A nurse is assessing an older adult client’s mouth.
The nurse should identify that which of the following is an expected variation for this client?
White patches on the tongue
Bleeding of the gums
Darkening of the mucosa
Red spots on the hard palate.
The Correct Answer is D
Darkening of the mucosa. This is an expected variation for an older adult client because the melanin production increases with age.
Some possible explanations for the other choices are:
• Choice A. White patches on the tongue could indicate candidiasis, an oral fungal infection.
• Choice B. Bleeding of the gums could indicate gingivitis, periodontitis, or vitamin C deficiency.
• Choice C. Red spots on the hard palate could indicate petechiae, which are small hemorrhages caused by trauma, infection, or bleeding disorders.
Normal ranges for oral mucosa color vary depending on the skin tone and ethnicity of the client. Generally, the oral mucosa should be pink and moist without lesions or discolorations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Place the newborn on the mother’s chest after delivery.This is because skin-to-skin contact between mother and baby promotes bonding and attachment, which are essential for the baby’s emotional and psychological development.Skin-to-skin contact also helps regulate the baby’s body temperature, heart rate, breathing and blood sugar levels.
Choice B is wrong because wrapping the newborn in a blanket reduces the skin-to-skin contact and may interfere with the bonding process.The father can also bond with the baby by holding him or her against his own skin.
Choice C is wrong because placing the newborn in an isolette separates the baby from the mother and prevents close interaction and communication.The baby may feel insecure and isolated in an isolette.
Choice D is wrong because dressing the newborn in a gown and hat also reduces the skin-to-skin contact and may delay the initiation of breastfeeding.The baby may also lose more heat through clothing than through direct contact with the mother’s body.
Correct Answer is B
Explanation
Cover the newborn’s eyes with eye shields or patches.This is because phototherapy can cause eye damage and irritation to the newborn, so the eyes should be protected while the lights are on.
Some possible explanations for the other choices are:
• Choice A is wrong because applying sunscreen to the newborn’s skin before placing under the lights can interfere with the effectiveness of phototherapy and increase the risk of skin irritation and infection.
• Choice C is wrong because turning off the phototherapy lights during feedings can reduce the exposure time and delay the clearance of bilirubin from the newborn’s blood.
• Choice D is wrong because keeping the newborn fully clothed to prevent heat loss can also interfere with the effectiveness of phototherapy and increase the risk of overheating and dehydration.
Normal ranges for bilirubin levels in newborns vary depending on the age, gestational age, and risk factors of the newborn.Generally, a total serum bilirubin level of less than 12 mg/dL (205 micromol/L) is considered normal for term newborns in the first week of life.Phototherapy is usually indicated when the total serum bilirubin level exceeds 15 mg/dL (257 micromol/L) for term newborns or 10 mg/dL (171 micromol/L) for preterm newborns.
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