The nurse is performing a rectal examination on a client and finds a firm, irregularly shaped mass. Which of the following is the next action the nurse should take?

Report the finding, and refer the client to a specialist for further examination.

Tell the client that a mass was felt, but is nothing to worry about.

Instruct the client to return for a repeat assessment in 1 month.

Continue the examination, and document the findings on the chart.

Answer and Explanation

The Correct Answer is A

A firm, irregularly shaped mass found during a rectal examination could potentially indicate a serious condition such as a tumor or other pathology. It's essential to report such findings and refer the client to a specialist for further evaluation and appropriate diagnosis.
B.   It's important not to dismiss or downplay the significance of finding a mass, as it could signify a serious health issue.
C.   Waiting a month for reassessment could potentially delay necessary medical intervention if the mass is concerning.
D.   While documentation is important, it's crucial to prioritize immediate reporting and referral for further evaluation when such findings are discovered.

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Correct Answer is C

Explanation

A. The sigmoid is a part of the large intestine located in the left lower quadrant, so tenderness in the right lower quadrant is unlikely to be related to the sigmoid.
B. The liver is situated higher in the abdomen, typically more towards the right upper quadrant, and its tenderness wouldn't manifest in the right lower quadrant.
C. Tenderness in the right lower quadrant is a classic sign of appendicitis, suggesting inflammation of the appendix.
D. The gallbladder is positioned closer to the liver, in the right upper quadrant, and wouldn't typically cause tenderness in the right lower quadrant.

A. Motor component of CN X and sensory component of CN VII B. Motor and sensory component of CN XI C. Motor component of CN IV D. Motor component of CN VII

Correct Answer is D

Explanation

A. Dysfunction of the motor component of CN X (vagus nerve) and sensory component of CN VII (facial nerve) would present with different symptoms, such as difficulty swallowing and impaired taste sensation, not the observed facial asymmetry and puffing of cheeks.
B. CN XI (accessory nerve) dysfunction primarily affects the sternocleidomastoid and trapezius muscles and wouldn't cause the observed facial asymmetry.
C. Dysfunction of CN IV (trochlear nerve) leads to issues with downward and inward eye movement, not the facial asymmetry described.
D. Dysfunction of the motor component of CN VII (facial nerve) leads to facial asymmetry during expressions and difficulty controlling facial muscles, which matches the observed findings.

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The nurse is performing a rectal examination on a client and finds a firm, irregularly shaped mass. Which of the following is the next action the nurse should take?

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Naxlex Comprehensive Predictor Exams

During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes that this finding could indicate a problem with which organ?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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