A nurse is assessing the tonsils of a client and notes that the tonsils are involuted, granular in appearance, and have deep crypts. nurse should recognize that which of the following is the correct response to these findings?

Obtain a throat culture for possible streptococcal (strep) infection

Continue with the assessment, looking for any other abnormal findings

Refer the client to their primary provider

No response is needed; this appearance is normal for the tonsils

Answer and Explanation

The Correct Answer is D

A) Obtain a throat culture for possible streptococcal (strep) infection:
A throat culture would be indicated if the client presents with symptoms of a strep throat infection, such as a sore throat, fever, or difficulty swallowing. However, the description of involuted, granular tonsils with deep crypts is typically a normal finding, particularly in adults. This appearance is not suggestive of a bacterial infection like strep throat, which usually presents with signs of acute inflammation, exudates, or tenderness. Therefore, a throat culture is not necessary based on these findings alone.

B) Continue with the assessment, looking for any other abnormal findings:
While continuing the assessment is important in any physical exam, the appearance of granular, involuted tonsils with deep crypts is generally considered a normal anatomical variation, particularly in adults. There is no indication of an abnormality that would require further investigation unless other concerning symptoms are present. If no other abnormal findings are identified, no additional action is needed at this point.

C) Refer the client to their primary provider:
Referral to a primary provider would be appropriate if there were signs of infection, significant symptoms, or concerns about the tonsils, such as severe swelling, pain, or visible pus. However, the description of the tonsils as involuted and granular, with deep crypts, does not suggest a need for referral. This is a normal variation, and no referral is necessary unless other abnormal findings or symptoms are present.

D) No response is needed; this appearance is normal for the tonsils:
This is the correct response. Tonsils can naturally become more granular and involuted (shrunken or indented) as a person ages. The deep crypts are also a normal feature of tonsils and do not necessarily indicate pathology. These findings are typically seen in adults and do not require intervention unless accompanied by signs of infection or other abnormalities. Therefore, no further action is necessary for this normal anatomical appearance.

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Correct Answer is A

Explanation

A) Whisper random numbers and letters, then have the client repeat them:
This is correct. The voice test is a simple way to assess a client's hearing. The nurse should stand about 2 feet away from the client and whisper random numbers or letters. The client should repeat what they hear. This test checks the ability to hear and distinguish sounds, particularly for high-frequency tones. It's an effective screening method for detecting hearing loss.

B) Shield the lips so that the sound is muffled:
This is incorrect. The nurse should not shield their lips during the voice test because it could interfere with the client's ability to hear and potentially read the nurse's lips, which can help with understanding. The client should be allowed to observe lip movements to aid in comprehension of the sounds being spoken.

C) Stand approximately 4 feet away from the client:
This is incorrect. The recommended distance for performing the voice test is typically around 2 feet, not 4 feet. Standing too far away can make it more difficult for the client to hear the whispered numbers or letters and could affect the accuracy of the test. The nurse should stand close enough (about 2 feet) to ensure that the sound is audible to the client but not too close as to distort the test.

D) Have the client place a finger in the ear canal to occlude outside noise:
This is incorrect. While the client should be instructed to avoid distractions or loud environments during the test, placing a finger in the ear canal is not necessary. The test assesses the client's ability to hear sound, and occluding the ear could affect the results. The client should simply be in a quiet environment.

A. Lid lag when moving the eyes from a superior to an inferior position B. Nystagmus when reading the Snellen chart C. Parallel movement of both eyes D. Convergence of the eyes

Correct Answer is C

Explanation

A) Lid lag when moving the eyes from a superior to an inferior position:
This is incorrect. Lid lag refers to a delay in the movement of the eyelid as the eyes move downward. It is considered an abnormal finding and is often associated with conditions like hyperthyroidism (Graves' disease), where the eyelid does not follow the downward gaze appropriately. In the diagnostic positions test, normal eye movement should not include lid lag.

B) Nystagmus when reading the Snellen chart:
This is incorrect. Nystagmus is an involuntary, rhythmic oscillation of the eyes, which can be indicative of a neurological or vestibular issue. It is not a normal finding during the diagnostic positions test. Nystagmus may be seen with certain disorders, such as vestibular dysfunction, neurologic damage, or alcohol intoxication, but it should not occur as a normal response to eye movement during the diagnostic positions test.

C) Parallel movement of both eyes:
This is the correct answer. In a normal result of the diagnostic positions test, both eyes should move in parallel and remain aligned during all directions of gaze. The purpose of this test is to assess for any eye muscle weakness or cranial nerve dysfunction that might cause misalignment, such as strabismus or a disorder affecting the extraocular muscles. If both eyes track smoothly and simultaneously without deviation or lag, this is a normal and expected finding.

D) Convergence of the eyes:
This is incorrect. While convergence (the inward movement of both eyes toward the nose) is a normal response when focusing on a near object, it is not the specific goal of the diagnostic positions test. The diagnostic positions test is primarily concerned with assessing the ability of the eyes to move together in all directions of gaze without misalignment or abnormal movement. While convergence is a sign of normal eye function, it is not the primary focus of this particular test.

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A nurse is assessing the tonsils of a client and notes that the tonsils are involuted, granular in appearance, and have deep crypts. nurse should recognize that which of the following is the correct response to these findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a voice test to assess a client's hearing. Which of these actions should the nurse perform?

Correct Answer is A

Explanation

A nurse is performing the diagnostic positions test. The nurse recognizes that normal findings from the diagnostic positions test should be which of these results?

Correct Answer is C

Explanation

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