During the physical assessment of a client, the nurse observes ...

[Bob-Dole]

During the physical assessment of a client, the nurse observes flat, round, colored, nonpalpable areas on the face. How should the nurse document this finding?
 
  A) Papules
  B) Macules
  C) Pustules
  D) Nodules

Question 2

A nurse is assessing a client with constipation and severe rectal pain. Which of the following actions should the nurse perform to determine the presence of fecal impaction?
 
  A) Inserted a lubricated, gloved finger into the rectum.
  B) Facilitate a barium enema.
  C) Insert a lubricated rectal tube into the rectum.
  D) Administer an oil retention enema into the rectum.

[bblaney]

Answer to Question 1

B
Feedback:
The nurse should document this finding as macules. A papule is an elevated, palpable solid. A pustule is an elevated, raised border filled with pus. A nodule is an elevated, solid mass, deeper and firmer than a papule.

Answer to Question 2

A
Feedback:
The nurse should insert a lubricated, gloved finger into the rectum to determine the presence of fecal impaction. Fecal impaction occurs when a large, hardened mass of stool interferes with defecation. Obtaining a barium enema is not a good idea because the barium retained in the intestine causes fecal impaction. Insertion of a rectal tube and administration of an oil retention enema are measures used to remove hardened stool, not assess it.

[Bob-Dole]

Gracias!

[Jossy]

TYSM