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. Interphalangeal joints are the joints between the phalanges, since the client is unable to remove a ring, the most likely affected joint is the interphalangeal joint.
B. The Tibiotalar joint is the ankle joint.
C. Metacarpophalangeal joint refers to the joint between the metacarpal bones in the upper limbs and the phalanges.
D. Tarsometatarsal joints are the joints between the tarsal bones of the foot and metatarsal bones.

A. measure the circumference of the ankle. B. measure the calf at the widest point with a tape measure. C. check the dorsalis pedis pulse with the palm of the hand. D. compress the dorsalis pedis pulse, looking for blood return.

Correct Answer is B

Explanation

A. Measuring the circumference of the ankle is not a specific method for screening DVT.
B. Assessing the calf at its widest point with a tape measure can reveal differences in calf size, which might indicate swelling due to a DVT.
C. Checking the dorsalis pedis pulse assesses peripheral circulation but doesn't specifically screen for DVT.
D. Compressing the dorsalis pedis pulse to check for blood return is part of assessing peripheral circulation but doesn’t directly screen for DVT.

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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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