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 B
Explanation
A. Glandular tissue, which supports the breast by attaching to the chest wall: Glandular tissue is indeed a part of the breast structure, but it is not responsible for supporting the breast by attaching to the chest wall. It's the Cooper's ligaments, which are fibrous connective tissue, that provide structural support.
B. Fibrous, glandular, and adipose tissues: This statement is correct. The breast is composed of glandular tissue (responsible for milk production), fibrous tissue (including Cooper's ligaments for support), and adipose tissue (fat).
C. Primarily muscle with very little fibrous tissue: The breast contains very little muscle tissue. The main supportive structure is fibrous tissue, not muscle.
D. Primarily milk ducts, known as lactiferous ducts: Milk ducts are part of the glandular tissue and are responsible for carrying milk. However, the breast is not primarily made up of milk ducts; it consists of a combination of glandular, fibrous, and adipose tissues.
Correct Answer is D
Explanation
A. Indicates the beginning of diastole: This statement is not accurate. S2, the second heart sound, indicates the end of systole and the beginning of diastole. It is specifically associated with the closure of the aortic and pulmonary valves.
B. Coincides with the carotid artery pulse: This statement is not accurate. S2 is associated with the closure of the aortic and pulmonary valves in the heart, not with the carotid artery pulse.
C. Is louder than an S1: This statement is not accurate. S1, the first heart sound, is usually louder than S2. S1 is associated with the closure of the mitral and tricuspid valves and marks the beginning of systole.
D. Is caused by the closure of the semilunar valves: This statement is accurate. S2 is caused by the closure of the aortic and pulmonary valves, which are the semilunar valves in the heart. It marks the end of systole and the beginning of diastole.
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