While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip.
What other information would be most important for the nurse to assess?
a.
Nutritional status
b.
When the patient first noticed the lesion
c.
Whether the patient has had a recent cold
d.
Whether the patient has had any recent exposure to sick animals
Question 2During an assessment of a 26 year old at the clinic for a spot on my lip I think is cancer, the nurse notices a group of clear vesicles with an erythematous base around them located at the lip-skin border.
The patient mentions that she just returned from Hawaii. What would be the most appropriate response by the nurse?
a.
Tell the patient she needs to see a skin specialist.
b.
Discuss the benefits of having a biopsy performed on any unusual lesion.
c.
Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they will heal in 4 to 10 days.
d.
Tell the patient that these vesicles are most likely the result of a riboflavin deficiency and discuss nutrition.
Question 3The nurse is assessing a 3 year old for drainage from the nose. On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms.
What should the nurse do next?
a.
Refer to the physician for an antibiotic order.
b.
Have the mother bring the child back in 1 week.
c.
Perform an otoscopic examination of the left nares.
d.
Tell the mother that this drainage is normal for a child of this age.
Question 4The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. During an inspection of his mouth, the nurse should look for:
a. Swollen, red tonsils.
b. Ulcerations on the hard palate.
c. Bruising on the buccal mucosa or gums.
d. Small yellow papules along the hard palate.
Question 5Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next?
a. Attempt to suction again with a bulb syringe.
b. Wait a few minutes, and try again once the infant stops crying.
c. Recognize that this situation requires immediate intervention.
d. Contact the physician to schedule an appointment for the infant at his or her next hospital visit.
Question 6A 10 year old is at the clinic for a sore throat that has lasted 6 days. Which of these findings would be consistent with an acute infection?
a. Tonsils 1+/1-4+ and pink; the same color as the oral mucosa
b. Tonsils 2+/1-4+ with small plugs of white debris
c. Tonsils 3+/1-4+ with large white spots
d. Tonsils 3+/1-4+ with pale coloring
Question 7A 32-year-old woman is at the clinic for little white bumps in my mouth. During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek.
What would the nurse tell the patient?
a.
These spots indicate an infection such as strep throat.
b.
These bumps could be indicative of a serious lesion, so I will refer you to a specialist.
c.
This condition is called leukoplakia and can be caused by chronic irritation such as with smoking.
d.
These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition.
Question 8During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of:
a. Dehydration.
b. Irritation by gastric juices.
c. A normal oral assessment.
d. Side effects from nausea medication.
Question 9During an oral assessment of a 30-year-old Black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding?
a. Check the patient's hemoglobin for anemia.
b. Assess for other signs of insufficient oxygen supply.
c. Proceed with the assessment, knowing that this appearance is a normal finding.
d. Ask if he has been exposed to an excessive amount of carbon monoxide.
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