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 B
Explanation
Choice A reason: Food restrictions identify allergies or preferences, but not intake patterns. This limits nutritional status insight, missing recent consumption data critical for assessing current health, making it less foundational for this initial evaluation fully here.
Choice B reason: A 24-hour recall details recent intake, offering a snapshot of diet quality and quantity. This directly informs nutritional status, habits, and deficits, making it the most appropriate starting question for a comprehensive assessment accurately here.
Choice C reason: Family obesity history suggests genetic risk, not the client’s nutrition. This indirect data lacks specificity on current intake, rendering it less useful than a direct dietary recall for this nutritional assessment entirely and fully here.
Choice D reason: Meal frequency provides structure, not content or quality. It’s less informative than a 24-hour recall, which captures specifics of what’s eaten, making it secondary for initiating a detailed nutritional evaluation comprehensively here fully.
Correct Answer is D
Explanation
Choice A reason: Bilateral malalignment implies both eyes misalign variably, but esotropia specifies inward deviation, often unilateral. This vague term doesn’t match the precise diagnosis of esotropia present for five years, making it less expected here fully.
Choice B reason: Left eye turning outward is exotropia, not esotropia, which turns inward. This contradicts the client’s documented condition, misaligning with the expected inward deviation from cranial nerve VI or muscle imbalance entirely and accurately here.
Choice C reason: Oscillating eyes suggest nystagmus, not esotropia’s fixed inward turn. Esotropia is static misalignment, not rhythmic movement, excluding this as the priority finding for this client’s established eye condition in this exam fully here.
Choice D reason: Right eye turning inward fits esotropia, a common misalignment where one eye deviates medially. Given the five-year history, this is the expected external exam finding, reflecting the diagnosis accurately and consistently in this case here.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.