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","C","D","E"]
Explanation
A. Age: While age itself is not modifiable, it is included in the list because aging increases the risk of developing cardiovascular disease. However, individuals cannot change their age, so it is not a modifiable risk factor.
B. Smoking: Smoking is a significant risk factor for cardiovascular disease. It damages the heart and blood vessels and can lead to atherosclerosis (narrowing and hardening of the arteries), which can result in heart attacks and strokes.
C. Hypertension: High blood pressure is a leading cause of cardiovascular disease. It can damage the arteries over time, making them more susceptible to atherosclerosis.
D. Diabetes: Diabetes, especially if poorly controlled, increases the risk of cardiovascular disease. High blood sugar levels can damage the blood vessels and the heart.
E. High cholesterol: Elevated levels of cholesterol, especially low-density lipoprotein (LDL) cholesterol, can lead to the buildup of plaque in the arteries, increasing the risk of atherosclerosis and cardiovascular events.
Correct Answer is B
Explanation
A. AV node - SA node - bundle of His - bundle branches:
This sequence is incorrect. The SA node (sinoatrial node) initiates the electrical impulse in the heart, followed by the AV node (atrioventricular node), bundle of His, and then the bundle branches.
B. SA node - AV node - bundle of His - bundle branches:
This sequence is correct. The electrical stimulus of the cardiac cycle starts at the SA node, which is the natural pacemaker of the heart. From the SA node, the impulse travels to the AV node, then to the bundle of His, and finally to the bundle branches, which distribute the impulse to the ventricles, causing them to contract.
C. Bundle of His - AV node - SA node - Erb's Point:
This sequence is incorrect. Erb's Point is a point on the chest where heart sounds S2 and S3 can be heard most distinctly.
D. AV node - SA node - bundle of His - Erb's Point:
This sequence is incorrect. The AV node comes after the SA node in the electrical conduction system of the heart. Erb's Point is not a part of the normal cardiac conduction pathway; it is a location for auscultation on the chest.
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