While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

Dimpled area above anus.

Flap of tissue at sphincter.

Increased pigmentation and coarse skin.

Hypotonic tone of the anal sphincter.

Answer and Explanation

The Correct Answer is C

A) Dimpled area above anus:
This finding may indicate a pilonidal cyst, which is an abnormality rather than a normal appearance of the anus.

B) Flap of tissue at sphincter:
A flap of tissue at the anal sphincter, also known as the anal valve, is a normal anatomical feature. It helps maintain continence and prevents leakage of stool.

C) Increased pigmentation and coarse skin:
Increased pigmentation and coarse skin may be typical findings in the perianal area due to factors such as friction, moisture, or aging. While not everyone will have this appearance, it is within the range of normal variations.

D) Hypotonic tone of the anal sphincter:
Hypotonic tone of the anal sphincter may suggest weakness or dysfunction of the anal sphincter, which is not considered a normal finding.

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Correct Answer is A

Explanation

When unable to palpate peripheral pulses, particularly the pedal pulses, using a Doppler ultrasonic stethoscope is an appropriate action to further assess circulation. The Doppler device uses sound waves to detect and amplify blood flow, allowing the nurse to locate pulses that may be difficult to palpate by traditional means. This assessment technique can provide valuable information about vascular status and potential circulation issues in the extremities.

B. Notify the healthcare provider:
Notifying the healthcare provider is not the initial action for the inability to palpate pedal pulses. The nurse should first attempt to assess the pulses using alternative methods, such as a Doppler device, before escalating the concern to the provider.

C. Apply warm blankets to both feet:
Applying warm blankets may be appropriate for clients with cold extremities due to peripheral vasoconstriction, but it does not directly address the issue of being unable to palpate pulses. Additionally, warmth alone may not improve circulation if there is an underlying vascular problem causing the absence of pulses.

D. Palpate pulse points with legs dependent:
Palpating pulse points with the legs dependent may facilitate blood flow to the lower extremities, potentially making pulses easier to palpate. However, if pulses are not palpable in the supine or seated position, it is unlikely that changing positions will significantly improve their detectability. Using a Doppler device would be a more appropriate next step in this situation.

A. Presents with a hacking nonproductive cough of 6 weeks duration. B. Expresses concern of "lung cancer" symptoms for last 6 weeks. C. An adult male presents with fears that he has "lung cancer." D. Describes having a "body wracking dry cough" of 6 weeks duration.

Correct Answer is D

Explanation

A) Presents with a hacking nonproductive cough of 6 weeks duration:
This documentation accurately describes the client's symptom of a cough but does not capture the client's expressed concern about the possibility of lung cancer. It is important to document the client's specific concerns and fears.

B) Expresses concern of "lung cancer" symptoms for last 6 weeks:
While this option captures the client's concern about lung cancer, it does not specifically describe the client's symptom of a dry cough. Effective documentation should include both the client's expressed concerns and the associated symptoms.

C) An adult male presents with fears that he has "lung cancer":
This option captures the client's fear of having lung cancer but does not describe the specific symptom of a dry cough that the client is experiencing. Including the specific symptom in the documentation is important for comprehensive assessment and evaluation.

D) Describes having a "body wracking dry cough" of 6 weeks duration:
This option effectively documents both the client's specific symptom (dry cough) and the duration of the symptom (6 weeks), which aligns with the client's expressed concerns. It accurately reflects the client's statement and provides valuable information for the healthcare provider's assessment and management.

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While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

While obtaining a client's health history related to smoking cigarettes, the nurse plans to determine the client's smoking pack years. What information should the nurse obtain for this calculation? Select all that apply.

An adult client exhibits an allergic reaction to an insect bite. The nurse should observe the client's skin for which finding?

A client presents with itching and pain in the left ear that started several days after beginning swim lessons. The nurse observes a discharge coming from the ear with a musty odor. How should the nurse expect the ear to appear when performing an otoscopic examination?

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

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During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?