While completing an admission assessment for a client with rectal bleeding, the nurse observes dried, dark red blood on the surface of a purple, shiny tissue mass that extrudes from the anal opening. When documenting in the client's electronic medical record (EMR), which finding should the nurse enter in the client's physical assessment?

Anal mucosa prolapse and loose sphincter tone.

Dried dark red blood on swollen external hemorrhoids.

Serosanguineous and purulent exudate from anus.

Tears of the anal mucosa with old blood around anus.

Answer and Explanation

The Correct Answer is B

A.   Anal mucosa prolapse may be a concern but would not explain the appearance of the dark red blood and external hemorrhoidal mass.
B.   Dried, dark red blood on swollen external hemorrhoids suggests hemorrhoidal bleeding, which is common and associated with the appearance of a purple, shiny tissue mass.
C.   Serosanguineous or purulent exudate suggests infection or other concerns but does not fit the description of the observed finding in this case.
D.   Tears in the anal mucosa with old blood may occur, but they are not as likely to present as a shiny, purple mass with dark red blood on the surface.

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Correct Answer is D

Explanation

A. Borborygmi refers to the audible rumbling sounds produced by the movement of gas through the intestines. While these sounds may be present in this case, they are more commonly described as prolonged, loud, or audible sounds, not as typical gurgles occurring at the interval described.
B. Hyperactive bowel sounds are frequent and loud, often heard in conditions like diarrhea or early bowel obstruction. The described pattern here, with sounds occurring every 5 to 10 seconds, doesn't necessarily suggest hyperactivity.
C. Hypoactive bowel sounds are reduced or absent, commonly seen in conditions like ileus or bowel obstruction. The sounds described here are not consistent with hypoactive sounds, which would be faint or absent.
D. The description provided aligns with normal bowel sounds, which are intermittent and occur every 5 to 30 seconds in a healthy individual. This pattern of gurgles with the stated frequency is typical of normal bowel function.

A. The right pupil constricts and the left consensually responds. B. Both pupils are equal in size and constrict readily to the light source. C. Bilateral pupil size changes as the distance of the light source varies. D. The left iris is "notched" and the pupil size changes minimally.

Correct Answer is D

Explanation

A. This is a normal finding where the right pupil constricts when the light is directed at it, and the left pupil constricts consensually as well. This suggests normal function of the pupillary light reflex pathway, and no further evaluation is needed.
B. This also indicates normal pupillary function. Equal pupil size and appropriate constriction to light are typical findings, suggesting no immediate issues with the nervous system.
C. Pupil size should not change in response to distance unless there is a near response (accommodation). If the pupil size changes to distance of the light source instead of light reflex, this suggests potential abnormality in the pupillary reflex response.
D. This is an abnormal finding. A "notched" iris suggests possible damage or congenital anomalies, and minimal change in pupil size may indicate impaired pupil reflexes, requiring further evaluation to rule out neurological or ophthalmologic issues.

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Naxlex Comprehensive Predictor Exams

While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?

Correct Answer is D

Explanation

While conducting a physical assessment, the nurse shines a pen light into a client's right eye and moves the light source to check the client's left eye. Which finding indicates the need for further evaluation?

Correct Answer is D

Explanation

The nurse learns in report that a client is stuporous. Which assessment should the nurse perform to confirm this report?

A nurse performs a Tinetti assessment on an older adult client and calculates a balance score of 12 and a gait score of 8. Which do these results indicate?

The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?

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The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?

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