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 D

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

While comparing measured circumferences of each extremity joint can provide information on swelling or muscle atrophy, it does not directly assess for asymmetry in leg length, which is the primary concern when legs appear asymmetrical. This measurement is more indicative of fluid accumulation or muscle wasting patterns.

Choice B rationale

Measuring the length of each leg directly quantifies any disparity, providing objective data regarding potential limb length discrepancy. This is crucial for identifying underlying skeletal or muscular issues that could cause asymmetrical appearance and guide appropriate interventions.

Choice C rationale

Observing the client's gait can reveal compensatory mechanisms due to leg length discrepancy, such as a limp or uneven stride. However, gait analysis alone does not definitively confirm or quantify the actual leg length difference, which requires precise measurement.

Choice D rationale

Performing passive range of motion assesses joint mobility and flexibility, but it does not directly measure leg length. While limitations in range of motion might be associated with underlying conditions, they do not specifically address the perceived asymmetry in leg length.

A. Observe the client’s respirations for rate, rhythm, and depth B. Inspect the skin and mucus membranes C. Measure the apical pulse for 60 seconds D. Auscultate chest E. Have the client demonstrate use of the incentive spirometer F. Determine the heart rhythm

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale: Observing respirations for rate, rhythm, and depth is crucial in pneumonia management as respiratory compromise may develop rapidly. Changes in respiratory pattern such as tachypnea, irregular rhythm, or shallow breaths can indicate worsening lung function, hypoxia, or impending respiratory failure, requiring immediate intervention.

Choice B rationale: Inspecting skin and mucous membranes helps assess for signs of hypoxia or poor perfusion, such as cyanosis or pallor. These findings can indicate inadequate oxygen delivery due to impaired lung function in pneumonia. Monitoring skin integrity is also important for infection control and early detection of complications.

Choice C rationale: Measuring the apical pulse for 60 seconds is important in cardiac assessments, especially if arrhythmias or murmurs are suspected. However, in pneumonia without cardiac symptoms or abnormal heart sounds, continuous assessment of apical pulse is not prioritized in a focused respiratory assessment.

Choice D rationale: Auscultating the chest is essential to evaluate breath sounds for signs of consolidation, crackles, or diminished air entry, which directly reflect pneumonia severity and progression. Regular auscultation helps guide treatment decisions and detect complications like pleural effusion or pneumothorax.

Choice E rationale: Having the client demonstrate incentive spirometer use ensures proper technique, promoting lung expansion and preventing atelectasis. Correct use reduces pulmonary complications and supports recovery, making it an important part of nursing assessment and education in pneumonia care.

Choice F rationale: Determining heart rhythm is important in cardiac assessments, but in the absence of arrhythmia symptoms or abnormal ECG findings, it is not a primary focus in pneumonia care. Monitoring vital signs regularly is sufficient unless clinical indications suggest otherwise.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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