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 C

Explanation

A. Fifth intercostal space, left of the midclavicular line: This placement is used to auscultate the mitral valve, which is best heard at the apex of the heart. The mitral valve sounds are typically heard around the fifth intercostal space, midclavicular line.

B. Left lower sternal border: This placement is used to auscultate the tricuspid valve, which is best heard at the lower left sternal border.

C. Second left intercostal space: This is the correct placement for auscultating the pulmonic valve. The pulmonic valve sounds are best heard at the second left intercostal space, which is close to the upper left sternal border.

D. Second right intercostal space: This placement is used to auscultate the aortic valve, which is best heard at the second right intercostal space, close to the upper right sternal border.

A. The atria contract toward the end of diastole and push the remaining blood into the ventricles. B. The atria contract during systole and attempt to push against closed valves. C. Atrial kick is the pressure exerted against the atria as the ventricles contract during systole. D. Contraction of the atria at the beginning of diastole can be felt as a palpitation.

Correct Answer is A

Explanation

A. The atria contract toward the end of diastole and push the remaining blood into the ventricles.

This choice is correct. During atrial systole (atrial contraction), the atria contract, pushing the remaining blood into the ventricles. This additional filling of the ventricles optimizes cardiac output.

B. The atria contract during systole and attempt to push against closed valves.

This statement is incorrect. The atria do not contract during systole; they contract during diastole (atrial systole) to fill the ventricles.

C. Atrial kick is the pressure exerted against the atria as the ventricles contract during systole.

This statement is incorrect. Atrial kick refers to the atrial contraction, not the pressure exerted against the atria.

D. Contraction of the atria at the beginning of diastole can be felt as a palpitation.

This statement is not entirely accurate. A palpitation is a sensation of rapid or strong heartbeat, which might be felt during various cardiac events, not specifically during atrial contraction at the beginning of diastole.

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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 assessing the heart sounds of a client. The nurse understands that to listen to the pulmonic valve, the stethoscope should be placed where?

Correct Answer is C

Explanation

A nurse is reviewing the anatomy and physiologic functioning of the heart. The nurse should recognize that which statement best describes the atrial kick?

Correct Answer is A

Explanation

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