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

Number of blood clots expelled with each stool.

Unique odor noted with gastrointestinal bleeding.

Color characteristics of each stool.

Evidence of internal hemorrhoids.

Answer and Explanation

The Correct Answer is C

A. Number of blood clots expelled with each stool. This is not the most comprehensive approach as it focuses solely on clots without addressing other key aspects, such as stool color or consistency. Clots are also not always present with rectal bleeding.

B. Unique odor noted with gastrointestinal bleeding. While gastrointestinal bleeding, particularly upper GI bleeding, can produce a distinct odor, odor is subjective and not a reliable or standard assessment criterion to document.

C. Color characteristics of each stool. Stool color provides critical information about the source of the bleeding. For example, bright red blood (hematochezia) indicates lower GI bleeding, while black, tarry stools (melena) suggest upper GI bleeding. Documenting stool color helps in identifying the location and nature of the bleeding.

D. Evidence of internal hemorrhoids. While hemorrhoids are a common cause of rectal bleeding, the nurse cannot confirm the presence of internal hemorrhoids without diagnostic tools like anoscopy or sigmoidoscopy. The nurse should focus on documenting observable and measurable findings.

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Correct Answer is A

Explanation

Choice A rationale
Intranasal edema and swelling of turbinates are classic signs of allergic rhinitis. Allergic rhinitis is an inflammatory response to allergens, leading to swelling and congestion in the nasal passages. The turbinates, which are structures inside the nose that help filter and humidify the air, become swollen due to the inflammatory response, causing symptoms such as nasal congestion, runny nose, and sneezing.
Choice B rationale
Purulent secretions from the eyes and nares are more indicative of an infection, such as bacterial sinusitis or conjunctivitis, rather than allergic rhinitis. Allergic rhinitis typically involves clear, watery secretions rather than purulent (pus-like) discharge.
Choice C rationale
Snoring and bilateral, pale gray nodules are suggestive of nasal polyps, which can occur in chronic rhinosinusitis but are not specific to allergic rhinitis. Nasal polyps are non-cancerous growths that can obstruct nasal passages and cause breathing difficulties.
Choice D rationale
Eye tearing and thick yellow nasal drainage are more characteristic of an infection, such as bacterial sinusitis or conjunctivitis. Allergic rhinitis usually causes clear, watery secretions and may involve eye symptoms like itching and tearing, but not thick yellow drainage.

A. Describes having a “body-wracking dry cough” of 6 weeks duration. B. Expresses concern of “lung cancer” symptoms for the last 6 weeks. C. Presents with a hacking nonproductive cough of 6 weeks duration. D. An adult male presents with fears that he has “lung cancer.”.

Correct Answer is A

Explanation

Choice A rationale
Describing the client’s exact words, “body-wracking dry cough” of 6 weeks duration, provides a clear and specific account of the client’s symptoms and concerns.
Choice B rationale
Expressing concern of “lung cancer” symptoms for the last 6 weeks is less specific and does not accurately capture the client’s primary symptom, which is the dry cough.
Choice C rationale
Presenting with a hacking nonproductive cough of 6 weeks duration is a clinical interpretation and does not use the client’s own words, which is important for accurate documentation.
Choice D rationale
An adult male presents with fears that he has “lung cancer” is a subjective interpretation and does not accurately describe the client’s primary symptom.

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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 A

Explanation

Correct Answer is A

Explanation

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