A nurse is assessing the tonsils of a client and notes that the tonsils are involuted, granular in appearance, and have deep crypts. nurse should recognize that which of the following is the correct response to these findings?

Obtain a throat culture for possible streptococcal (strep) infection

Continue with the assessment, looking for any other abnormal findings

Refer the client to their primary provider

No response is needed; this appearance is normal for the tonsils

Answer and Explanation

The Correct Answer is D

A) Obtain a throat culture for possible streptococcal (strep) infection:
A throat culture would be indicated if the client presents with symptoms of a strep throat infection, such as a sore throat, fever, or difficulty swallowing. However, the description of involuted, granular tonsils with deep crypts is typically a normal finding, particularly in adults. This appearance is not suggestive of a bacterial infection like strep throat, which usually presents with signs of acute inflammation, exudates, or tenderness. Therefore, a throat culture is not necessary based on these findings alone.

B) Continue with the assessment, looking for any other abnormal findings:
While continuing the assessment is important in any physical exam, the appearance of granular, involuted tonsils with deep crypts is generally considered a normal anatomical variation, particularly in adults. There is no indication of an abnormality that would require further investigation unless other concerning symptoms are present. If no other abnormal findings are identified, no additional action is needed at this point.

C) Refer the client to their primary provider:
Referral to a primary provider would be appropriate if there were signs of infection, significant symptoms, or concerns about the tonsils, such as severe swelling, pain, or visible pus. However, the description of the tonsils as involuted and granular, with deep crypts, does not suggest a need for referral. This is a normal variation, and no referral is necessary unless other abnormal findings or symptoms are present.

D) No response is needed; this appearance is normal for the tonsils:
This is the correct response. Tonsils can naturally become more granular and involuted (shrunken or indented) as a person ages. The deep crypts are also a normal feature of tonsils and do not necessarily indicate pathology. These findings are typically seen in adults and do not require intervention unless accompanied by signs of infection or other abnormalities. Therefore, no further action is necessary for this normal anatomical appearance.

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Correct Answer is B

Explanation

A) The eye focuses the image in the center of the pupil:
This option describes the accommodation reflex, not the pupillary light reflex. The accommodation reflex involves the focusing of the eye to bring an image to the center of the retina, but it does not relate to the constriction of the pupils in response to light. Therefore, it is not the correct answer for describing the pupillary light reflex.

B) Constriction of both pupils occurs in response to bright light:
This is the correct description of the pupillary light reflex. When light is shined into one eye, the normal response is for both pupils (direct and consensual response) to constrict. The pupillary light reflex tests the integrity of the optic nerve (cranial nerve II) and the oculomotor nerve (cranial nerve III), which control the constriction of the pupil in response to light. A normal pupillary light reflex is characterized by the constriction of both pupils when exposed to light.

C) The eye focuses the light on the sclera:
This statement is inaccurate. The sclera is the white part of the eye, and light is focused on the retina (specifically the fovea) for proper vision. This does not relate to the pupillary light reflex, which specifically refers to the constriction of the pupils in response to light.

D) Dilation of both pupils occurs in response to bright light:
This is incorrect. Dilation of the pupils occurs in low light conditions as part of the pupillary dilation reflex (also called the "dark reflex") to allow more light into the eye. However, in response to bright light, the pupils constrict, not dilate. The constriction of the pupils in bright light is the primary characteristic of a normal pupillary light reflex.

A. Both lungs are equal in size with varying numbers ‹ lobes B. The diaphragm rises in the chest during inspiration C. The left lung has two lobes to make room for the heart D. The right lung has two lobes to make room for the liver

Correct Answer is C

Explanation

A) Both lungs are equal in size with varying numbers of lobes:
This is incorrect. The right lung is slightly larger than the left lung, as the left lung is somewhat smaller to accommodate the heart. The right lung has three lobes, while the left lung has only two lobes.

B) The diaphragm rises in the chest during inspiration:
This is incorrect. During inspiration (inhalation), the diaphragm contracts and moves downward to allow the lungs to expand and fill with air. It rises during exhalation as it relaxes and pushes air out of the lungs.

C) The left lung has two lobes to make room for the heart:
This is correct. The left lung has two lobes (upper and lower) compared to the three lobes of the right lung. The left lung is slightly smaller due to the space the heart occupies on the left side of the chest, allowing for asymmetry between the two lungs.

D) The right lung has two lobes to make room for the liver:
This is incorrect. The right lung has three lobes, not two. The liver is located lower in the abdomen and does not influence the number of lobes in the right lung. The asymmetry of the lungs is due to the position of the heart on the left side of the chest.

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A nurse is assessing the tonsils of a client and notes that the tonsils are involuted, granular in appearance, and have deep crypts. nurse should recognize that which of the following is the correct response to these findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse document that a client has a normal pupillary light reflex. The nurse should recognize that this reflex indicates which of the following?

Correct Answer is B

Explanation

A nurse is performing a lung assessment on a client. The nurse should understand which information about lung structures?

Correct Answer is C

Explanation

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