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 D

Explanation

A) Compare the shape of each of the pupils bilaterally with normal room light:
Assessing the shape of the pupils with normal room light is not specifically related to assessing pupillary reaction to accommodation. This action may be more relevant for assessing pupillary symmetry and shape, but it does not directly evaluate accommodation.

B) Determine if dilation of the pupils occurs when the room is darkened:
This action assesses the pupillary response to changes in light (pupillary light reflex), not specifically accommodation. While it is an important assessment, it does not target accommodation specifically.

C) Note the speed of pupil constriction when a penlight is shined into the eye:
This action assesses the pupillary light reflex, which involves the constriction of the pupils in response to light. While it is related to pupillary function, it does not specifically evaluate accommodation.

D) Observe pupil size when focusing on a near object and then a far object:
This action directly assesses the pupillary reaction to accommodation. When focusing on a near object, the pupils should constrict (miosis), and when focusing on a far object, the pupils should dilate (mydriasis). This response indicates that the pupils are adapting to changes in focal distance, demonstrating accommodation.

A. Number of attempts to quit smoking. B. Client's current age. C. Age when the client started smoking. D. Packs of cigarettes smoked per day. E. Number of years the client smoked.

Correct Answer is ["C","D","E"]

Explanation

Answer: C. Age when the client started smoking.
Knowing when the client began smoking is essential for determining the total duration of smoking. This information allows the nurse to calculate how long the client has been exposed to tobacco, which is critical for assessing potential health risks associated with their smoking history.

D. Packs of cigarettes smoked per day.
This information is crucial as it directly contributes to the calculation of pack years. Understanding how many packs the client smokes each day helps quantify their level of tobacco exposure. For instance, smoking one pack per day for ten years results in ten pack years, while two packs per day over the same period would lead to twenty pack years.

E. Number of years the client smoked.
This detail is necessary to determine the total duration of the smoking habit. The total number of years smoked, combined with the daily pack consumption, provides a comprehensive view of the client's smoking history. It allows the nurse to assess the cumulative risk associated with long-term tobacco use, which is important for evaluating the client’s health and potential interventions.

Rationale for Options Not Selected:

A. Number of attempts to quit smoking.
While this information can provide insight into the client's motivation and efforts to quit, it is not relevant for calculating pack years. Pack years focus specifically on the amount and duration of smoking, rather than attempts to quit, which may be useful in assessing readiness for cessation interventions but does not factor into the calculation of exposure.

B. Client's current age.
Although the client's age can provide context regarding their smoking history, it is not necessary for the actual calculation of pack years. Instead, it is the age when the client started smoking, along with the total years smoked and the number of packs smoked per day, that are critical for this specific assessment. The current age is not needed to compute pack years directly.

Summary of Calculation:

To calculate pack years, use the formula:

Pack Years = (Number of packs smoked per day) × (Number of years smoked)

For example, if a client smoked 1 pack per day for 20 years, they would have 20 pack years. If they smoked 2 packs a day for the same period, that would equate to 40 pack years. This measurement is essential for understanding the health risks associated with smoking and guiding further assessment and intervention strategies.

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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

To assess a client's pupillary reaction to accommodation, which action should the nurse take?

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.

Correct Answer is ["C","D","E"]

Explanation

Summary of Calculation:

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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?

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