The nurse assesses an older client reporting mouth pain. What additional actions should the nurse take at this time? Select all that apply.

Question

1. Review vital sign trends.
2. Auscultate all lung fields.
3. Palpate the face for tenderness.
4. Assess the client's oral mucosa.
5. Feel for enlarged lymph nodes around the jawline.

Answer 1

1. Review vital sign trends.
2. Auscultate all lung fields.
5. Feel for enlarged lymph nodes around the jawline.

Explanation: 1. When older clients complain of mouth pain the vital signs should be checked to rule out an acute infection.
2. If other assessment data leads the nurse to think respiratory function is decreased, then this is appropriate. Reports of mouth pain does not immediately implicate respiratory issues.
3. Other causes of mouth pain can include neurological conditions or sinus infection.
4. Oral mucosa is assessed for sores, white patches, or other abnormalities.
5. Clients with a dental abscess will often have swollen or enlarged lymph nodes under the ear or jaw.