documenting the client’s history directly related to the current admission diagnoses ensures the information is relevant and addresses the issue at hand. It helps prioritize concerns specific to the new onset seizures.
C. Recording at the bedside can be useful for accuracy but is not as effective for thoroughness as
entering information directly in the client’s electronic medical record with appropriate organization.
D. Documenting assessment findings at the nursing station might delay real-time recording and cause the information to be less accurate, especially if not recorded immediately after assessment.

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While completing an admission assessment for a client with fatigue, weakness, and unexplained weight loss, the nurse notes scleral jaundice. Which finding during percussion of the abdomen should the nurse document indicating hepatomegaly?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client is being evaluated for admission to an assisted living facility. During the health assessment, the nurse implements which technique to determine the client's ability to reside in this environment?

Correct Answer is C

Explanation

The nurse is obtaining a health history for a client being admitted for new onset seizures. Which action should the nurse implement to accurately record the health history findings?

Correct Answer is B

Explanation

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