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?

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Hypertonic sphincter indicates increased muscle tone. 2. Inquiring about anxiety or pain helps assess the patient's comfort level. 3. Anxiety or pain can cause increased muscle tension. 4. Addressing emotional factors can help relax the sphincter for a more comfortable examination. Summary: - Option B focuses on neurologic causes, not immediate patient care. - Option C suggests referral without addressing patient comfort. - Option D addresses past trauma, not the current situation of hypertonic sphincter.

Correct Answer: A

Rationale: The correct answer is A because it directly asks about the patient's sexual partners without assuming their orientation. This open-ended question allows the patient to freely disclose their sexual orientation and related risk factors. Answer B assumes a preference rather than orientation. Answer C focuses on activities rather than orientation. Answer D limits the options to specific labels, which may not accurately reflect the patient's experience.

Correct Answer: B

Rationale: The correct answer is B: Assisting the client into a lithotomy position. This task can be safely delegated to the UAP as it involves physically assisting the client into a specific position and does not require specialized nursing knowledge or assessment skills. The nurse should be available to provide guidance and supervision to ensure the safety and comfort of the client during the procedure. Choices A, C, and D involve tasks that require nursing assessment and critical thinking skills, which should be performed by the nurse. Witnessing the consent form (choice A) ensures proper documentation and understanding of the procedure. Asking about allergies to iodine or shellfish (choice C) is crucial to prevent adverse reactions during the procedure. Assessing for pelvic or shoulder pain after the study (choice D) is important to monitor for any potential complications post-procedure. These tasks are within the scope of nursing practice and should not be delegated to a UAP.

Correct Answer: C

Rationale: The correct answer is C: Luteinizing hormone (LH). LH is responsible for stimulating the development of the corpus luteum after ovulation. It triggers the release of the egg from the follicle and promotes the transformation of the follicle into the corpus luteum, which is crucial for the production of progesterone. Estrogen (A) is involved in the development of the follicle, not the corpus luteum. Progesterone (B) is produced by the corpus luteum, not responsible for its development. FSH (D) is primarily involved in stimulating the growth of ovarian follicles, not the formation of the corpus luteum.

Correct Answer: A

Rationale: The correct sequence is A: Zygote - morula - 2 cells - 4 cells - 8 cells - blastula. After fertilization, the zygote undergoes cleavage to form the morula, which then divides into 2 cells, then 4 cells, and further into 8 cells. These cells then rearrange to form the blastula. This sequence aligns with the natural progression of post-fertilization cleavage in embryonic development. Choices B, C, and D are incorrect because they do not follow the correct chronological order of events in post-fertilization cleavage. In these sequences, the order of cell divisions is mixed up, leading to an inaccurate representation of the cleavage process. It is crucial to understand the logical progression of events in embryonic development to identify the correct sequence of post-fertilization cleavage.