The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?

Document this finding in the medical record.

Ask if the client recently received any antibiotics.

Ask the client about use of irritating chemical agents.

Schedule an appointment with a dermatologist.

Answer and Explanation

The Correct Answer is A

A.   Documenting the finding is important to ensure proper record-keeping, especially in clients with dark pigmented skin, where some variations in skin tone may be normal.
B.   Asking about antibiotics is unnecessary unless there's suspicion of a drug-induced reaction or side effect.
C.   While use of irritating chemicals could cause changes, this scenario does not directly suggest that as the cause.
D.   Referral to a dermatologist is not required without further investigation to determine if the discoloration is concerning.

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Correct Answer is C

Explanation

A. The fifth intercostal space, midclavicular line, is the location for auscultating the mitral valve.
B. The third left intercostal space is typically used for the pulmonic valve.
C. The tricuspid valve is best auscultated at the left fourth intercostal space near the left sternal border.
D. The second right intercostal space is used to listen to the aortic valve.

A. Ask the client if he took any pain medication at home. B. Observe for nonverbal signs to measure pain intensity. C. Use a standard pain assessment questionnaire and scale. D. Collect a urine sample and strain for granules or calculi.

Correct Answer is D

Explanation

A. While it’s important to assess whether the client has already taken pain medication, this should not be the first intervention. The priority is to assess the client's current status and gather information to guide the next steps in care.
B. Observing nonverbal signs of pain can be helpful, but the first priority is to assess the cause of the pain and collect pertinent data to determine if it’s related to kidney stones or another condition. Nonverbal signs are secondary to clinical assessment.
C. Using a pain scale would be appropriate after performing an initial assessment to determine the cause of the pain. While this helps gauge pain intensity, it is not the most urgent action in the case of suspected kidney stones.
D. The first priority in a client with flank pain and a history of kidney stones is to collect a urine sample and strain it for calculi.

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The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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