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 D

Explanation

A. Perform the confrontation test:

The confrontation test is a basic visual field screening test. It assesses the peripheral vision by having the patient cover one eye and the examiner covers the opposite eye. The patient and the examiner then bring their fingers into the visual field from the periphery, and the patient indicates when they see the fingers.

B. Ask the patient to read the print on a handheld Jaeger card:

Jaeger cards are used for near vision testing. The patient reads progressively smaller print to assess their near vision acuity.

C. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches:

This method assesses near vision. It is often used informally in clinical settings, where the patient is asked to read a newspaper or similar print at a comfortable reading distance.

D. Use the Snellen chart positioned 20 feet away from the patient:

The Snellen chart is a standardized chart used for visual acuity testing. It is placed 20 feet away from the patient, and the patient is asked to read the letters or symbols on the chart with one eye covered at a time.

A. Frenulum B. Palate C. Uvula D. Papillae.

Correct Answer is A

Explanation

A. Frenulum:

The frenulum is a thin band of tissue in the mouth that connects the tongue to the floor of the mouth. It aids in the tongue's movement and flexibility during speaking and swallowing.

B. Palate:

The palate refers to the roof of the mouth. It has two parts: the hard palate (at the front, made of bone) and the soft palate (at the back, made of muscle). The palate plays a crucial role in speech and swallowing.

C. Uvula:

The uvula is a small, fleshy extension at the back of the soft palate in the mouth. It participates in various functions, including speech articulation, preventing food from entering the nasal cavity during swallowing, and producing certain sounds.

D. Papillae:

Papillae are small, raised structures on the tongue that contain taste buds. They are responsible for detecting different tastes: sweet, salty, sour, bitter, and umami (savory). Papillae give the tongue its rough texture.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to assess the visual acuity of an adult patient, which of the following assessment should the nurse use for visual acuity

Correct Answer is D

Explanation

The nurse is performing an assessment of the client's mouth. The nurse recognizes that the tissue that connects the tongue to the floor of the mouth is the:

Correct Answer is A

Explanation

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