The nurse is performing a rectal examination on a client and finds a firm, irregularly shaped mass. Which of the following is the next action the nurse should take?

Report the finding, and refer the client to a specialist for further examination.

Tell the client that a mass was felt, but is nothing to worry about.

Instruct the client to return for a repeat assessment in 1 month.

Continue the examination, and document the findings on the chart.

Answer and Explanation

The Correct Answer is A

A firm, irregularly shaped mass found during a rectal examination could potentially indicate a serious condition such as a tumor or other pathology. It's essential to report such findings and refer the client to a specialist for further evaluation and appropriate diagnosis.
B.   It's important not to dismiss or downplay the significance of finding a mass, as it could signify a serious health issue.
C.   Waiting a month for reassessment could potentially delay necessary medical intervention if the mass is concerning.
D.   While documentation is important, it's crucial to prioritize immediate reporting and referral for further evaluation when such findings are discovered.

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Correct Answer is B

Explanation

A. The Glasgow Coma Scale assesses a patient's level of consciousness, not specifically limb weakness.
B. A complete neurological examination would involve assessing cranial nerves, motor and sensory functions, reflexes, coordination, and gait, which are essential when a client presents with unilateral weakness in the arm and leg.
C. A muscular examination might focus more on muscle strength and tone but might not cover the breadth of neurological assessment needed in this scenario.
D. Neurologic recheck examination suggests a reassessment after an initial neurological exam but doesn’t specify the need for a comprehensive evaluation.

A. Vertigo B. Seizure activity C. Dizziness D. Syncope

Correct Answer is A

Explanation

A. Vertigo is the sensation of spinning or movement when stationary and is often associated with inner ear problems.
B. Seizure activity involves abnormal electrical activity in the brain and might present with various symptoms but not necessarily the feeling of spinning.
C. Dizziness is a more general term that can include feelings of light-headedness or unsteadiness without a specific spinning sensation.
D. Syncope refers to fainting or loss of consciousness due to decreased blood flow to the brain, not the sensation of spinning.

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The nurse is performing a rectal examination on a client and finds a firm, irregularly shaped mass. Which of the following is the next action the nurse should take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client comes to the clinic and reports having weakness in the left arm and leg for the past week. The nurse should perform which type of neurological exam?

Correct Answer is B

Explanation

The nurse is taking a health history from a client. The client tells the nurse that. "It feels like the room is spinning." How should the nurse document this finding?

Correct Answer is A

Explanation

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