The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?

Document this finding in the medical record.

Ask if the client recently received any antibiotics.

Ask the client about use of irritating chemical agents.

Schedule an appointment with a dermatologist.

Answer and Explanation

The Correct Answer is A

A.   Documenting the finding is important to ensure proper record-keeping, especially in clients with dark pigmented skin, where some variations in skin tone may be normal.
B.   Asking about antibiotics is unnecessary unless there's suspicion of a drug-induced reaction or side effect.
C.   While use of irritating chemicals could cause changes, this scenario does not directly suggest that as the cause.
D.   Referral to a dermatologist is not required without further investigation to determine if the discoloration is concerning.

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Correct Answer is ["B","C","D"]

Explanation

A. Osteopenia refers to decreased bone density, which is often noted on X-ray or bone mineral density tests rather than through direct visual inspection. However, the nurse may observe signs of frailty or changes in posture that could suggest underlying osteopenia.
B. Contractures, which are abnormal shortening of muscles or tendons leading to limited joint mobility, are often detectable through inspection. The nurse may observe deformities or restricted movement in the joints, especially in patients with neurological or musculoskeletal disorders.
C. Muscle atrophy, or the wasting away of muscle tissue, can be observed during inspection. The nurse may note reduced muscle bulk or asymmetry in muscle size, which is a sign of muscle wasting.
D. Kyphosis, an abnormal curvature of the spine resulting in a hunchback appearance, can be easily observed during inspection of the client’s posture. This condition is common in older adults and may indicate musculoskeletal or age-related changes.
E. Crepitus refers to the grinding or popping sounds felt or heard when moving joints. While crepitus is assessed by palpation or auscultation rather than visual inspection, the nurse may note joint deformities that suggest the presence of crepitus.

A. Manipulate the testicles upon rising. B. Inspect the testicles using a mirror. C. Examine the testicles during bathing. D. Compare both testicles concurrently.

Correct Answer is C

Explanation

A. Manipulating the testicles upon rising is not a recommended time for TSE and could lead to unnecessary manipulation that doesn't focus on examination.
B. Inspecting the testicles using a mirror is not as effective as feeling for lumps and abnormalities through touch.
C. It is ideal to perform testicular self-examination during bathing, as the warm water relaxes the scrotal skin and makes it easier to detect any lumps or changes in texture.
D. Comparing both testicles concurrently is important, but the technique is not as effective when done without the warmth of a bath or shower.

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The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

The college health clinic nurse is preparing a seminar on testicular self-examination (TSE). Which instruction should be included in the content for this seminar?

Correct Answer is C

Explanation

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