The nurse assesses thick, white plaques on a client's tongue and hard palate. Which of the following nursing actions should the nurse do next?

Facilitate blood testing for human immunodeficiency virus (HIV)

Refer the client to a primary care provider for prescriptive medication

Assess the client for signs of jaundice

Assess the client's laboratory values for zinc deficiency

Answer and Explanation

The Correct Answer is A

Choice A reason: Thick, white plaques suggest oral thrush, often Candida, linked to HIV immunosuppression. Facilitating HIV testing addresses a potential underlying cause, as CD4 decline allows opportunistic infections, making this the critical next step for diagnosis and management here.

Choice B reason: Referral for medication treats thrush symptomatically but misses underlying HIV risk. Antifungals help, yet without addressing immunosuppression, recurrence persists, making this less urgent than testing for a systemic condition driving the plaques in this scenario fully.

Choice C reason: Jaundice causes yellowing, not white plaques, which are fungal, not hepatic. Assessing for this misaligns with the finding’s etiology, as thrush ties to immunity, not liver function, rendering it irrelevant to the client’s oral presentation entirely here.

Choice D reason: Zinc deficiency causes taste loss or ulcers, not thick plaques like thrush. Lab review for this overlooks the infectious, possibly HIV-related cause, missing the immunological context critical to addressing the client’s specific oral condition accurately and promptly.

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Correct Answer is A

Explanation

Choice A reason: Trigeminal neuralgia causes sharp, intermittent facial pain lasting minutes due to cranial nerve V irritation. Normal vitals and no systemic symptoms align with this neuropathic condition, distinguishing it from inflammatory or vascular headache causes in this presentation.

Choice B reason: Meningitis presents with fever, neck stiffness, and severe headache, not intermittent facial pain. Normal temperature and vitals here rule out this acute infection, which affects meninges broadly, not just facial nerves, making it an unlikely fit.

Choice C reason: Migraines involve throbbing head pain, often with nausea or photophobia, lasting hours, not minutes of facial pain. The client’s brief, episodic description and normal vitals don’t match migraine’s typical systemic or prolonged profile, excluding it here.

Choice D reason: TMJ dysfunction causes jaw pain, often with chewing difficulty or joint sounds, not intermittent facial pain alone. Normal vitals and no joint-specific complaints suggest this isn’t TMJ-related, pointing instead to a neural origin like trigeminal neuralgia.

A. "I am going to place my hand on your cheek, and I want you to turn your head against resistance." B. "I’m going to place my fingers in front of your ear, and I want you to open your mouth as wide as possible." C. "I want you to move your jaw from side to side and tell me if there is any pain with the movement." D. "Push out and pull in your lower jaw and let me know if you experience popping or grating."

Correct Answer is A

Explanation

Choice A reason: Turning the head against resistance assesses neck muscles, not the temporomandibular joint (TMJ), which hinges the jaw. TMJ evaluation requires jaw-specific movements, not cervical rotation, indicating a misunderstanding of TMJ anatomy and function, misaligning with headache assessment needs.

Choice B reason: Opening the mouth wide while fingers are placed near the ear directly tests TMJ range of motion and joint integrity. This is a standard technique to detect dysfunction or pain, correctly targeting the jaw’s articulation point relevant to headaches.

Choice C reason: Moving the jaw side to side evaluates TMJ lateral excursion, a key diagnostic motion. Pain reporting during this action helps identify joint issues tied to chronic headaches, making it an appropriate and precise instruction for TMJ assessment.

Choice D reason: Pushing out and pulling in the jaw tests TMJ protrusion and retraction, critical for assessing joint stability and sounds like popping, which may link to headache etiology. This instruction correctly focuses on TMJ mechanics and symptoms.

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The nurse assesses thick, white plaques on a client's tongue and hard palate. Which of the following nursing actions should the nurse do next?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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