A client with Streptococcus pharyngitis reports high fever, difficulty swallowing and a muffled voice. Which complication should the nurse suspect?

A. Tears of the anal mucosa with old blood around anus: This description aligns more with anal fissures, which are painful tears in the mucosa. Anal fissures typically present with bright red blood and sharp pain during bowel movements and are often associated with pain not a shiny, purple mass.

B. Serosanguineous and purulent exudate from anus: This finding suggests infection or an abscess rather than hemorrhoids. Purulent discharge would indicate pus, which is not characteristic of external hemorrhoids and would require a different diagnostic and treatment approach.

C. Anal mucosa prolapse and loose sphincter tone: While anal mucosa prolapse can occur, the presence of a purple, shiny, protruding mass with dark red blood more accurately describes thrombosed external hemorrhoids rather than mucosal prolapse or incontinence.

D. Dried dark red blood on swollen external hemorrhoids: This is the most accurate documentation. External hemorrhoids can appear as shiny, swollen, purple masses, and dried dark red blood indicates prior bleeding from engorged and irritated veins typical in these hemorrhoids.

A. Right side deep tendon reflex 2+: A 2+ reflex is considered normal and would not correlate with the nurse’s observation of diminished reflexes. Documenting 2+ would fail to reflect the neurological deficit noted in the assessment.

B. Right side deep tendon reflex 0: A 0 reflex indicates complete absence of a response, suggesting flaccid paralysis or severe lower motor neuron damage. The nurse observed diminished reflexes, not absent, so 0 would overstate the impairment.

C. Right side deep tendon reflex 4+: A 4+ reflex indicates hyperreflexia, often associated with upper motor neuron lesions, not weakness and diminished reflexes. This would contradict the nurse’s findings of decreased neuromuscular activity on the right side.

D. Right side deep tendon reflex 1+: A 1+ rating represents diminished or hypoactive reflexes, which aligns with the nurse’s findings of generalized weakness and reduced deep tendon activity. This accurately reflects the likely residual neurological effects post-CVA.