A nurse in the emergency center is assessing the tonsils of a patient and observes that the tonsils are swollen to the point of touching. How should the nurse document this finding?

Choice A reason: Measuring respirations during pulse assessment can lead to inaccurate counts, as patients may alter their breathing when aware of pulse measurement. Conscious awareness often causes irregular or controlled breathing, which does not reflect the true respiratory rate, making this an unreliable time.

Choice B reason: Auscultation involves listening to lung or heart sounds, which requires patient cooperation and often affects breathing patterns. Patients may consciously modify their respirations during this process, leading to inaccurate respiratory rate measurements, rendering this an unsuitable time for assessment.

Choice C reason: Interviewing involves patient interaction, which can influence breathing due to speech or emotional responses. This conscious activity often results in irregular or controlled breathing patterns, making it an unreliable time to accurately measure the patient’s natural respiratory rate.

Choice D reason: Measuring respirations when the patient is sleeping ensures an undisturbed, natural breathing pattern, as the patient is unaware of the assessment. This allows the nurse to count the respiratory rate accurately, reflecting the true resting state, making it the optimal time.

Choice A reason: Checking the ophthalmoscope’s light source is unnecessary unless the device malfunctions. The red glow is a normal finding, reflecting light off the retina’s blood vessels, not indicating equipment issues, making this an inappropriate action.

Choice B reason: The red glow, or red reflex, is a normal finding during ophthalmoscopy, caused by light reflecting off the vascular retina. It indicates a clear optical pathway, ruling out opacities like cataracts, making this the correct action to document as normal.

Choice C reason: An opacity in the lens or cornea (e.g., cataract or corneal scar) would block the red reflex, causing a dark or absent glow. The presence of a red glow indicates a clear media, making this suspicion incorrect.

Choice D reason: Stopping the exam and referring the patient is unwarranted, as the red glow is a normal finding. Referral is only needed for abnormal findings like absent reflex or opacities, making this an unnecessary and incorrect action.