When assessing a client's mouth, which finding requires immediate follow-up by the nurse?

Gingival inflammation.

White, curd-like lesions.

Buccal mucosa ulceration.

Fruity odor of the breath.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Gingival inflammation, or gingivitis, is a common oral finding indicative of mild to moderate periodontal disease. While it requires follow-up for proper oral hygiene and management, it does not typically represent an immediate, acute threat to a client's health requiring urgent intervention. It suggests bacterial accumulation and host inflammatory response.

Choice B rationale

White, curd-like lesions in the mouth are highly characteristic of oral candidiasis (thrush), a fungal infection caused by *Candida albicans*. In adults, especially those who are immunocompromised or on certain medications, this can spread, indicate systemic illness, or cause significant discomfort and nutritional compromise. It warrants immediate assessment and treatment.

Choice C rationale

Buccal mucosa ulceration, while causing discomfort and potentially indicating local trauma, viral infection, or systemic conditions, is not typically an immediate emergency unless associated with severe pain, bleeding, or signs of rapid progression. Isolated ulcers usually heal spontaneously or with symptomatic treatment.

Choice D rationale

A fruity odor of the breath, often described as a sweet, acetone-like smell, is a hallmark sign of diabetic ketoacidosis (DKA). This is a life-threatening metabolic emergency characterized by severe hyperglycemia, acidosis, and ketone body production, requiring immediate medical intervention to prevent severe complications like cerebral edema and coma.

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Correct Answer is B

Explanation

Choice A rationale

Cleaning the ears to remove excess wax buildup is inappropriate here because the description explicitly states the tympanic membranes (TMs) are visible and translucent gray, indicating no significant wax obstruction. Ear wax, or cerumen, naturally protects the ear canal; excessive buildup typically manifests as obscured TMs or hearing impairment, neither of which is present.

Choice B rationale

Recording the findings in the client's record is the most appropriate action. The presence of dense white patches on the tympanic membranes, known as tympanosclerosis, is a common sequela of chronic otitis media and typically represents calcification within the TM, not active infection or hearing loss. Given no current symptoms, this is an expected, benign finding.

Choice C rationale

Culturing the white patches for possible fungal growth is not indicated. Tympanosclerosis is a non-infectious, degenerative process involving hyaline degeneration and calcification of the TM, often following inflammation. Fungal infections of the ear typically present with different characteristics, such as otorrhea, pruritus, or pain, none of which are reported here.

Choice D rationale

Referral to an audiologist for a hearing evaluation is not immediately necessary. The client reports no hearing loss, and while tympanosclerosis can sometimes impact hearing, especially if extensive, the current lack of symptoms and clear visualization of landmarks suggest a stable, non-acute condition. An audiogram would be indicated if hearing changes were reported.

A. Masses. B. Peristaltic waves. C. Homogeneous color. D. Heterogeneous color.

Correct Answer is C

Explanation

Choice A rationale

The presence of abdominal masses is an abnormal finding during inspection. Masses can indicate tumors, organ enlargement, or other pathological conditions that require further investigation and are not considered a normal anatomical variation.

Choice B rationale

Peristaltic waves, while physiologically present, are typically not visible on inspection of the abdomen in healthy adults. Visible peristaltic waves can indicate increased intestinal motility or obstruction, which are abnormal findings requiring medical evaluation.

Choice C rationale

Homogeneous color, meaning a uniform and consistent skin tone across the abdomen, is considered a normal finding. This indicates healthy skin perfusion and the absence of localized discoloration, inflammation, or other dermatological abnormalities.

Choice D rationale

Heterogeneous color, meaning uneven or varied skin tone, is generally considered an abnormal finding. This could indicate localized areas of hyperpigmentation, hypopigmentation, bruising, rashes, or other dermatological conditions that deviate from normal skin presentation.

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When assessing a client's mouth, which finding requires immediate follow-up by the nurse?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse completes inspection of the abdomen on an adult client. Which finding is considered normal for this client?

Correct Answer is C

Explanation

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