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: 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.

A. Paraphimosis of prostate B. Epispadias C. Urethral stricture of bladder D. Age related changes

Correct Answer is B

Explanation

Choice A reason: Paraphimosis involves foreskin retraction, not meatal position, and isn’t prostate-related. Dorsal urethral meatus points to a congenital defect, not this acquired condition, making it an incorrect concern for this genitourinary finding entirely here fully.
Choice B reason: Epispadias is a congenital dorsal urethral opening, a key concern in males. This abnormal positioning may cause urinary issues or infertility, making it the most significant finding requiring attention in this assessment accurately and comprehensively here.
Choice C reason: Urethral stricture narrows the urethra, not shifting its position dorsally. This acquired issue isn’t bladder-specific, misaligning with the congenital anomaly observed, excluding it as the primary concern in this genitourinary exam fully here.
Choice D reason: Age doesn’t reposition the urethral meatus dorsally; this is congenital, not degenerative. Normal aging affects prostate size, not meatal anatomy, rendering this less critical than epispadias as the identified issue in this case entirely here.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working with a client who has a history of headaches for greater than two months. When preparing to assess the client's temporomandibular joint, what instruction provided to the client would indicate the nurse needs more teaching?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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