14. While performing an assessment of the perianal area of a patient, the nurse notices that the
pigmentation of the anus is darker than the surrounding skin, the anal opening is closed, and a
skin sac that is shiny and blue is noted. The patient mentioned that he has had pain with bowel
movements and has occasionally noted some spots of blood. What does this assessment and
history most likely indicate?
15. The nurse is preparing to palpate the rectum and should use which of these techniques?
Flex the finger, and slowly insert it toward the umbilicus.
Insert an extended index finger at a right angle to the anus.
First instruct the patient that this procedure will be painful.
Place the finger directly into the anus to overcome the tight sphincter.
16. While performing a rectal examination, the nurse notices a firm, irregularly shaped mass.
What should the nurse do next?
Continue with the examination, and document the finding in the chart.
Instruct the patient to return for a repeat assessment in 1 month.
Tell the patient that a mass was felt, but it is nothing to worry about.
Report the finding, and refer the patient to a specialist for further examination.
17. During an assessment of the newborn, the nurse expects to see which finding when the anal
area is slightly stroked?