A nurse is assessing an older adult client’s mouth.
The nurse should identify that which of the following is an expected variation for this client?
White patches on the tongue
Bleeding of the gums
Darkening of the mucosa
Red spots on the hard palate.
The Correct Answer is D
Darkening of the mucosa. This is an expected variation for an older adult client because the melanin production increases with age.
Some possible explanations for the other choices are:
• Choice A. White patches on the tongue could indicate candidiasis, an oral fungal infection.
• Choice B. Bleeding of the gums could indicate gingivitis, periodontitis, or vitamin C deficiency.
• Choice C. Red spots on the hard palate could indicate petechiae, which are small hemorrhages caused by trauma, infection, or bleeding disorders.
Normal ranges for oral mucosa color vary depending on the skin tone and ethnicity of the client. Generally, the oral mucosa should be pink and moist without lesions or discolorations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Swaddling, pacifiers, gentle touch and music therapy are all non-pharmacological interventions that can help soothe a newborn during an assessment.
These methods can provide comfort, security, distraction and stimulation for the newborn.
Choice D is wrong because glucose water is a pharmacological intervention that can be used to reduce pain during procedures such as heel sticks or circumcision.Glucose water should not be given routinely to newborns as it can interfere with breastfeeding and cause electrolyte imbalances.
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Correct Answer is A
Explanation
The nurse should follow the sequence of 1, 2, 3, 4, 5 when assessing the client’s conjunctiva.This is because the nurse should first apply examination gloves to prevent contamination and infection.Then, the nurse should instruct the client to look up to expose the lower eyelid and conjunctiva.Next, the nurse should place the thumbs below each of the client’s lower eyelids and gently pull the skin down to the top edge of the bony orbital rim.This allows the nurse to inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, drainage, or lesions.The sclera should be white and the conjunctiva should be pink.
Choice B is wrong because the nurse should not pull down the skin before instructing the client to look up.
This could cause discomfort and injury to the eye.
Choice C is wrong because the nurse should not instruct the client to look up after pulling down the skin.
This could also cause discomfort and injury to the eye.
Choice D is wrong because the nurse should not place the thumbs below each of the client’s lower eyelids before applying examination gloves.
This could introduce infection and irritants to the eye.
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