During an internal examination of a patient's anus, the nurse notes that the patient has a hypertonic sphincter. What is the most relevant action for the nurse to take at this time?
a. Ask the patient about anxiety or pain related to the examination.
b. Inquire if the patient has had any neurologic injury that causes a hypertonic sphincter.
c. Refer the patient to the physician for evaluation.
d. Question the patient about a history of anal trauma.
ANS: A
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