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. This is unlikely to be associated with perimenopause. Often, perimenopause is linked to hormonal fluctuations that can lead to decreased libido rather than an increase.
B. While cessation of menstruation may indicate menopause, it is not typically seen during the perimenopausal phase, which is the time leading up to menopause. Perimenopause is characterized by irregular periods, not complete cessation.
C. Perimenopausal symptoms typically involve a decrease in vaginal moisture due to reduced estrogen levels. Excessive vaginal moisture would not be indicative of perimenopause and might suggest an infection or other conditions.
D. This is a classic symptom of perimenopause. Hormonal fluctuations during this time can lead to hot flashes and night sweats, which are commonly experienced as part of the transition toward menopause.

A. Bronchitis. B. Asthma. C. Pneumonia. D. Pneumothorax.

Correct Answer is B

Explanation

A. Bronchitis may cause wheezing, but it typically presents with a productive cough and can be associated with fever, which this client does not have. The absence of a productive cough and the degree of difficulty breathing suggest another condition.
B. Asthma is the most likely diagnosis. The client’s wheezing, decreased tactile fremitus, prolonged expirations, and history of exercise-induced symptoms are consistent with an asthma exacerbation. Asthma often presents with wheezing and difficulty breathing, especially during or after physical exertion.
C. Pneumonia typically presents with fever, chills, productive cough, and localized lung findings, which are not present in this client. The lack of fever and the presence of wheezing make pneumonia unlikely.
D. Pneumothorax may cause dyspnea and decreased breath sounds, but the wheezing, prolonged expirations, and history of exertion suggest asthma as the primary concern. A pneumothorax would typically present with more abrupt onset and significant breath sounds asymmetry, which is not seen in this case.

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Naxlex Comprehensive Predictor Exams

The nurse is obtaining a health history for a client during an annual physical examination. When evaluating the client for menopausal symptoms, which finding indicates the client is perimenopausal?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

When assessing the left foot planter reflex of an adult client, the nurse observes an extension of the great toe and fanning of other toes. Which interpretation of this finding is accurate?

The college health clinic nurse is preparing a seminar on testicular self-examination (TSE). Which instruction should be included in the content for this seminar?

During the precordium assessment, the nurse palpates the apical impulse of a client on the 5th intercostal space left mid-clavicular line. The pulse is more vigorous than expected. Which action should the nurse take in response to this finding?

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

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?

The nurse is assessing a client with gallstones for jaundice. Which action should the nurse perform to confirm this information?

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?

A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?