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 C
Explanation
In this sequence:
Vena cava brings deoxygenated blood from the body into the right atrium.
Blood flows from the right atrium to the right ventricle through the tricuspid valve.
The right ventricle pumps blood into the pulmonary artery to the lungs.
In the lungs, blood is oxygenated and returns to the heart via the pulmonary veins into the left atrium.
From the left atrium, blood moves to the left ventricle through the bicuspid (mitral) valve.
The left ventricle then pumps oxygenated blood into the body through the aorta.
This sequence represents the systemic and pulmonary circulation of the heart.
Correct Answer is A
Explanation
A. Auricle (Pinna):
The auricle, also known as the pinna, is the visible external part of the ear. It consists of movable cartilage and skin. When administering eardrops, pulling the auricle up and back helps to straighten the ear canal, allowing the drops to enter the ear effectively.
B. Mastoid Process:
The mastoid process is a bony prominence located behind the ear. It is not a part of the outer ear structure involved in administering eardrops.
C. Outer Meatus:
The outer meatus, also known as the external acoustic meatus or ear canal, is the tube-like structure leading from the auricle to the eardrum. It is the passage through which eardrops are administered. Pulling the auricle up and back helps to straighten the outer meatus for the proper administration of eardrops.
D. Concha:
The concha refers to the bowl-shaped depression next to the ear canal. While it is a part of the outer ear, pulling the concha is not a technique used for administering eardrops. The auricle, specifically, is manipulated to facilitate the process.
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