When assessing the anus, the nurse should inspect for: (Select all that apply)
Bleeding
Hemorrhoids
Pain
Prostate enlargement
Correct Answer : A,B,C
Prostate enlargement is not directly assessed through an anal examination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When a patient is admitted with a complaint of chest pain, the priority assessment would be to determine whether the patient is experiencing an acute cardiac event, such as a heart attack. This would involve a comprehensive assessment that includes obtaining the patient's medical history, vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation), performing a physical exam, and obtaining an electrocardiogram (ECG).
Other important factors to assess include the location and nature of the pain, any associated symptoms (such as shortness of breath or diaphoresis), the patient's current medications and medical history (including any history of heart disease or risk factors), and any recent procedures or interventions that may have led to the current presentation.
Prompt assessment and intervention are crucial in managing a patient with chest pain, as timely treatment can help to minimize damage to the heart muscle and prevent further complications. Therefore, any signs of an acute cardiac event should be immediately reported to the healthcare provider in charge, and appropriate interventions should be initiated promptly.
Correct Answer is D
Explanation
Nurses are mandated reporters, meaning they are legally required to report any suspected or confirmed cases of child, elder, or vulnerable adult abuse or neglect to the appropriate authorities, such as child protective services or adult protective services. This duty applies regardless of whether the abuse or neglect was disclosed by the victim or observed by the nurse.
While nurses may choose to involve family members or refer the individual to social services, these actions do not replace the legal obligation to report abuse or neglect. Failure to report can result in legal and professional consequences for the nurse.
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