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 B

Explanation

A. Intermittent pain on deep inspiration could suggest pleuritic pain, which is related to the lungs or pleura rather than the abdomen. While this might be significant, it is less directly related to the client’s deep abdominal pain radiating to the back. This finding may be less urgent compared to other potential signs of serious abdominal pathology.

B. An abdominal bruit is a sound heard over the abdomen due to turbulent blood flow, often associated with vascular abnormalities like aneurysms or significant arterial stenosis. An audible abdominal bruit, especially if associated with deep abdominal pain, could indicate a serious vascular condition such as an abdominal aortic aneurysm (AAA).
C. A bulge over the umbilicus when coughing could indicate an umbilical hernia. While a hernia can be problematic and may require treatment, it is generally less urgent compared to findings that might suggest more acute or severe conditions like vascular issues.
D. Hypoactive bowel sounds can indicate decreased gastrointestinal activity, which might be related to various conditions such as ileus or bowel obstruction. While this finding is significant and warrants attention, it is often less immediately critical compared to signs of serious vascular issues or acute abdominal pathology.

A. Shake and call the client's name. B. Press firmly on the center of the sternum. C. Use aromatic spirits of peppermint. D. Run a pointed object up the sale of foot.

Correct Answer is B

Explanation

A. Shaking the client and calling their name is generally used to assess responsiveness in clients who are not deeply unconscious but may be drowsy or semi-conscious. However, in clients with a marked reduction in LOC, this approach might not be effective because it does not provide sufficient stimulation to elicit a response from someone with significantly diminished consciousness.
B. Applying firm pressure to the center of the sternum (sternal rub) is an effective method for assessing a client's response to painful stimuli, especially when there is a marked reduction in LOC. This technique involves using the knuckles to rub or press firmly on the sternum, which provides a strong and potentially painful stimulus to evaluate the client's responsiveness.
C. Aromatic spirits of peppermint are used to stimulate a client's sense of smell but are not effective for assessing response to painful stimuli. This method is more suitable for clients who are semi-conscious and may respond to sensory stimulation but does not provide the level of stimulation needed for assessing deep unconsciousness.
D. Running a pointed object up the sole of the foot is a method used to test the plantar reflex (Babinski reflex) and is not typically used to assess a response to painful stimuli. This method might be useful in neurological assessments but does not provide sufficient stimulation to assess responsiveness in a client with a marked reduction in LOC.

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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

The nurse examines a client admitted with a deep, constant pain in the abdomen that radiates to the back. Which finding is most important for the nurse to report to the healthcare provider?

Correct Answer is B

Explanation

Which method should the nurse use to assess response to painful stimuli for a client with a marked reduction in the level of consciousness (LOC)?

Correct Answer is B

Explanation

The nurse is assessing the visual acuity of a client who reports changes in vision. How many feet away from the Snellen chart should the client stand? (Enter a whole number only.)

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