Upon inspection, you observe a 3 cm spherical bluish lump on your patient's anal mucosa. The overlying skin is mildly edematous. This is most likely a(n)
a. anal skin tag. c. herpes simplex lesion.
b. anal wart. d. thrombosed external hemorrhoid.
D
A spherical, bluish lump that appears suddenly at the anus and ranges in size from a few millimeters to several centimeters is most likely a thrombosed external hemorrhoid. An anal skin tag is excess anal or perianal tissue of varying sizes that is soft, pliable, and covered by normal skin. Warts are lesions that are beefy red, flesh colored, irregular, and pedunculated. Herpes simplex lesions are erythematous plaques that develop into vesicular lesions that may become pustules and ulcerate.
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A mother of a young child kicks a trashcan in anger and says to the nurse, "You just don't understand! Why can't the doctor find out what is wrong with my child?" This behavior is most likely an example of:
a. suppression b. sublimation c. displacement d. rationalization
Which are intended responses of antispasmodic drugs used to treat overactive bladder? (Select all that apply.)
a. Urine leakage is contained in adult diapers. b. Frequency of urination is decreased. c. Perspiration (sweating) is increased. d. Incontinence of urine is decreased. e. Detrusor muscle spasm is strengthened. f. Sense if urinary urgency is decreased.
The nurse is preparing to perform a health assessment of the abdomen. Which of the following is the correct order to perform the assessment?
A) Inspect, auscultate, percuss, palpate. B) Auscultate, percuss, palpate, inspect. C) Inspect, auscultate, palpate, percuss. D) Palpate, percuss, auscultate, inspect.
A client with a nephrostomy tube complains of pain and pressure at the site. The nurse would:
1. Assess for obstruction. 2. Irrigate the tube. 3. Clamp the tube. 4. Administer pain medication.