While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess?

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Vital Signs Assessment Chapter 7 Questions

Question 1 of 5

While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess?

Correct Answer: B

Rationale: With carcinoma, the initial lesion is round and indurated, but then it becomes crusted and ulcerated with an elevated border. Most cancers occur between the outer and middle thirds of the lip. Any lesion that is still unhealed after 2 weeks should be referred.

Question 2 of 5

The tissue that connects the tongue to the floor of the mouth is the:

Correct Answer: D

Rationale: The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth. The uvula is the free projection hanging down from the middle of the soft palate. The palate is the arching roof of the mouth. Papillae are the rough, bumpy elevations on the tongue's dorsal surface.

Question 3 of 5

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:

Correct Answer: C

Rationale: Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds.

Question 4 of 5

Which of the following is true regarding breast self-examination?

Correct Answer: C

Rationale: Although self-examination has not been shown to reduce mortality and is not recommended by all groups making screening recommendations, many choose to teach women a systematic method in which to examine their breasts. A high proportion of breast masses are detected by breast self-examination.

Question 5 of 5

The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child's respirations?

Correct Answer: A

Rationale: For irregular respiratory patterns, respirations should be counted for a full minute to ensure accuracy.

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