During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. Which problem should the nurse document?

Angular cheilitis

Herpes simplex

Angioedema

Answer and Explanation

The Correct Answer is B

Choice A Reason:
Angular cheilitis is characterized by inflammation of one or both corners of the mouth. It often presents as red, swollen patches in the corners of the mouth and can be associated with fungal or bacterial infection. However, it does not typically cause vesicular eruptions, which are more indicative of viral infections like herpes simplex.

Choice B Reason:
Herpes simplex virus (HSV) is known for causing vesicular eruptions, commonly referred to as cold sores or fever blisters, around the lips and mouth area. These eruptions are fluid-filled blisters that can be painful and are highly indicative of an HSV infection, particularly HSV type 1, which commonly affects the oral region.

Choice C Reason:
Angioedema involves the rapid swelling of the deeper layers of the skin, often seen with hives. While it can affect the lips and surrounding areas, it does not cause vesicular eruptions. Angioedema is more associated with allergic reactions and can be part of anaphylaxis, a severe systemic reaction.

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Correct Answer is B

Explanation

Choice a reason:
Educational Prevention is not a recognized level of prevention in healthcare. While education is a key component in all levels of prevention, it is not a standalone category. Education is typically included in primary prevention as it involves informing the public about health practices to prevent the onset of disease.

Choice b reason:
Tertiary Prevention is the level of prevention that aims to manage and treat an existing disease to prevent further complications or deterioration. In the case of immobile stroke patients, tertiary prevention would involve measures to prevent skin breakdown and other complications associated with immobility and the stroke's long-term effects.

Choice c reason:
Secondary Prevention involves early detection and prompt intervention to prevent the progression of a disease. For stroke patients, secondary prevention might include monitoring for signs of skin breakdown so that early treatment can be initiated. However, the scenario described focuses on managing an existing condition rather than early detection.

Choice d reason:
Primary Prevention aims to prevent the disease or injury before it occurs. This would involve strategies to prevent strokes in the first place, such as controlling high blood pressure or encouraging healthy lifestyle changes. It does not directly relate to the prevention of skin breakdown in patients who have already had a stroke.

A. The immunization schedule recommended for the client's age. B. The need for regular mammogram screening to identify breast cancer lesions. C. The need for consistent use of seat belts when in a motor vehicle. D. The impact of annual vision examinations on personal health and safety.

Correct Answer is B

Explanation

Choice a reason:
Immunization schedules are typically considered a part of primary prevention. They are intended to prevent diseases before they occur by using vaccines to provide immunity against infections.

Choice b reason:
Regular mammogram screenings are a form of secondary prevention. They are used to detect breast cancer lesions early before symptoms appear, which can lead to more effective treatment and better outcomes.

Choice c reason:
The consistent use of seat belts is a primary prevention strategy. It is a proactive measure to prevent injuries in the event of a motor vehicle accident.

Choice d reason:
Annual vision examinations can be considered part of secondary prevention if they are used to detect vision problems or eye diseases in their early stages. However, they can also be seen as primary prevention because they help maintain and protect eye health before issues arise.

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During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. Which problem should the nurse document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse educator is presenting at a continuing education seminar for nurses. As part of his presentation, he is emphasizing the prevention of skin breakdown in immobile patients who have suffered from a stroke. The level of prevention being discussed by the nurse educator is:

Correct Answer is B

Explanation

While conducting the health assessment, the nurse instructs the client about secondary prevention activities. What information did the nurse most likely provide to this client?

Correct Answer is B

Explanation

A client has been receiving intravenous antibiotics (ototoxic) for several weeks. Which prevention strategy would be best for the nurse to recommend for this client?

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During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. Which problem should the nurse document?

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