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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Significant weight loss can be a concern for overall health and may be related to various conditions, including nutritional deficiencies. However, weight loss alone does not specifically indicate the need for bone density screening. It may be a factor in a broader health assessment but is not a direct indicator for bone density measurement.
B. A diminished appetite can affect nutritional intake, which in turn may impact bone health over time. However, diminished appetite itself does not directly suggest a need for a bone density screening unless it leads to significant weight loss or is part of a broader concern about nutritional status affecting bone health.
C. Decreased height is a key indicator that may suggest osteoporosis or significant bone loss. This can be due to vertebral compression fractures, which are common in individuals with osteoporosis. A reduction in height over time can be a direct sign that warrants a bone density screening to assess bone health and risk for fractures.
D. A lower BMI can be associated with lower bone mass and increased risk for osteoporosis, particularly in individuals who are underweight. However, while a low BMI can be a risk factor for osteoporosis, it is not as specific as decreased height for prompting a bone density screening.
Correct Answer is D
Explanation
A. Lymph nodes that feel ropey and rubbery might indicate chronic inflammation or fibrosis. This texture is not typically considered normal. In elderly clients, lymph nodes may become less palpable due to age- related changes, but they should not feel ropey or rubbery. If lymph nodes feel this way, it may warrant further investigation to rule out pathological conditions.
B. In elderly clients, axillary lymph nodes may feel softer and less defined due to fatty tissue changes associated with aging. However, "soft and fatty" should be interpreted cautiously. While some degree of change is normal, nodes should not be excessively soft, nor should they have an abnormal appearance. The key is that they should not be hard, fixed, or tender, which would be indicative of pathology.
C. Enlarged and warm inguinal lymph nodes suggest infection or inflammation rather than a normal finding. In the elderly, while lymph nodes can sometimes be palpable, they should not be enlarged or warm, as this could indicate an underlying condition or infection that requires further evaluation.
D. It is normal for lymph nodes to be non-palpable in many individuals, including older adults. Age- related changes can cause lymph nodes to be less prominent or difficult to palpate. If lymph nodes are non-palpable, it usually means they are not enlarged or abnormal, which is a normal finding, especially if the client is not experiencing any symptoms of infection or other related issues.
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