The nurse's comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages?

Presence of a painless sore with raised edges

Diffuse inflammation of the buccal mucosa

Dull pain radiating to the ears and teeth

Areas of tenderness that make chewing difficult

Answer and Explanation

The Correct Answer is A

Choice A reason:

A painless sore with raised edges is a characteristic early sign of oral cancer. It may appear as a small, painless lump or sore in the mouth, often with raised edges. This finding should raise suspicion and prompt further evaluation.

Choice B reason:

Diffuse inflammation of the buccal mucosa is a non-specific finding and can be caused by various factors, including infection or irritation. While it's important to assess the oral mucosa for any abnormalities, it is not specific to oral cancer.

Choice C reason:

Dull pain radiating to the ears and teeth is not a characteristic early sign of oral cancer. Pain associated with oral cancer may occur in later stages or if there is local invasion of nerves.

Choice D reason:

Areas of tenderness that make chewing difficult may occur for various reasons, including dental issues or other oral health problems. While this can be distressing for the patient, it is not specific to oral cancer.

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Correct Answer is C

Explanation

Choice A reason:

A shiny, moist stoma is generally a healthy sign, indicating good blood supply and adequate hydration of the stoma tissue. It is not a cause for concern.

Choice B reason:

A rosebud-like stoma orifice is a normal appearance for some types of stomas. It indicates a healthy stoma with good blood supply. This finding is expected and does not warrant concern.

Choice C reason:

A purplish-colored stoma may indicate compromised blood supply to the stoma, which is a serious concern and should be reported to the provider promptly. It may suggest inadequate blood flow to the stoma, which could lead to tissue necrosis.

Choice D reason:

Stoma oozing red drainage may be normal immediately postoperatively. It can be due to some oozing from the surgical site, and if it's minimal and stops after a short while, it's generally not a cause for concern.

A. Remove the NG tube promptly and obtain an order for reinsertion from the primary care provider. B. Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating. C. Withdraw the NG tube slightly and attempt to dislodge by flicking the tube with the fingers. D. Withdraw the NG tube 3 to 5 cm and reattempt aspiration.

Correct Answer is B

Explanation

Choice A reason:

Removing the NG tube without further attempts to unclog it may not be necessary and could be an unnecessary intervention.

Choice B reason:

This statement is correct. Attempting to unclog the NG tube with warm water and an in-and-out motion is an appropriate next step.

Choice C reason:

Flicking the tube with the fingers may not be effective in dislodging the clog, and it could potentially cause harm to the patient.

Choice D reason:

Withdrawing the tube 3 to 5 cm may not effectively address the clog and could potentially lead to complications.

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The nurse's comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages?

Nursing Test Bank

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