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.
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.
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