When evaluating a client's rectal bleeding, which findings should the nurse document?

Number of blood clots expelled with each stool.

Evidence of internal hemorrhoids.

Unique odor noted with gastrointestinal bleeding.

Color characteristics of each stool.

Answer and Explanation

The Correct Answer is D

A. Number of blood clots expelled with each stool:
While the number of blood clots expelled with each stool may be relevant in assessing the severity of bleeding, it does not provide as much information about the potential underlying causes of bleeding as documenting the color characteristics of the stool does. Therefore, although it may be noted, it is not the most crucial aspect to document initially.

B. Evidence of internal hemorrhoids:
Documenting evidence of internal hemorrhoids is important in assessing rectal bleeding, but it is not as fundamental as documenting the color characteristics of the stool. Internal hemorrhoids can be one potential cause of rectal bleeding, but other more serious conditions may also cause bleeding, so a comprehensive assessment of the stool is necessary.

C. Unique odor noted with gastrointestinal bleeding:
While gastrointestinal bleeding may have a distinct odor, documenting this alone does not provide as much diagnostic information as describing the color characteristics of the stool. Documenting odor may be important in some cases, but it is not as critical as documenting the color of the stool, which can help identify potential causes of bleeding.

D. Color characteristics of each stool:
When evaluating rectal bleeding, documenting the color characteristics of each stool is crucial. Different colors of stool can indicate various underlying causes of bleeding. Bright red blood typically suggests lower gastrointestinal bleeding, while darker, tarry stools (melena) may indicate bleeding higher in the gastrointestinal tract. Describing the color, consistency, and presence of any abnormal substances in the stool helps healthcare providers assess the severity and potential causes of the bleeding.

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Correct Answer is D

Explanation

A) Neurological status intact: While the findings suggest that the client's neurological status is intact, this description does not specifically address the pupillary assessment.

B) Glasgow Coma Scale (GCS) of 15: The Glasgow Coma Scale evaluates a client's level of consciousness based on eye, verbal, and motor responses. While the findings may contribute to an overall assessment of neurological function, they specifically pertain to pupillary assessment.

C) Pupils equal, round, reacts to light, and accommodation (PERLA): This description includes accommodation, which is the ability of the pupils to constrict when focusing on a near object. The assessment provided in the scenario does not mention accommodation testing, so including it in the documentation would be inaccurate.

D) Pupils equal, round, reacts to light (PERRL): This notation accurately summarizes the findings of the pupillary assessment. It indicates that both pupils are equal in size, round in shape, and react briskly to light, which is a normal finding. This documentation is concise and specific to the pupillary examination without including additional findings not assessed in the scenario.

A. Notify the healthcare provider of the rebound tenderness. B. Obtain a prescription to catheterize the client's bladder. C. Offer to administer a laxative prescribed for PRN use. D. Instruct the client in distraction and relaxation techniques.

Correct Answer is A

Explanation

A) Notify the healthcare provider of the rebound tenderness:
Rebound tenderness, also known as Blumberg's sign, is a clinical sign that suggests peritoneal irritation, which can be indicative of underlying pathology such as peritonitis. Reporting rebound tenderness to the healthcare provider is crucial for further evaluation and management of the client's condition.

B) Obtain a prescription to catheterize the client's bladder:
While urinary retention can present with lower abdominal discomfort, the scenario described does not specifically suggest urinary retention. Catheterization should be considered based on additional assessments and indications related to urinary symptoms, not solely based on the client's report of pain upon release of abdominal pressure.

C) Offer to administer a laxative prescribed for PRN use:
Administering a laxative would not be appropriate based solely on the client's report of pain upon release of abdominal pressure. Laxatives are indicated for constipation, which may cause abdominal discomfort, but they would not address rebound tenderness or the underlying cause of the client's pain.

D) Instruct the client in distraction and relaxation techniques:
While distraction and relaxation techniques can be helpful for managing pain, they would not address the underlying cause of rebound tenderness. Reporting rebound tenderness to the healthcare provider is necessary for further evaluation and appropriate management.

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When evaluating a client's rectal bleeding, which findings should the nurse document?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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