Hesi rn health assessment proctored exam
While completing an admission assessment for a client with rectal bleeding, the nurse observes dried, dark red blood on the surface of a purple, shiny tissue mass that extrudes from the anal opening. When documenting in the client's electronic medical record (EMR), which finding should the nurse enter in the client's physical assessment?
Explanation & Rationale
A. Anal mucosa prolapse may be a concern but would not explain the appearance of the dark red blood and external hemorrhoidal mass. B. Dried, dark red blood on swollen external hemorrhoids suggests hemorrhoidal bleeding, which is common and associated with the appearance of a purple, shiny tissue mass. C. Serosanguineous or purulent exudate suggests infection or other concerns but does not fit the description of the observed finding in this case. D. Tears in the anal mucosa with old blood may occur, but they are not as likely to present as a shiny, purple mass with dark red blood on the surface.
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