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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Naxlex Comprehensive Predictor Exams

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Correct Answer is []

Explanation

Condition: Pleural Effusion

Pleural effusion is an accumulation of fluid in the pleural space, leading to difficulty breathing, decreased lung sounds, and dullness upon percussion (as noted in the nurse's assessment).

Actions to Take:

Auscultate the lungs for adventitious breath sounds: Pleural effusion may result in decreased or absent breath sounds due to fluid in the pleural cavity. Adventitious sounds such as crackles or a pleural friction rub can sometimes be heard, but in this case, decreased sounds are noted.
Inspect the chest for lag on the affected side: In pleural effusion, there may be a delay in chest expansion on the affected side due to fluid buildup, which is consistent with the decreased expansion noted in the assessment.

Parameters to Monitor:

Cyanosis: Cyanosis may occur if the fluid accumulation severely impairs oxygenation.
Respiratory rate and pulse: Monitoring respiratory rate and pulse is critical to assess for signs of respiratory distress and hypoxia, which could result from the pleural effusion.

A. Multiple maculopapular pustules over forehead and chin on an adolescent. B. Bilateral patellar abrasions with eschar formation on a preschool-aged child. C. Red, swollen, painful nodule located on upper back on a school-aged boy. D. Small, white flecks on the hair shafts throughout scalp on a school-aged girl.

Correct Answer is A

Explanation

A. Multiple maculopapular pustules over the forehead and chin are suggestive of acne vulgaris or possibly another dermatologic condition that may require medical intervention. If the pustules are widespread or persistent, it should be reported for further evaluation.
B. Bilateral patellar abrasions with eschar formation are common in children and are usually non- threatening unless there are signs of infection. This finding may not require immediate reporting unless the condition worsens.
C. A red, swollen, painful nodule on the upper back is likely a boil or abscess, but it’s important to consider the overall presentation and if there is a risk for systemic infection. This may not need immediate reporting unless symptoms worsen.
D. Small, white flecks on the hair shafts indicate possible head lice, which, while needing treatment,
doesn’t require immediate reporting unless there is a larger health concern associated with it.

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

Which finding, obtained during a skin assessment, should the school nurse report to the healthcare provider?

Correct Answer is A

Explanation

Which subjective assessment data supports the nurse's conclusion that a client is experiencing orthopnea?

Patient Data Exhibits The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment. Which assessment(s) should the nurse conduct? Select all that apply.

The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?

In assessing an adult client, the nurse calculates the body mass index (BMI) as 14 kg/m2. Which nursing problem should be included in this client's plan of care? Reference Range: Body mass index (BMI) [normal 18.0 to 24.9 kg/m2]

When conducting a physical examination, the nurse uses a tuning fork to assess for which condition?

The nurse assesses a young adult female who was brought to the emergency department (ED) by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?

Patient Data Exhibits Nurse analyzes the findings. Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.