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

White, curd-like lesions.

Gingival inflammation.

Buccal mucosa ulceration.

Fruity odor of the breath.

Answer and Explanation

The Correct Answer is D

A. White, curd-like lesions: These are often indicative of oral candidiasis (thrush), a fungal infection that may require antifungal treatment. While it needs follow-up, it is not typically emergent unless the patient is immunocompromised.

B. Gingival inflammation: This suggests gingivitis or periodontal disease and warrants dental evaluation, but it does not pose an immediate systemic risk unless associated with infection or abscess.

C. Buccal mucosa ulceration: Ulcerations can result from trauma, infection, or systemic conditions. They require assessment and possibly treatment but do not usually demand urgent intervention unless severe or rapidly worsening.

D. Fruity odor of the breath: A fruity or sweet breath odor can be a sign of diabetic ketoacidosis (DKA), a life-threatening complication of uncontrolled diabetes. It requires immediate medical attention due to the risk of severe metabolic imbalance and potential for rapid deterioration.

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Correct Answer is D

Explanation

A. Observe the client's eye movements through the cardinal fields of vision: This test evaluates extraocular muscle function and cranial nerves III, IV, and VI. It helps detect muscle weakness or nerve damage but does not measure visual acuity or diagnose legal blindness.

B. Observe the client's pupillary response to a penlight: This assesses the integrity of the optic and oculomotor nerves and reflexes, such as pupil constriction. While useful in neurological assessments, it does not determine the level of visual acuity needed to confirm legal blindness.

C. Observe the client's optic disc through an ophthalmoscope: Direct visualization of the optic disc can reveal issues like glaucoma or optic atrophy. However, it does not quantify vision loss or determine functional blindness as defined by acuity measurements.

D. Assess the client's ability to read a Snellen chart from a distance of 20 feet: This is the standard method for evaluating visual acuity. Legal blindness is defined in the U.S. as visual acuity of 20/200 or worse in the better eye with corrective lenses, making this test the most appropriate for supporting the client’s statement.

A. Ask if the client often feels weak or hungry. B. Compare the range of motion of both legs. C. Measure the client's capillary glucose. D. Palpate the client's dorsalis pedis pulses.

Correct Answer is D

Explanation

A. Ask if the client often feels weak or hungry: While important in overall diabetes assessment, weakness or hunger are more related to poor glucose control and they do not specifically indicate peripheral vascular changes such as shiny skin and hair loss.

B. Compare the range of motion of both legs: Assessing range of motion can be useful in evaluating joint or muscular issues but does not provide specific information about vascular status or circulation, which is the primary concern here.

C. Measure the client's capillary glucose: Blood glucose levels are essential in managing diabetes but do not assess the presence or severity of peripheral vascular disease, which can lead to changes in skin and hair growth on the lower legs.

D. Palpate the client's dorsalis pedis pulses: Shiny skin and hair loss on the legs suggest poor peripheral circulation, often related to peripheral arterial disease, a common complication of diabetes mellitus. High blood sugar levels can damage blood vessels over time, leading to narrowing and reduced blood flow, particularly in the lower extremities. Palpating dorsalis pedis pulses helps assess arterial blood flow and supports evaluation of vascular insufficiency.

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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

A client states, "I am legally blind." Which assessment technique should the nurse use to obtain data to support the client's statement?

Correct Answer is D

Explanation

The nurse observes that the lower legs of a client with diabetes mellitus are shiny, and with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?

Correct Answer is D

Explanation

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