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 A

Explanation

A. 4+ edema is characterized by very deep pitting, where the indentation remains for an extended period (several minutes), indicating severe fluid accumulation in the tissue.
B. Deep pitting that lasts for a few minutes is more consistent with 2+ or 3+ edema, not the severe 4+ edema described.
C. Mild pitting with no perceptible swelling does not align with 4+ edema; this level of pitting suggests minimal fluid accumulation.
D. Moderate pitting where the indentation subsides rapidly is indicative of 2+ edema, not the profound swelling described as 4+ edema.

A. 1 minute in the center of the abdomen. B. 10 minutes in each quadrant. C. 1 minute in each quadrant. D. 5 minutes in each quadrant. E. None F. None

Correct Answer is D

Explanation

A. One minute may not provide a sufficient duration to declare absent bowel sounds, especially if the client has a slower bowel motility.
B.

Listening for 10 minutes in each quadrant is excessive and not supported by clinical guidelines. It would unnecessarily delay care and increase patient discomfort.

C. One minute in each quadrant might not provide an adequate assessment time.
D. This is the correct answer because clinical guidelines recommend auscultating for at least 5 minutes in each quadrant before concluding that bowel sounds are absent. This ensures sufficient time to detect infrequent bowel sounds and accurately assess the situation.

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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

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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