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.

Question

Quizplus · Accepted Answer

Option A is the relevant action for the nurse to collect more data from the patient about the reaction to the examination. Option B probably would have been gathered during the history, so that the nurse would have anticipated an abnormal finding. Option C is not the action of most importance at this time. The nurse needs to collect more data from the patient before considering a referral. Option D is not the action of most importance at this time. The nurse needs to collect more data from the patient before asking about trauma.

During an Internal Examination of a Patient's Anus, the Nurse