The nurse is assessing a female client who states that her hemorrhoids are inflamed and hurt constantly. Which intervention is best for the nurse implement to complete a focused assessment?

Place the client in a standing position, leaning over the exam bed for inspection.

Determine if the client uses any over-the-counter preparations for hemorrhoids.

Position client in left lateral position to inspect perianal area for fissures or sacs.

Ask the client how long she has experienced discomfort related to hemorrhoids.

Answer and Explanation

The Correct Answer is C

A.   A standing position leaning over the exam bed may not provide the best view or allow for thorough examination of the perianal area. This position is less commonly used and may not be ideal for a focused assessment of hemorrhoids.
B.   Finding out if the client uses over-the-counter preparations for hemorrhoids provides useful information about the management and treatment approach being used. However, while this information is valuable, it does not directly involve the physical assessment of the hemorrhoids themselves.
C.   The left lateral position (also known as the Sims' position) is commonly used for the examination of the perianal area. It provides optimal access for visual inspection of hemorrhoids, fissures, or other abnormalities in the anal region. This position allows the nurse to examine the area more thoroughly and comfortably, making it the most appropriate choice for a focused assessment of hemorrhoids.

D.   Asking about the duration of discomfort provides valuable information about the history and progression of the condition. Understanding how long the client has been experiencing symptoms can help in assessing the chronicity and possible treatment history of the hemorrhoids.

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Correct Answer is C

Explanation

A. The client’s current symptoms—pain, significant leg edema, and swelling—are more pressing and suggest a need to evaluate the physical cause of these symptoms rather than focusing immediately on mental status.
B. Obtaining a blood alcohol level might be relevant if there is a suspicion that recent alcohol use is contributing to the client’s condition or affecting his overall health. However, the primary concern in this case is the significant edema and pain in the left leg.
C. This is the most pertinent action to take first. The client’s symptoms of severe edema and pain in one leg, along with a history of CVA and alcohol abuse, raise concerns about possible causes such as deep vein thrombosis (DVT), infection, or trauma. Inspecting the legs for signs of infection or trauma (bruising, cuts) is crucial to determine the underlying cause of the symptoms and guide appropriate treatment.

D. While excessive salt intake can contribute to fluid retention and edema, the degree of swelling described (4+ pitting edema) and the localized nature of the problem in the left leg make it less likely that dietary salt alone is the cause.

A. Ask the client about progressive contractures of the 4th and 5th fingers. B. Compress the ulnar and radial arteries, then observe for flushing in the hand when ulnar pressure is released. C. Compare the client's hands bilaterally for pain, pallor, pulses, paralysis, and paresthesia. D. Instruct the client to place the backs of the hands together and flex both wrists.

Correct Answer is D

Explanation

A. Contractures of the 4th and 5th fingers are more indicative of ulnar nerve involvement, not median nerve compression. Carpal tunnel syndrome primarily affects the thumb, index finger, middle finger, and part of the ring finger. Thus, asking about contractures of the 4th and 5th fingers would not provide useful information about carpal tunnel syndrome.
B. This technique is used to assess the patency of the radial and ulnar arteries, commonly referred to as the Allen test. It is used to evaluate blood flow in the hand, particularly before performing procedures that may impact arterial circulation. This test is not specific to carpal tunnel syndrome and does not provide useful information about median nerve compression.
C. While comparing the hands bilaterally for various signs can be useful in assessing general hand function and circulation, this method does not specifically target the symptoms or diagnostic tests associated with carpal tunnel syndrome. It provides a broad overview but is not specific enough to confirm CTS.
D. This technique is known as the Phalen’s test, which is specifically used to assess for carpal tunnel
syndrome. During the Phalen’s test, the client is asked to flex their wrists and hold the position for about 60 seconds. If the client experiences tingling, numbness, or pain in the median nerve distribution (thumb, index, middle finger, and part of the ring finger), it suggests carpal tunnel syndrome.

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The nurse is assessing a female client who states that her hemorrhoids are inflamed and hurt constantly. Which intervention is best for the nurse implement to complete a focused assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client is concerned about developing carpal tunnel syndrome. Which screening technique should the nurse perform to provide the client with useful information?

Correct Answer is D

Explanation

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