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. Nasal polyps: Nasal polyps are soft, noncancerous growths in the nasal passages or sinuses, often linked to chronic inflammation, asthma, or allergies. They do not cause sore throat, fever, or difficulty swallowing, and are not associated with strep pharyngitis.

B. Laryngeal polyps: Laryngeal polyps typically present with hoarseness due to vocal cord involvement but are not associated with high fever, painful swallowing, or infections like streptococcal pharyngitis. They are usually non-infectious and develop gradually.

C. Foreign body obstruction: A foreign body obstruction causes sudden onset symptoms such as choking, coughing, or respiratory distress. This does not align with a progressive infectious presentation like fever and muffled voice, which suggests a localized infection.

D. Peritonsillar abscess: A peritonsillar abscess is a common complication of untreated or severe streptococcal pharyngitis. It presents with high fever, difficulty swallowing (dysphagia), muffled or "hot potato" voice, and unilateral throat pain due to pus collection near the tonsils.

A. Right breath sounds louder than left. B. Slight crackling throughout lung fields. C. Faint whistling over both lung bases. D. Blowing, hollow sounds above sternum.

Correct Answer is D

Explanation

A. Right breath sounds louder than left: While there might be slight variations, breath sounds should generally be equal in intensity on both sides of the chest. Breath sounds should be relatively equal bilaterally. Asymmetry in sound intensity can indicate consolidation, obstruction, or a pneumothorax.

B. Slight crackling throughout lung fields: Crackles (rales) are abnormal sounds typically associated with fluid in the alveoli, as seen in conditions like heart failure, pneumonia, or pulmonary fibrosis. They are not a normal finding in healthy lung tissue.

C. Faint whistling over both lung bases: Whistling or high-pitched sounds suggest wheezing, often caused by narrowed airways due to asthma, bronchitis, or other obstructive airway diseases. This is considered an abnormal finding.

D. Blowing, hollow sounds above sternum: These describe bronchial breath sounds, which are normally heard over the trachea and manubrium (above the sternum). They have a blowing, hollow quality and are considered a normal finding in that location.

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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

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Correct Answer is D

Explanation

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