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

A) Notify the healthcare provider of the rebound tenderness:
Rebound tenderness, also known as Blumberg's sign, is a clinical sign that suggests peritoneal irritation, which can be indicative of underlying pathology such as peritonitis. Reporting rebound tenderness to the healthcare provider is crucial for further evaluation and management of the client's condition.

B) Obtain a prescription to catheterize the client's bladder:
While urinary retention can present with lower abdominal discomfort, the scenario described does not specifically suggest urinary retention. Catheterization should be considered based on additional assessments and indications related to urinary symptoms, not solely based on the client's report of pain upon release of abdominal pressure.

C) Offer to administer a laxative prescribed for PRN use:
Administering a laxative would not be appropriate based solely on the client's report of pain upon release of abdominal pressure. Laxatives are indicated for constipation, which may cause abdominal discomfort, but they would not address rebound tenderness or the underlying cause of the client's pain.

D) Instruct the client in distraction and relaxation techniques:
While distraction and relaxation techniques can be helpful for managing pain, they would not address the underlying cause of rebound tenderness. Reporting rebound tenderness to the healthcare provider is necessary for further evaluation and appropriate management.

A. Obese, serious threat to well-being. B. Appropriate weight for height, good general health. C. Extreme obesity, at risk for multiple co-morbidities. D. Undernutrition, at risk for malnutrition.

Correct Answer is A

Explanation

A) Obese, serious threat to well-being: A BMI of 32 kg/m² places the client in the category of obesity (BMI ≥ 30 kg/m²). Obesity is a significant health concern associated with increased risks for various conditions such as cardiovascular disease, diabetes, hypertension, and certain cancers. The client's BMI indicates that she is obese, which poses a serious threat to her overall well-being and health.

B) Appropriate weight for height, good general health: This is incorrect because a BMI of 32 kg/m² does not fall within the normal range of 18.5 to 24.9 kg/m². The client is not at an appropriate weight for her height and is not considered to be in good general health based on this BMI.

C) Extreme obesity, at risk for multiple co-morbidities: While a BMI of 32 kg/m² does indicate obesity, it does not reach the threshold for extreme obesity (BMI ≥ 40 kg/m²). Therefore, the client is not categorized as extremely obese, although she is still at risk for several co-morbidities associated with obesity.

D) Undernutrition, at risk for malnutrition: This is incorrect because a BMI of 32 kg/m² is indicative of excess weight, not undernutrition or malnutrition. The client's BMI suggests an over-nutrition status rather than undernutrition.

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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

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. Which action should the nurse implement?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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