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 A

Explanation

A. Assessing the client's functional capacity and identifying potential environmental hazards is essential, especially in older adults, as they may face physical limitations or risks in their environment that could impact their safety and quality of life.
B. Medication history is always important, particularly in older adults who may be taking multiple medications for chronic conditions. However, while relevant, it is not the most critical aspect in this scenario.
C. Differentiating between symptoms of aging and those caused by disease is important for accurate diagnosis and treatment. However, the priority should be to assess the client's overall health and risks related to their daily function and environment.
D. While discussing advance directives is essential for future care planning, it is not the immediate priority in this health history assessment. The focus should be on addressing any current health issues that impact the client’s quality of life.

A. Enter subjective data in the note section of the client's electronic medical record. B. Document the client's history that is directly related to current admission diagnoses. C. Enter the information in the electronic medical record at the client's bedside. D. Document the assessment findings on the computer at the nursing station.

Correct Answer is B

Explanation

A. While subjective data is important, it should be categorized appropriately based on relevance to the diagnosis, not just placed in the notes section without context.
B. Documenting the client’s history directly related to the current admission diagnoses ensures the information is relevant and addresses the issue at hand. It helps prioritize concerns specific to the new onset seizures.
C. Recording at the bedside can be useful for accuracy but is not as effective for thoroughness as
entering information directly in the client’s electronic medical record with appropriate organization.
D. Documenting assessment findings at the nursing station might delay real-time recording and cause the information to be less accurate, especially if not recorded immediately after assessment.

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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

Correct Answer is A

Explanation

The nurse is obtaining a health history for a client being admitted for new onset seizures. Which action should the nurse implement to accurately record the health history findings?

Correct Answer is B

Explanation

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