While completing an admission assessment for a client with rectal bleeding, the nurse observes dried, dark red blood on the surface of a purple, shiny tissue mass that extrudes from the anal opening. When documenting in the client's electronic medical record (EMR), which finding should the nurse enter in the client's physical assessment?

Anal mucosa prolapse and loose sphincter tone.

Dried dark red blood on swollen external hemorrhoids.

Serosanguineous and purulent exudate from anus.

Tears of the anal mucosa with old blood around anus.

Answer and Explanation

The Correct Answer is B

A.   Anal mucosa prolapse may be a concern but would not explain the appearance of the dark red blood and external hemorrhoidal mass.
B.   Dried, dark red blood on swollen external hemorrhoids suggests hemorrhoidal bleeding, which is common and associated with the appearance of a purple, shiny tissue mass.
C.   Serosanguineous or purulent exudate suggests infection or other concerns but does not fit the description of the observed finding in this case.
D.   Tears in the anal mucosa with old blood may occur, but they are not as likely to present as a shiny, purple mass with dark red blood on the surface.

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Correct Answer is A

Explanation

A. Skin tenting is a sign of dehydration. It occurs when the skin, after being pinched, does not quickly return to its normal position. This is often seen in areas with loose skin such as the subclavicular region.
B. Loss of skin elasticity is a normal aging process and not specifically indicative of dehydration. It can be seen in older adults regardless of hydration status.
C. Warm and dry skin can be a sign of dehydration. Dehydration leads to reduced sweating, which can result in dry skin, and it may also increase the body temperature, making the skin feel warm.
D. Thinning hair, especially in the lower extremities, is typically associated with circulatory issues or aging. It is not a direct sign of dehydration.

A. Advise the client to see his healthcare provider for immediate evaluation. B. Ask the client if he often spends time outside in the sun without a shirt. C. Encourage the client to keep checking the mole with a magnifying mirror. D. Offer to teach a family member how to monitor the skin around the mole.

Correct Answer is A

Explanation

A. A mole that changes color and size is concerning for melanoma, a type of skin cancer. Immediate evaluation by a healthcare provider is essential for diagnosis and possible biopsy.
B. While sun exposure can increase the risk of skin cancer, the priority is to have the mole evaluated by a healthcare provider rather than focus on past behaviors.
C. Encouraging self-monitoring is not a priority when the mole shows signs of malignancy.
D. Teaching family members to monitor is secondary to seeking professional evaluation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing an older adult client, which finding is most indicative of dehydration?

Correct Answer is A

Explanation

A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

Correct Answer is A

Explanation

Patient Data Exhibits Nurse analyzes the findings. Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.

The nurse is assessing a client with gallstones for jaundice. Which action should the nurse perform to confirm this information?

The nurse is doing a health assessment of a client who smoked three packs of cigarettes every day for the last twenty years before quitting two years ago. How should the nurse document the client's pack-years? (Enter the numerical value only.)

The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

Which finding, obtained during a skin assessment, should the school nurse report to the healthcare provider?

A client states, "I am legally blind." Which assessment technique should the nurse use to obtain subjective data to support the client's statement?

The nurse is obtaining a health history for a client being admitted for new onset seizures. Which action should the nurse implement to accurately record the health history findings?

The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? Select all that apply.