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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A. Dullness above the right costal margin could indicate an enlarged liver. Referring the client to a healthcare provider is crucial for further evaluation and diagnosis.
B. Documenting hepatomegaly without further investigation or confirmation by a healthcare provider could be premature.
C. While alcohol intake can be a factor in liver conditions, additional history alone may not confirm the cause of the dullness. Direct evaluation by a healthcare provider is necessary.
D. Finding an area of dullness above the right costal margin, particularly of such magnitude, should prompt further investigation rather than being considered normal.
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