The nurse is assessing the tonsils of an adult client. The nurse notices that the tonsils are involuted, granular in appearance, and has deep crypts. The nurse recognizes that which of the following is the correct response to these findings?
Continue with the assessment, looking for any other abnormal findings.
Refer the patient to a throat specialist.
No response is needed; this appearance is normal for the tonsils.
Obtain a throat culture on the patient for possible streptococcal (strep) infection.
The Correct Answer is A
A. Continue with the assessment, looking for any other abnormal findings: This is the correct response. Tonsils in adults can have various appearances, and a granular appearance with deep crypts is within the range of normal. It's essential for the nurse to continue the assessment and observe for other signs or symptoms that might indicate an issue.
B. Refer the patient to a throat specialist: Referring the patient based solely on the appearance of the tonsils, especially if it's a normal variant, might be unnecessary and could cause undue concern for the patient. It's important to assess the patient comprehensively before considering a specialist referral.
C. No response is needed; this appearance is normal for the tonsils: This is the correct explanation. In adults, tonsils often appear granular with deep crypts, which is considered a normal variation. No further action is required regarding the tonsils.
D. Obtain a throat culture on the patient for possible streptococcal (strep) infection: Based on the description provided (involution, granular appearance, and deep crypts), there's no specific indication of a streptococcal infection. Conducting a throat culture should be based on the presence of specific symptoms and signs indicative of a streptococcal infection, such as sore throat, fever, and swollen tonsils with white patches, rather than just the appearance of the tonsils.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Continue with the assessment, looking for any other abnormal findings: This is the correct response. Tonsils in adults can have various appearances, and a granular appearance with deep crypts is within the range of normal. It's essential for the nurse to continue the assessment and observe for other signs or symptoms that might indicate an issue.
B. Refer the patient to a throat specialist: Referring the patient based solely on the appearance of the tonsils, especially if it's a normal variant, might be unnecessary and could cause undue concern for the patient. It's important to assess the patient comprehensively before considering a specialist referral.
C. No response is needed; this appearance is normal for the tonsils: This is the correct explanation. In adults, tonsils often appear granular with deep crypts, which is considered a normal variation. No further action is required regarding the tonsils.
D. Obtain a throat culture on the patient for possible streptococcal (strep) infection: Based on the description provided (involution, granular appearance, and deep crypts), there's no specific indication of a streptococcal infection. Conducting a throat culture should be based on the presence of specific symptoms and signs indicative of a streptococcal infection, such as sore throat, fever, and swollen tonsils with white patches, rather than just the appearance of the tonsils.
Correct Answer is A
Explanation
A. The pupils constrict when the examiner's index finger slowly moves toward the client's nose.
This statement is correct. Visual accommodation is the process by which the eye's lens changes shape to focus on objects at varying distances. When an object moves closer to the eyes, the pupils constrict to adjust and focus on the near object, preventing double vision.
B. The client involuntarily blinks in the presence of bright light directed over the pupils during the eye exam.
This statement describes the pupillary light reflex, not visual accommodation. The pupillary light reflex is the response of the pupils to light exposure.
C. The client's peripheral vision becomes sharper when the examiner shines a light over the pupils.
This statement is not accurate. Peripheral vision sharpness is not related to visual accommodation. Visual accommodation mainly involves adjusting focus for objects at varying distances.
D. The pupils dilate when the examiner's index finger slowly moves toward the client's nose.
This statement is incorrect. Pupils should constrict, not dilate, when focusing on a near object (as in visual accommodation). Dilation occurs in low-light conditions or in response to sympathetic stimulation.
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