During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. Which problem should the nurse document?
Angular cheilitis
Herpes simplex
Angioedema
The Correct Answer is B
Choice A Reason:
Angular cheilitis is characterized by inflammation of one or both corners of the mouth. It often presents as red, swollen patches in the corners of the mouth and can be associated with fungal or bacterial infection. However, it does not typically cause vesicular eruptions, which are more indicative of viral infections like herpes simplex.
Choice B Reason:
Herpes simplex virus (HSV) is known for causing vesicular eruptions, commonly referred to as cold sores or fever blisters, around the lips and mouth area. These eruptions are fluid-filled blisters that can be painful and are highly indicative of an HSV infection, particularly HSV type 1, which commonly affects the oral region.
Choice C Reason:
Angioedema involves the rapid swelling of the deeper layers of the skin, often seen with hives. While it can affect the lips and surrounding areas, it does not cause vesicular eruptions. Angioedema is more associated with allergic reactions and can be part of anaphylaxis, a severe systemic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice a reason:
Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormones. This can lead to a variety of symptoms, including hoarseness, fatigue, and weight gain. The hoarseness can be due to the effect of hormone deficiency on the vocal cords, while fatigue and weight gain are common due to the slowed metabolism associated with hypothyroidism.
Choice b reason:
Gingivitis is inflammation of the gums and does not typically cause hoarseness, fatigue, or weight gain. It is more commonly associated with symptoms like red, swollen gums and bleeding during brushing or flossing.
Choice c reason:
Aphthous ulcers, also known as canker sores, are small, shallow lesions that develop on the soft tissues in the mouth or at the base of the gums. While they can be painful and cause difficulty with eating and speaking, they do not cause systemic symptoms such as hoarseness, fatigue, or weight gain.
Choice d reason:
Dysphagia, or difficulty swallowing, can lead to hoarseness if there is an associated throat disorder. However, it is not typically associated with systemic symptoms like fatigue and weight gain unless it is part of a broader condition that affects the body's metabolism or energy levels.
Correct Answer is B
Explanation
Choice A Reason:
Tracheal sounds are harsh, high-pitched breath sounds typically heard over the trachea in the neck. They are not expected to be heard over the peripheral lung fields of a young adult during a routine lung auscultation.
Choice B Reason:
Vesicular breath sounds are the normal sounds heard over most of the lung fields. They are characterized by a soft, low-pitched, rustling sound during inhalation and are softer during exhalation. These sounds are created by air moving through the smaller airways such as the bronchioles and alveoli.
Choice C Reason:
Bronchovesicular sounds are heard over the major bronchi and are characterized by a moderate pitch and intensity. They are typically heard between the first and second intercostal spaces at the sternal border anteriorly and between the scapulae posteriorly, not over most of the lung fields.
Choice D Reason:
Bronchial breath sounds are high-pitched and louder than vesicular sounds, with a hollow quality, and are normally heard over the manubrium. If heard over the peripheral lung fields, they may indicate lung consolidation or other abnormalities.
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