Author Question: While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ... (Read 116 times)

jake · **on:** Jun 25, 2018

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?
a.
Nutritional status
b.
When the patient first noticed the lesion
c.
Whether the patient has had a recent cold
d.
Whether the patient has had any recent exposure to sick animals

Question 2

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?
a.
Tell the patient she needs to see a skin specialist.
b.
Discuss the benefits of having a biopsy performed on any unusual lesion.
c.
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.
d.
Tell the patient that these vesicles are most likely the result of a riboflavin deficiency and discuss nutrition.

potomatos · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: B
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.

Answer to Question 2

ANS: C
Cold sores are groups of clear vesicles with a surrounding erythematous base. These evolve into pustules or crusts and heal in 4 to 10 days. The most likely site is the lip-skin junction. Infection often recurs in the same site. Recurrent herpes infections may be precipitated by sunlight, fever, colds, or allergy.