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    Wgu rn hesi health assessment proctored exam

    The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa- Which action should the nurse take?

    Explanation & Rationale

    A. Document this finding in the medical record: Patchy discoloration in the buccal mucosa may be normal in clients with darkly pigmented skin, often resulting from racial pigmentation variations. Documenting the finding helps monitor it over time for any changes. B. Ask the client about use of irritating chemical agents: While chemical agents could cause irritation or staining, it is more common in individuals with lighter skin. This is less likely the cause here. C. Schedule an appointment with a dermatologist: Referral to a dermatologist is unnecessary unless other signs suggest a condition like oral melanoma or other serious concerns. D. Ask if the client recently received any antibiotics: Antibiotic use can cause oral changes, but there is no immediate link to discoloration in this case.

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