Which finding should raise the greatest concern for a nurse who is performing an ear nose and throat (ENT) examination?

A painful ulcerated mucosal area inside the cheek for 1 day.

Stippled gingival margins that adhere firmly to the teeth.

A number of small yellowish-white and raised lesions on the buccal mucosa.

An ulceration under the tongue that has been present for the last three

Answer and Explanation

The Correct Answer is D

A.   A painful ulcerated mucosal area inside the cheek that has been present for only 1 day is concerning but less alarming in the short term compared to chronic lesions. Acute ulcers can be caused by minor trauma, infections, or canker sores. While it is important to monitor and evaluate these lesions, especially if they persist or worsen, a duration of only 1 day typically suggests it might be related to a transient condition.
B.   Stippled gingival margins that adhere firmly to the teeth can indicate gingival hyperplasia or certain systemic conditions like vitamin deficiencies. While this finding can be concerning and warrants further investigation into oral health or potential systemic issues, it is generally less urgent compared to other findings that may indicate malignancy or severe chronic conditions.

C.   Small yellowish-white lesions on the buccal mucosa could be oral leukoplakia or aphthous ulcers, which can be benign or related to underlying conditions. While these lesions need to be assessed to determine their cause, they are usually less immediately concerning than persistent ulcers that could indicate more serious issues.
D.   An ulceration under the tongue that has been present for three weeks is the most concerning finding. Chronic oral ulcers, especially those persisting for more than two weeks, can be indicative of serious conditions such as oral cancer or other malignancies. Persistent lesions warrant thorough investigation to rule out or address potential malignancy or other significant pathologies.

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Correct Answer is ["20"]

Explanation

The standard distance for a visual acuity test using the Snellen chart is 20 feet. This distance allows for an accurate assessment of how well a person can see the details of the letters on the chart, which is a common method used by eye doctors to measure visual acuity.

A. Nodes feel ropey and rubbery. B. Axillary nodes feel soft and fatty. C. Inguinal nodes are enlarged and warm to the touch. D. Nodes are non-palpable.

Correct Answer is D

Explanation

A. Lymph nodes that feel ropey and rubbery might indicate chronic inflammation or fibrosis. This texture is not typically considered normal. In elderly clients, lymph nodes may become less palpable due to age- related changes, but they should not feel ropey or rubbery. If lymph nodes feel this way, it may warrant further investigation to rule out pathological conditions.
B. In elderly clients, axillary lymph nodes may feel softer and less defined due to fatty tissue changes associated with aging. However, "soft and fatty" should be interpreted cautiously. While some degree of change is normal, nodes should not be excessively soft, nor should they have an abnormal appearance. The key is that they should not be hard, fixed, or tender, which would be indicative of pathology.
C. Enlarged and warm inguinal lymph nodes suggest infection or inflammation rather than a normal finding. In the elderly, while lymph nodes can sometimes be palpable, they should not be enlarged or warm, as this could indicate an underlying condition or infection that requires further evaluation.
D. It is normal for lymph nodes to be non-palpable in many individuals, including older adults. Age- related changes can cause lymph nodes to be less prominent or difficult to palpate. If lymph nodes are non-palpable, it usually means they are not enlarged or abnormal, which is a normal finding, especially if the client is not experiencing any symptoms of infection or other related issues.

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Which finding should raise the greatest concern for a nurse who is performing an ear nose and throat (ENT) examination?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the visual acuity of a client who reports changes in vision. How many feet away from the Snellen chart should the client stand? (Enter a whole number only.)

Correct Answer is ["20"]

Explanation

The nurse has just completed palpation maneuvers for lymph nodes on an older adult female client. Which findings are considered normal for this elderly client?

Correct Answer is D

Explanation

A client is concerned about developing carpal tunnel syndrome. Which screening technique should the nurse perform to provide the client with useful information?

An older adult client with a history of heart failure (HF) is brought to the clinic by a family member. Which finding(s) confirm to the nurse that the client is experiencing an exacerbation of the HP? Select all that apply.

The nurse places the diaphragm of a warmed stethoscope on a client's abdomen to auscultate the bowel sounds. Which finding is considered normal?

A client reports to the healthcare provider's office for a routine post-surgical evaluation six weeks after a hysterectomy. Which history-taking approach should the nurse use to gather the needed information?

A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response. Which interpretation of this finding is accurate?

Patient Data Exhibits

While performing a health history the nurse asks the client, "You don't use recreational drugs, do you?" This approach is most likely to elicit which response from the client?

The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating the spleen?