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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period:

This statement is correct. Performing BSE a few days after the menstrual period ensures that the breasts are less likely to be swollen or tender, which can make it easier to detect any unusual changes.

B. If she suspects that she is pregnant, then the woman should not perform a BSE until her baby is born:

This statement is incorrect. Pregnant women can still perform breast self-examinations. In fact, it's important for pregnant women to be aware of any changes in their breasts.

C. The best time to perform BSE is in the middle of the menstrual cycle:

This statement is not as accurate as the first choice. While it's true that performing BSE a few days after the menstrual period can be easier due to reduced breast tenderness, it doesn't necessarily mean the middle of the menstrual cycle for every woman. The timing can vary based on an individual's menstrual cycle.

D. The woman needs to perform BSE only bimonthly unless she has fibrocystic breast tissue:

This statement is incorrect. Regular monthly breast self-examinations are recommended for all women, regardless of whether they have fibrocystic breast tissue or not. Detecting changes early is crucial for breast health.

A. The third heart sound (S3) B. A friction rub C. The fourth heart sound (S4) D. A split second heart sound S2

Correct Answer is A

Explanation

A. The third heart sound (S3):

The third heart sound (S3) is an abnormal heart sound that occurs during early diastole, immediately after S2 (the second heart sound). It is caused by the rapid filling of the ventricles and is often associated with conditions like heart failure. In heart failure, the ventricles become stiff, causing vibrations that produce the S3 sound.

B. A friction rub:

A friction rub is a high-pitched, scratchy sound heard during both systole and diastole. It is caused by the rubbing together of inflamed pericardial layers (pericarditis) and is usually heard best at the left lower sternal border. Friction rubs can indicate pericardial inflammation and are often heard in conditions such as pericarditis or after a myocardial infarction.

C. The fourth heart sound (S4):

The fourth heart sound (S4) occurs late in diastole, just before S1, and is caused by atrial contraction. It is associated with increased resistance to ventricular filling, often due to conditions like hypertension or aortic stenosis. The S4 sound is heard as a low-pitched "atrial gallop."

D. A split second heart sound S2:

The second heart sound (S2) represents the closure of the aortic and pulmonic valves. Normally, S2 has two components: A2 (aortic valve closure) and P2 (pulmonic valve closure). A split S2 occurs when A2 and P2 do not close simultaneously. A physiological split S2 is common during inspiration and occurs due to delayed closure of the pulmonic valve. An abnormal or fixed split S2 can indicate underlying heart conditions such as atrial septal defect (ASD) or right bundle branch block (RBBB).

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is conducting a class on Breast Self Examination (BSE). The nurse should include which of these statements that indicates the proper BSE technique.

Correct Answer is A

Explanation

The nurse is auscultating heart sounds on a client and hears an extra sound late in diastole, just before the S1. How should the nurse document this finding?

Correct Answer is A

Explanation

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