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. Repeat vocalizing the letter "E" while the thorax is auscultated. B. Whisper "one, two, three" in sequence during auscultation of the thorax. C. Repeat the number "99" during a systematic auscultation of the thorax. D. Breathe in and out while all lobes of both lungs are auscultated.

Correct Answer is A

Explanation

A. Repeat vocalizing the letter "E" while the thorax is auscultated: Egophony is assessed by having the client say "E" while the nurse auscultates the chest. In the presence of lung consolidation, such as in a lung abscess, the "E" sound may be auscultated as an "A"—a finding known as the "E-to-A" change, which is a hallmark of egophony.

B. Whisper "one, two, three" in sequence during auscultation of the thorax: This technique is used to assess whispered pectoriloquy, not egophony. It helps detect areas of lung consolidation if whispered words are heard clearly through the stethoscope.

C. Repeat the number "99" during a systematic auscultation of the thorax: This test is used to assess bronchophony, increased loudness and clarity of spoken words, another sign of lung consolidation. Clear transmission of "99" may suggest fluid or consolidation in the lungs.

D. Breathe in and out while all lobes of both lungs are auscultated: This is a standard part of respiratory assessment but is not specific for egophony. It helps detect abnormal breath sounds like wheezes, crackles, or diminished sounds, not vocal resonance changes.

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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

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Correct Answer is A

Explanation

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