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 B

Explanation

A. A bone spur is a bony projection often caused by joint damage, but it does not typically produce audible crunching or grating sounds.
B. Crepitation refers to a crunching, grating, or popping sound or sensation that occurs with movement of a joint. It's often associated with conditions like osteoarthritis.
C. Tendonitis involves inflammation of a tendon and may cause pain or tenderness, but it does not typically produce audible sounds like crepitation.
D. Fluid in the knee joint might cause swelling and limited movement, but it does not usually produce audible crunching or grating sounds.

A. estimate the degree of flexion and extension in each joint. B. measure the degree of force that it takes to overcome joint flexion or extension. C. apply an opposing force when the individual puts a joint in flexion or extension. D. observe muscles for the degree of contraction when the individual lifts a heavy object.

Correct Answer is C

Explanation

A. Estimating the degree of flexion and extension in each joint primarily assesses the range of motion, not specifically muscle strength.
B. Measuring the degree of force required to overcome joint flexion or extension may assess resistance but doesn't directly evaluate muscle strength.
C. Applying an opposing force when the individual puts a joint in flexion or extension is an accurate method to assess muscle strength, as it evaluates the force the muscle can generate against resistance.
D. Observing muscles for contraction while lifting a heavy object evaluates muscle usage but doesn’t offer a standardized way to assess muscle strength.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is C

Explanation

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