While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

Dimpled area above anus.

Flap of tissue at sphincter.

Increased pigmentation and coarse skin.

Hypotonic tone of the anal sphincter.

Answer and Explanation

The Correct Answer is C

A) Dimpled area above anus:
This finding may indicate a pilonidal cyst, which is an abnormality rather than a normal appearance of the anus.

B) Flap of tissue at sphincter:
A flap of tissue at the anal sphincter, also known as the anal valve, is a normal anatomical feature. It helps maintain continence and prevents leakage of stool.

C) Increased pigmentation and coarse skin:
Increased pigmentation and coarse skin may be typical findings in the perianal area due to factors such as friction, moisture, or aging. While not everyone will have this appearance, it is within the range of normal variations.

D) Hypotonic tone of the anal sphincter:
Hypotonic tone of the anal sphincter may suggest weakness or dysfunction of the anal sphincter, which is not considered a normal finding.

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Correct Answer is C

Explanation

A) Paresthesia: Paresthesia refers to abnormal sensations such as tingling, pricking, or numbness, typically without an external stimulus. The client's ability to discriminate two points at specific distances on the fingertips and palms does not indicate abnormal sensations or paresthesia.

B) Rebound reaction to the needle points: A rebound reaction would involve a delayed response or heightened sensitivity following the removal of a stimulus. This test does not measure rebound reactions but rather the ability to discriminate two separate points.

C) Normal sensory finding: The ability to sense two points at a distance of 3 mm on the fingertips and 10 mm on the palms is within the normal range for two-point discrimination. The fingertips typically have a higher density of sensory receptors and thus can discriminate smaller distances between two points, whereas the palms have fewer receptors and require a greater distance to discern two points.

D) Marginal decline in sensory function: The described ability to sense two points at these specific distances does not indicate a decline in sensory function. It aligns with normal findings for a middle-aged adult.

A. Palpate dorsal surface of feet for warmth. B. Test feet for a positive Babinski reflex. C. Measure skin elasticity around the ankles. D. Assess volume of the pedal pulses. E. Observe color of the feet and toes.

Correct Answer is ["A","D","E"]

Explanation

A) Palpate dorsal surface of feet for warmth:
Assessing the temperature of the dorsal surface of the feet helps determine peripheral circulation and can indicate whether the feet are indeed cold. Cold feet may suggest poor peripheral perfusion or circulation issues, which require further assessment.

B) Test feet for a positive Babinski reflex:
The Babinski reflex is typically tested to assess upper motor neuron dysfunction and is not directly relevant to evaluating the complaint of cold feet.

C) Measure skin elasticity around the ankles:
Measuring skin elasticity around the ankles may be relevant for assessing skin turgor and hydration status but is not specifically related to evaluating the client's complaint of cold feet.

D) Assess volume of the pedal pulses:
Assessing the volume of pedal pulses provides information about peripheral perfusion and circulation. Diminished or absent pedal pulses may indicate peripheral vascular disease or other circulatory issues contributing to cold feet. It's essential to evaluate the strength and symmetry of pedal pulses to determine peripheral vascular status.

E) Observe color of the feet and toes:
While observing the color of the feet and toes is important for assessing circulation and perfusion, it is not specific to evaluating the client's complaint of cold feet. However, color changes, such as pallor or cyanosis, may provide additional information about peripheral circulation and require further assessment.

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While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

An older male client reports to the nurse that his feet are cold. Before covering the client's feet, which assessment(s) should the nurse complete? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

The nurse completes palpation of the thoracic region on an adult client. Which finding is considered normal for this client?

While observing a client's face, which assessment finding requires immediate intervention by the nurse?

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take?

A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client's paresthesia?

When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?