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
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.
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