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 A

Explanation

A. Understanding the onset and activities related to the back pain can help the nurse determine if it is musculoskeletal, posture-related, or indicative of a more serious underlying issue.
B. Asking about medication is secondary until more information is gathered about the pain's onset and nature.
C. Changing positions may be relevant later, but initially, it is important to identify any possible triggers for the pain.
D. Asking about previous pain episodes may be helpful, but understanding the current episode’s cause is more pressing.

A. Observe for any facial asymmetry. B. Determine the response to stimuli. C. Assess for a positive Romberg sign. D. Check the pupillary response to light.

Correct Answer is B

Explanation

A. Facial asymmetry may indicate neurological issues, but it does not directly assess the stuporous state.
B. A stuporous state is characterized by a reduced level of consciousness, and the nurse should assess
the client’s response to stimuli to confirm the report of stupor.
C. A positive Romberg sign indicates a balance issue, but it is not directly related to confirming a stuporous state.
D. While pupillary response is important, it does not provide sufficient information to confirm a stuporous state without assessing responsiveness to stimuli.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The school nurse is interviewing a 13-year-old girl who wants to go home from school because of "back pain." Which question should the nurse ask the adolescent first?

Correct Answer is A

Explanation

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

Correct Answer is B

Explanation

Which assessment finding, obtained during chest auscultation, should the nurse consider a normal finding?

An adult male client tells the nurse that he smokes approximately one pack of cigarettes daily. How can the nurse expect smoking to affect this client's sleep?

When the nurse is obtaining health history during an annual physical examination, the client reports having difficulty with erections for the past 8 months. Which information in the client's history should the nurse consider as a potential reason for erectile dysfunction?

Which question by the nurse is likely to elicit the most information regarding a client's use of medications to treat a chronic cough?

While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

The nurse is performing a head-to-toe physical examination on a known victim of intimate partner violence. The visual exam reveals several round, flat, pinpoint, red spots. How should the nurse document this finding?

The nurse plans to assess a client's ability to think abstractly. Which question or statement is likely to provide the best information about the client's abstract thinking?

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