The nurse is performing an abdominal assessment. After percussing ...

[pragya sharda]

The nurse is performing an abdominal assessment. After percussing the abdomen, the nurse notes that the liver span is approximately 11 centimeters. How will the nurse document this finding in the medical record?
 
  1. Hepatomegaly.
  2. A normal finding.
  3. Related to recent diagnosis of chronic bronchitis.
  4. Presence of ascites.

Question 2

The nurse is assessing a client with reports of right upper quadrant pain that radiates toward the right upper portion of the back.
 
  The client states, This has been happening more often after I eat rich, high-fat foods. Which disorder does the nurse suspect based on these findings?
  1. Cholecystitis.
  2. Duodenal ulcer.
  3. Gastritis.
  4. Pancreatitis.

[Ddddd]

Answer to Question 1

Correct Answer: 1
The liver span is the distance between the lower and upper border of the liver. It should be approximately 4 to 9 centimeters (2 to 4 inches). The liver in this situation is not enlarged, and it would be inappropriate for the nurse to determine that client has an enlarged liver (hepatomegaly). The client with chronic bronchitis may have a liver that is displaced downward within the abdomen. The client with ascites may have a liver that is displaced upward within the abdomen.

Answer to Question 2

Correct Answer: 1
Right upper quadrant pain that radiates to the right scapula is characteristic of cholecystitis. The pain usually occurs after the client eats a fatty meal. Duodenal ulcers cause aching, gnawing, and epigastric pain, and are associated with stress and NSAID use. Gastritis causes epigastric pain, and is associated with NSAID use, alcohol abuse, stress, infection, H. pylori infection, and autoimmune responses. Pancreatitis produces upper abdominal, knifelike, deep epigastric or umbilical area pain, and is associated with alcohol abuse, use of acetaminophen, and infection.