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 D

Explanation

A. Tympany indicates the presence of gas within the intestines. This would not be expected over the liver area if there is hepatomegaly.
B. This is not an expected finding in hepatomegaly. Tympany is associated with air-filled structures, which would not be present over an enlarged liver.
C. A hollow sound is also indicative of air-filled organs like the intestines. It is not a sign of hepatomegaly, which would be characterized by dullness on percussion.
D. Dullness upon percussion outside the costal margins suggests an enlarged liver (hepatomegaly). This is due to the liver becoming larger and filling the space that normally contains air-filled organs like the intestines.

A. "What were you doing when you first noticed the problem?" B. "Have you taken any medications to relieve the pain?" C. "Does changing your position make the pain worse?" D. "Do you remember ever having this type of pain in the past?"

Correct Answer is A

Explanation

A. Understanding the onset and activities related to the back pain can help the nurse determine if it is musculoskeletal, posture-related, or indicative of a more serious underlying issue.
B. Asking about medication is secondary until more information is gathered about the pain's onset and nature.
C. Changing positions may be relevant later, but initially, it is important to identify any possible triggers for the pain.
D. Asking about previous pain episodes may be helpful, but understanding the current episode’s cause is more pressing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While completing an admission assessment for a client with fatigue, weakness, and unexplained weight loss, the nurse notes scleral jaundice. Which finding during percussion of the abdomen should the nurse document indicating hepatomegaly?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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