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 D
Explanation
Choice a reason:
Exophthalmos, or protrusion of the eyeballs, is not a typical finding in hypothyroidism. It is more commonly associated with hyperthyroidism, particularly Graves' disease, which is characterized by an overactive thyroid gland.
Choice b reason:
Photophobia, or light sensitivity, is not a common symptom of hypothyroidism. While it can be associated with other conditions, it is not directly related to the function of the thyroid gland.
Choice c reason:
Weight loss is typically not associated with hypothyroidism. In fact, individuals with hypothyroidism often experience weight gain due to a slowed metabolism, which is the opposite of weight loss.
Choice d reason:
Lethargy is a common symptom of hypothyroidism. The condition can lead to a decrease in thyroid hormone production, which can slow down the body's metabolism, resulting in feelings of fatigue, sluggishness, and lethargy.
Correct Answer is B
Explanation
Choice a reason:
Tympany is a drum-like, resonant sound that is typically heard over air-filled structures, such as the gastric bubble, not the chest. It is not a sound associated with the lungs, especially in the context of COPD.
Choice b reason:
Hyperresonance is an abnormally loud, lower-pitched sound than normal resonance heard over hyperinflated areas of the lung, such as in cases of COPD. This is due to the increased air content within the lungs, often because of overdistension or destruction of alveolar tissue, as seen in emphysema, a common type of COPD.
Choice c reason:
Resonance is the normal sound heard over healthy lung tissue when percussed. However, in the case of COPD, particularly emphysema, the destruction of lung tissue leads to hyperinflation and thus a hyperresonant sound rather than the normal resonance.
Choice d reason:
Dullness is heard when fluid or solid tissue replaces air in the lung or occupies the pleural space, as in the case of pneumonia or pleural effusion. This is not characteristic of COPD, where there is an increase in air due to the breakdown of alveolar walls.
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