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

question 25

Multiple Choice

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.