The nurse performs all of the following actions when examining ...

[Garrulous]

The nurse performs all of the following actions when examining the anus EXCEPT
 
  a. ask the patient to take a breath in and hold it
  b. glove and lubricate a finger and rotate the inserted finger 360 degrees
  c. assess for anal sphincter weakness
  d. document perianal varicosities as hemorrhoids

Question 2

A client tells the nurse that he continues to relive a situation in which his place of employment was robbed by gunmen and he has nightmares of being shot.
 
  The nurse would identify the most appropriate nursing diagnosis for this client as being: 1. Anxiety.
   2. Ineffective Coping.
   3. Post-traumatic Stress Disorder.
   4. Fear.

[daiying98]

Answer to Question 1

A
When the nurse examines the anus, the patient may be asked to bear down to allow for inspecting the anus for gaping. The anal sphincter is assessed for tone and symmetry. A gloved lubricated finger is gently inserted into the anal sphincter. The finger is rotated 360 degrees and the tone of the external sphincter is assessed. Hemorrhoids or perianal varicosities of the hemorrhoidal veins may be identified and documented.

Answer to Question 2

3. Post-traumatic Stress Disorder.

Rationale:
The client is reliving a traumatic event and has nightmares of being shot. This information would support the diagnosis of post-traumatic stress disorder. The other diagnoses might be appropriate; however, post traumatic stress disorder would be the priority diagnosis at this time.

[Garrulous]

Thanks

[daiying98]

Welcome