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?

Tonsil size is grade 5

Tonsil size is grade 3

Tonsil size is 2+

Tonsil size is 4+

Answer and Explanation

The Correct Answer is D

Choice A reason: There is no standard “grade 5” in tonsil size grading. The scale typically ranges from 0 to 4+, with 4+ indicating tonsils touching or overlapping, making this an incorrect and non-standard documentation term.

Choice B reason: Grade 3 tonsils are enlarged, occupying about 75% of the pharyngeal space, but not touching. The described tonsils are touching, which corresponds to a higher grade, making grade 3 incorrect for this finding.

Choice C reason: Grade 2+ tonsils are moderately enlarged, taking up about 50% of the pharyngeal space. The tonsils touching indicate a more severe enlargement, aligning with a higher grade, making this an incorrect documentation choice.

Choice D reason: Grade 4+ tonsils are severely enlarged, touching or overlapping in the midline, as described. This matches the standard tonsil grading scale, where 4+ indicates maximal swelling, making this the correct documentation.

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Correct Answer is C

Explanation

Choice A reason: Genital self-examination begins with inspection to observe abnormalities like swelling or lesions, followed by palpation to assess texture or masses. Starting with palpation may miss visual cues, making this sequence incorrect for effective self-examination.

Choice B reason: Testicular self-examination should be performed monthly, not yearly, to detect early changes like lumps, which could indicate testicular cancer. Annual exams are insufficient for timely detection, making this frequency incorrect for the teaching plan.

Choice C reason: Performing testicular self-examination while bathing is ideal, as warm water relaxes the scrotum, making it easier to palpate for abnormalities. This enhances detection of masses or irregularities, making it a key instruction for effective self-examination.

Choice D reason: Testicular self-examination is recommended for all adult males, not just those with prior cryptorchidism, which increases cancer risk. Restricting it to this group excludes others who could benefit from early detection, making this an incorrect limitation.

A. Check the light source of the ophthalmoscope to verify that it is functioning B. Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina C. Suspect that an opacity is present in the lens or cornea D. Stop the ophthalmoscopic examination, and refer the patient for further evaluation

Correct Answer is B

Explanation

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When teaching the patient about self-examination of the male genitalia, the nurse would include which instructions in the teaching plan?

Correct Answer is C

Explanation

In using the ophthalmoscope to assess a patient’s eyes, the nurse notices a red glow in the patient’s pupils. Based on this finding, what should the nurse do?

Correct Answer is B

Explanation

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