The nurse is preparing to palpate the rectum and should use which ...

[JGIBBSON]

The nurse is preparing to palpate the rectum and should use which of these techniques? The nurse should:
 
  a. Flex the finger, and slowly insert it toward the umbilicus.
  b. First instruct the patient that this procedure will be painful.
  c. Insert an extended index finger at a right angle to the anus.
  d. Place the finger directly into the anus to overcome the tight sphincter.

Question 2

While performing an assessment of the perianal area of a patient, the nurse notices that the pigmentation of anus is darker than the surrounding skin, the anal opening is closed, and a skin sac that is shiny and blue is noted.
 
  The patient mentioned that he has had pain with bowel movements and has occasionally noted some spots of blood. What would this assessment and history most likely indicate?
  a.
  Anal fistula
  b.
  Pilonidal cyst
  c.
  Rectal prolapse
  d.
  Thrombosed hemorrhoid

[cswans24]

Answer to Question 1

ANS: A
The nurse should gently place the pad of the index finger against the anal verge. The nurse will feel the sphincter tighten and then relax. As it relaxes, the nurse should flex the tip of the finger and slowly insert it into the anal canal in a direction toward the umbilicus. The nurse should never approach the anus at right angles with the index finger extended; doing so would cause pain. The nurse should instruct the patient that palpation is not painful but may feel like needing to move the bowels.

Answer to Question 2

ANS: D
The anus normally looks moist and hairless, with coarse folded skin that is more pigmented than the perianal skin, and the anal opening is tightly closed. The shiny blue skin sac indicates a thrombosed hemorrhoid.