The nurse is assessing a client for hepatomegaly by percussing over the liver. The nurse would expect to hear which of the following sounds when percussing the liver?
1. Loud, low-pitched
2. Soft, high-pitched
3. Drum-like
4. Abnormally loud
2
Rationale 1: Tympany is a loud, high-pitched, drum-like tone that is heard over air-filled organs such as the intestines.
Rationale 2: Dullness is a soft, high-pitched tone of short duration, usually heard over solid organs such as the liver.
Rationale 3: Resonance is a loud, low-pitched tone of normal findings over the lungs.
Rationale 4: Hyperresonance is an abnormally loud, low tone of longer duration heard when air is trapped in the lungs.
You might also like to view...
A nurse is caring for a client with high blood pressure. The client has a sphygmomanometer at home. A family member wishes to learn how to measure blood pressure. The nurse demonstrates to the client and the family member
how to take blood pressure measurements using the sphygmomanometer. The nurse identifies which domain of learning as being addressed? A) Psychomotor domain B) Affective domain C) Cognitive domain D) Intellectual domain
Which assessment data would help the health care team distinguish symptoms of conversion (functional neurological) disorder from symptoms of illness anxiety disorder (hypochondriasis)?
a. Voluntary control of symptoms b. Patient's style of presentation c. Results of diagnostic testing d. The role of secondary gains
What is the primary source of physiologic iron?
a. Transferrin from plasma b. Pepsin form pepsinogen c. Bile from bilirubin d. Heme from animal protein
The nurse is providing discharge teaching to a patient prescribed phenytoin (Dilantin) for management of a seizure disorder. Which patient statement indicates a need for further teaching?
a. "I need to avoid or limit caffeine intake." b. "I will check with the pharmacist before taking over-the-counter medication." c. "If I develop enlarged gums, I will stop taking the medication." d. "It is important for me to take my medicine at the same time daily."