A client with untreated otitis media develops mastoiditis. The nurse is most concerned about which complication?
Inflammation limited to the external ear.
Increased cerumen production.
Spread of infection to brain.
Temporary conductive hearing loss only.
The Correct Answer is C
Choice A rationale
Inflammation limited to the external ear, known as otitis externa, is a relatively benign condition compared to the severe risks associated with mastoiditis. While it causes localized pain and edema, it does not involve the bony structures of the skull. Mastoiditis represents an extension of infection from the middle ear into the mastoid air cells. The nurse's concern must focus on the potential for deeper, life-threatening structural involvement rather than simple external canal irritation.
Choice B rationale
Cerumen production is a physiological process of the external auditory canal designed to protect the ear from debris and infection. Increased earwax may cause temporary discomfort or minor hearing changes, but it is not a complication of a bacterial infection in the mastoid bone. Focusing on cerumen during a mastoiditis assessment would ignore the critical signs of systemic infection or intracranial involvement. This choice does not address the serious nature of the client's current pathology.
Choice C rationale
The mastoid air cells are located in close proximity to the temporal lobe of the brain and the sigmoid sinus. If mastoiditis is left untreated, the infection can erode through the thin bony partitions, leading to life-threatening complications such as meningitis, brain abscess, or dural sinus thrombosis. This represent the most significant risk because it involves the central nervous system. Early recognition of neurological changes or severe headaches is vital in preventing permanent disability or death.
Choice D rationale
While conductive hearing loss is a common finding in middle ear infections and mastoiditis due to fluid and debris blocking sound waves, it is typically manageable and often reversible. It does not carry the same level of acuity or mortality risk as an intracranial infection. The nurse prioritizes complications that threaten the client's life or basic neurological function. Temporary hearing loss, though concerning for the client, remains a secondary priority compared to the risk of brain infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Respiratory acidosis is the correct interpretation because the pH of 7.30 is below the normal range of 7.35 to 7.45, indicating an acidotic state. Additionally, the PaCO2 of 50 mmHg is above the normal range of 35 to 45 mmHg, which shows that the lungs are retaining carbon dioxide. Since CO2 acts as an acid in the blood, its elevation explains the drop in pH. The normal HCO3 level of 24 mEq/L indicates that no metabolic compensation has occurred yet.
Choice B rationale
Metabolic alkalosis is characterized by a pH greater than 7.45 and an elevated bicarbonate (HCO3) level greater than 26 mEq/L. In this case, the patient's pH is 7.30, which is acidic rather than alkaline, and the bicarbonate level is perfectly within the normal range of 22 to 26 mEq/L. Therefore, there is no evidence of a metabolic primary cause or an alkalotic state, making this interpretation completely inconsistent with the provided arterial blood gas laboratory values.
Choice C rationale
Metabolic acidosis involves a pH below 7.35 and a bicarbonate (HCO3) level below 22 mEq/L. While the patient's pH of 7.30 does indicate acidosis, the bicarbonate level of 24 mEq/L is normal and does not explain the acidic pH. In metabolic acidosis, the primary problem is a loss of base or an accumulation of non-volatile acids. Because the PaCO2 is the abnormal value driving the pH down, the cause is respiratory in nature rather than metabolic.
Choice D rationale
Respiratory alkalosis occurs when the pH is above 7.45 and the PaCO2 is below 35 mmHg, usually due to hyperventilation which causes excessive "blowing off" of carbon dioxide. The patient's results show the exact opposite: a low pH and a high PaCO2. This indicates that the patient is hypoventilating or having difficulty with gas exchange, leading to the accumulation of CO2 and the resulting decrease in blood pH. Thus, respiratory alkalosis is an incorrect interpretation. .
Correct Answer is A
Explanation
Choice A rationale
Hypertrophy is an increase in the size of individual cells, which leads to an increase in the overall size of the organ. In chronic hypertension, the left ventricle must pump against increased systemic vascular resistance. To compensate for this increased workload, the cardiac myocytes synthesize more proteins and organelles, becoming larger to generate more force. This is a common adaptive response in non-dividing cells like those found in the heart and skeletal muscles when facing stress.
Choice B rationale
Hyperplasia is an increase in the number of cells in an organ or tissue resulting from increased cellular division. This occurs in tissues capable of mitosis, such as the liver or the glandular epithelium of the breast during pregnancy. Since cardiac muscle cells are largely post-mitotic and have a very limited capacity for regeneration or division, the heart cannot adapt to hypertension by making more cells; it must rely on increasing the size of existing cells.
Choice C rationale
Metaplasia is a reversible change in which one adult cell type is replaced by another adult cell type of the same germ line. This is usually a protective response to chronic irritation. An example is the change from ciliated columnar epithelium to squamous epithelium in the airways of chronic smokers. This adaptation is not seen in the heart in response to pressure overload, as the tissue remains muscular but simply becomes thicker and less compliant.
Choice D rationale
Dysplasia refers to abnormal changes in the size, shape, and organization of mature cells. It is often a precursor to cancerous changes and is characterized by a loss of cellular uniformity and architectural orientation. While it can occur in various epithelial tissues due to chronic irritation or inflammation, it is not the mechanism by which the heart adapts to the mechanical stress of high blood pressure, which is a physiological/pathological growth process. .
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