During a routine checkup, a nurse observes that a 4-year-old child has noticeably enlarged tonsils but is otherwise healthy with no signs of infection. The child's parents express concern. Which statement BEST explains this finding?
Lymphoid tissue, including tonsils, normally enlarges in early childhood and may exceed adult size before gradually shrinking in adolescence.
This finding is abnormal and warrants an urgent referral to an ENT specialist.
The enlarged tonsils suggest the child's immune system is underdeveloped.
The enlarged tonsils indicate a chronic infection that requires immediate antibiotic treatment.
The Correct Answer is A
A. Tonsils are part of the lymphatic system, which is most active in early childhood to help the body respond to infections and build immunity. It is common for tonsils to appear large in healthy children between ages 3 and 6. This is a normal physiological finding and usually does not indicate illness unless accompanied by symptoms such as fever, difficulty breathing, or recurrent infections.
B. While significantly enlarged tonsils causing airway obstruction, sleep apnea, or recurrent infections may require evaluation, tonsillar enlargement alone in an otherwise healthy child is typically normal and does not require urgent referral.
C. Enlarged tonsils in this age group indicate a normally active immune system, not underdevelopment. They help the body recognize and respond to antigens, supporting healthy immune function.
D. Chronic or acute infections may cause tonsillar enlargement, but in the absence of symptoms such as fever, redness, or exudate, there is no evidence of infection, and antibiotics are not indicated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Infants cannot verbally communicate pain, so nurses rely on observational cues. Pulling at the ear, arching the back, grimacing, and irritability are valid behavioral indicators of pain and help guide assessment of location and severity. Combining these with physiological signs, such as increased heart rate or changes in respiratory pattern, provides a comprehensive understanding of the infant’s pain.
B. Physiological indicators like tachycardia, hypertension, or increased respiratory rate are nonspecific and may reflect stress, fever, or other illness, so relying solely on them is inadequate for pain assessment.
C. Infants cannot verbalize pain, but behavioral cues are well-recognized and validated indicators of pain. Assuming pain cannot be assessed without speech is inaccurate.
D. Infants do not exhibit pain behaviors to manipulate caregivers. Behaviors such as ear pulling, back arching, and grimacing are genuine indicators of discomfort or pain and should be taken seriously.
Correct Answer is ["A"]
Explanation
A. The client shows signs of magnesium sulfate toxicity: oliguria (urine output <30 mL/hr) and absent deep-tendon reflexes. These are potentially life-threatening signs that require immediate intervention, including preparing for emergent delivery if maternal or fetal status is unstable. Stopping the magnesium infusion and preparing for emergency interventions is critical.
B. Administering Vitamin K is not indicated in this scenario. Vitamin K is used to treat or prevent coagulopathy, such as in newborns or clients on certain anticoagulants, but it does not counteract magnesium toxicity.
C. Increasing the magnesium sulfate infusion would worsen toxicity. The correct action is to stop the infusion immediately and prepare to administer calcium gluconate as an antidote if prescribed.
D. Assessing maternal glucose levels is unrelated to the immediate concern of magnesium toxicity. While glucose monitoring may be part of overall prenatal care, it is not a priority in this emergent situation.
E. Placing the client in Trendelenburg position is not indicated. Positioning does not treat magnesium toxicity and could worsen respiratory compromise in a client with severe preeclampsia. The priority is stopping magnesium, assessing maternal and fetal status, and preparing for emergency delivery if necessary.
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