The nurse is assessing the perianal area of a female client who reports she has chronic constipation and has bright red blood on the toilet paper after having a bowel movement. Which finding should the nurse report to the healthcare provider (HCP) that is most consistent with the client's report?

Shiny blue skin sacs around anal opening and a linear split.

Flabby skin sac around the anal orifice that is painless.

Presence of dried brown stool around the perianal area.

Anus is moist, hairless, and has pigmented sphincter folds.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Shiny blue skin sacs around anal opening and a linear split: This description is consistent with thrombosed external hemorrhoids and an anal fissure, both of which are common in clients with chronic constipation. The linear split and bright red bleeding on toilet paper strongly suggest an anal fissure, which should be reported for appropriate treatment.

B. Flabby skin sac around the anal orifice that is painless: A flabby, painless skin sac is likely a skin tag, which is generally benign and not typically associated with active bleeding or significant discomfort following bowel movements.

C. Presence of dried brown stool around the perianal area: Dried stool suggests poor hygiene or fecal incontinence but does not specifically correlate with the complaint of bright red bleeding after bowel movements. It is not the primary concern related to the client's report.

D. Anus is moist, hairless, and has pigmented sphincter folds: This describes a normal finding for the perianal area. No pathology such as fissures, hemorrhoids, or bleeding would be associated with this description.

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Correct Answer is D

Explanation

Rationale:
A. Ask the interpreter to tell the client to write down questions: Asking the client to write down questions places an unnecessary burden on communication and may not be feasible if the client struggles with written English or literacy. It does not foster an open and supportive dialogue during the interview.

B. Give the interpreter a form that lists the interview questions: Providing the interpreter with a form could help with preparation but does not substitute for real-time interpretation and direct engagement. It risks turning the encounter into a transactional experience rather than building therapeutic rapport with the client.

C. Use an interpreter throughout client's hospitalization: While it is important to use an interpreter when needed, the question asks about what the nurse should implement during the interview itself. Additionally, not all interactions may require an interpreter if communication becomes clearer over time, so blanket use is not always appropriate.

D. Maintain eye contact with the client when questions are asked: Maintaining eye contact reinforces that the nurse is communicating directly with the client, not the interpreter. It promotes trust, respect, and engagement, helping the client feel heard and respected even when a language barrier exists.

Correct Answer is ["40"]

Explanation

Number of packs smoked per day: 2

Number of years the client has smoked at this rate: 20 years

Calculate the pack-years

Pack-years = (Number of packs smoked per day) x (Number of years smoked)

= 2 packs/day x 20 years

= 40

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The nurse is assessing the perianal area of a female client who reports she has chronic constipation and has bright red blood on the toilet paper after having a bowel movement. Which finding should the nurse report to the healthcare provider (HCP) that is most consistent with the client's report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a health interview for a client who does not speak fluent English and has obtained an interpreter. Which action should the nurse implement?

Correct Answer is D

Explanation

The nurse determines that a male client has smoked 2 packs of cigarettes daily for the past 20 years. In calculating his smoking history, how many pack-years should be documented for this client? (Enter numeric value only.)

Correct Answer is ["40"]

Explanation

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