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 A

Explanation

A. A change in awareness of surroundings: Altered awareness or sudden changes in level of consciousness can signal acute neurological issues such as stroke, brain injury, infection, or metabolic imbalances. This is a serious red flag requiring immediate medical evaluation to prevent potential deterioration.

B. Reduced fine motor skills: While reduced fine motor skills can indicate a neurological issue, it typically develops gradually due to conditions like arthritis, neurological disorders, or aging and may be monitored unless associated with other acute symptoms. It is not usually an emergency unless sudden in onset.

C. A negative Babinski reflex: A negative Babinski reflex is a normal finding in adults, indicating intact central nervous system function. It does not suggest the need for medical follow-up in the absence of other abnormal signs.

D. Diminished short term memory over the past year: Gradual memory decline may indicate cognitive changes like dementia, stress or early signs of cognitive impairment but it typically requires routine, not immediate, follow-up unless there's a rapid worsening or associated concerning symptoms.

A. Soft, barely heard on auscultation in a quiet room. B. Moderately loud, machine-like rumble, not associated with a thrill. C. Loud, at the apex, associated with a palpable thrill. D. Very loud, with no stethoscope, thrill easily palpable, heave visible.

Correct Answer is C

Explanation

A. Soft, barely heard on auscultation in a quiet room: This description refers to a murmur of a lower grade, Grade I, not a grade IV murmur. Grade I murmurs are very faint and may not be heard in all positions. A grade IV murmur is typically loud enough to be heard clearly and would likely be associated with a palpable thrill, which is not consistent with a soft murmur.

B. Moderately loud, machine-like rumble, not associated with a thrill: This description does not align with a grade IV systolic murmur, which is generally louder and more associated with a palpable thrill. A machine-like rumble could be indicative of a Grade III murmur or a different type of murmur, possibly related to other valvular conditions, but it would not match the characteristics of a grade IV systolic murmur.

C. Loud, at the apex, associated with a palpable thrill: A grade IV systolic murmur is loud and often associated with a palpable thrill, which can be felt at the apex of the heart, particularly in mitral valve regurgitation. This finding is consistent with the characteristics of a grade IV murmur and accurately reflects its clinical presentation.

D. Very loud, with no stethoscope, thrill easily palpable, heave visible: This description refers to a grade V or grade VI murmur, which is very loud and can be heard without a stethoscope. It also includes the visible heave, which is not typical for a grade IV murmur. Therefore, this is too extreme for the situation described.

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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

The nurse is assessing older adult clients in a community health clinic. Which assessment finding is an indicator for immediate medical follow-up?

Correct Answer is A

Explanation

The nurse auscultates the precordium of a client who is diagnosed with mitral valve regurgitation and hears a grade IV systolic murmur. When documenting the comparison of systolic murmurs, which characteristics should the nurse use to support this systolic finding?

Correct Answer is C

Explanation

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

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