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The nurse is obtaining a health history on a 3-month-old infant. During the interview, the
mother states, I think she is getting her first tooth because she has started drooling a lot. The
nurses best response would be:
She is just starting to salivate and hasn't learned to swallow the saliva
The nurse is assessing an 80-year-old patient. Which of these findings would be expected for
this patient?
Decreased ability to identify odors
The nurse is performing an oral assessment on a 40-year-old Black patient and notices the
presence of a 1 cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of
these statements is true? This lesion is:
Leukoedema and is common in dark-pigmented persons
While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and
asks the best way to get them to stop. What would be the nurses best response?
Sit up with your head tilted forward and pinch your nose.
A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might
also suspect which of these assessment findings?
Dysphagia
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,While obtaining a health history from the mother of a 1-year-old child, the nurse notices that
the baby has had a bottle in his mouth the entire time. The mother states, It makes a great
pacifier. The best response by the nurse would be:
Prolonged use of a bottle can increase the risk for tooth decay and ear infections.
A 72-year-old patient has a history of hypertension and chronic lung disease. An important
question for the nurse to include in the health history would be:
Have you noticed any dryness in your mouth?
The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct?
Avoiding touching the nasal septum with the speculum
The nurse is performing an assessment on a 21-year-old patient and notices that his nasal
mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask
the patient?
Are you aware of having any allergies?
The nurse is palpating the sinus areas. If the findings are normal, then the patient should report
which sensation?
Firm pressure
During an oral assessment of a 30-year-old Black patient, the nurse notices bluish lips and a dark
line along the gingival margin. What action would the nurse perform in response to this finding?
Proceed with the assessment, knowing that this appearance is a normal finding.
During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the
nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective
of:
Dehydration
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, A 32-year-old woman is at the clinic for little white bumps in my mouth. During the assessment,
the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on
the mucosa of her right cheek. What would the nurse tell the patient?
These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition.
A 10 year old is at the clinic for a sore throat that has lasted 6 days. Which of these findings
would be consistent with an acute infection?
Tonsils 3+/1-4+ with large white spots
Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is
made to pass a catheter through both nasal cavities with no success. What should the nurse do
next?
Recognize that this situation requires immediate intervention.
The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently
for various injuries and suspects there may be some child abuse involved. During an inspection
of his mouth, the nurse should look for:
Bruising on the buccal mucosa or gums.
The nurse is assessing a 3 year old for drainage from the nose. On assessment, a purulent
drainage that has a very foul odor is noted from the left naris and no drainage is observed from
the right naris. The child is afebrile with no other symptoms. What should the nurse do next?
Perform an otoscopic examination of the left nares.
During an assessment of a 26 year old at the clinic for a spot on my lip I think is cancer, the
nurse notices a group of clear vesicles with an erythematous base around them located at the
lip-skin border. The patient mentions that she just returned from Hawaii. What would be the
most appropriate response by the nurse?
Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they
will heal in 4 to 10 days.
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