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 A

Explanation

A. Instructing the client to close their eyes is crucial during sensory assessments, including temperature testing. This helps ensure that the client does not rely on visual cues to determine the temperature of
the stimuli, allowing the nurse to accurately assess the client’s sensory perception based purely on
touch and temperature differences.
B. Covering the client with a warmed blanket is not necessary for assessing temperature perception. This action could alter the client’s baseline sensory perception by affecting their skin temperature, which could lead to inaccurate results. The sensory assessment requires the client to experience temperature changes directly on their skin without external influences like additional warmth.
C. Darkening the room is not relevant for assessing temperature sensation. Visual impairment (like darkening the room) is not related to sensory nerve function related to temperature perception, and this step does not contribute to an accurate assessment of the client's ability to perceive temperature changes.
D. Measuring the client’s body temperature is not a direct method for assessing their sensory nerve function or temperature perception. While knowing the body temperature might be relevant for other reasons, it does not directly assess how well the client can sense temperature changes on their skin.

A. Circulation impaired. B. Paresthesia reported. C. Reports feeling "on fire." D. Inflammation present.

Correct Answer is B

Explanation

A. This term suggests a problem with blood flow, which could potentially cause symptoms such as numbness or tingling. However, it does not specifically address the sensation of burning. Using this term might lead to an incorrect or incomplete assessment of the client's condition.
B. Paresthesia is a term used to describe abnormal sensations in the skin, such as burning, tingling, or prickling. The client's report of a burning sensation in the hands and legs aligns well with the definition of paresthesia. Documenting it as "paresthesia reported" accurately reflects the nature of the symptoms and is a medically precise way to describe the abnormal sensory experience.
C. This documentation uses colloquial language ("on fire") to describe the client's symptoms. While it conveys the intensity of the sensation, it is not a standardized medical term and may not be as clear or useful for clinical documentation.
D. Inflammation refers to the body's response to injury or infection, which often involves redness, swelling, heat, and pain. The term "inflammation" does not specifically describe the sensation of burning reported by the client.

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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

In assessing a client's sensory nerve function, the nurse prepares to assess the client's response to temperature. What action should the nurse include during this assessment?

Correct Answer is A

Explanation

A male client reports the onset of a burning sensation in his hands and legs. How should the nurse document this finding in the electronic medical record (EMR)?

Correct Answer is B

Explanation

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