During an inspection of a client's tonsils with a penlight and tongue depressor, the nurse notes that the tonsils contact the client's uvula. The patient states they have had a sore throat and have been using lidocaine spray as directed by the provider. What would be the most accurate documentation of this finding?
4+
1+
2+
3+
The Correct Answer is A
Choice A reason: Tonsils touching the uvula indicate 4+ grading, where they obstruct over 75% of the oropharynx. This severe enlargement, with sore throat, fits the highest scale, reflecting significant inflammation or infection impacting airway and swallowing, accurately documented here.
Choice B reason: 1+ tonsils are slightly enlarged, less than 25% of the oropharynx, visible but not near the uvula. This underestimates the finding of tonsils contacting the uvula, misrepresenting the degree of obstruction and inflammation present in this case entirely.
Choice C reason: 2+ tonsils occupy 25-50% of the oropharynx, not touching the uvula. This moderate grade doesn’t match the observed contact, understating the severity of enlargement and potential airway compromise noted during the inspection clearly and significantly.
Choice D reason: 3+ tonsils cover 50-75% of the oropharynx, nearing but not contacting the uvula. This is close but inaccurate, as the finding shows full contact, warranting the higher 4+ grade for precise documentation of this advanced tonsillar size fully.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: BPH, a benign growth, doesn’t increase prostate cancer risk; they’re distinct conditions. This reassures the client factually, addressing his fear directly with evidence, making it the most appropriate and supportive response in this context accurately.
Choice B reason: Testicular self-exams check testes, not prostate. This misdirects from BPH and prostate cancer concerns, offering irrelevant advice that fails to address the client’s specific fear about his diagnosis and its implications entirely here fully.
Choice C reason: Prostate cancer isn’t rare at 53; incidence rises with age. This false reassurance dismisses real risk, undermining trust and education, making it less appropriate than clarifying BPH’s non-link to cancer in this scenario comprehensively here.
Choice D reason: While true, prostate cancer’s slow growth doesn’t address BPH’s relation to it. This generic statement misses the client’s core fear about BPH as a risk factor, rendering it less targeted than the direct clarification fully here.
Correct Answer is B
Explanation
Choice A reason: Loss of tactile sensation ties to parietal lobe damage, not frontal. A frontal contusion affects executive function and speech, not sensory processing, making this finding less likely given the injury’s location in this trauma scenario fully.
Choice B reason: Difficulty speaking, like Broca’s aphasia, is common with frontal lobe contusions, as this area houses speech production centers. Post-accident, this aligns with damage to motor speech pathways, making it the most probable finding here accurately.
Choice C reason: Blurred vision relates to occipital or optic nerve injury, not frontal lobe. A contusion here impacts cognition or speech, not visual processing, rendering this less expected than speech issues in this head injury context entirely.
Choice D reason: Inability to hear high-pitched sounds involves cranial nerve VIII or temporal lobe, not frontal. This contusion affects behavior and speech, not auditory function, excluding this as a primary finding in this frontal damage case fully.
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