A nurse is assessing a client who reports ear pain for the past 3 days that has suddenly resolved. The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the client has manifestations of which of the following conditions?
Acoustic neuroma
Perforated tympanic membrane
Ménière's disease
Mastoiditis
The Correct Answer is B
Rationale:
A. This is a benign tumor on the vestibulocochlear nerve and typically presents with unilateral hearing loss, tinnitus, and balance issues, not sudden pain relief followed by drainage.
B. A sudden resolution of ear pain followed by otorrhea (drainage) is a classic sign of a ruptured tympanic membrane. The rupture relieves the pressure and pain but allows fluid or pus to drain.
C. Ménière’s disease presents with episodic vertigo, tinnitus, fluctuating hearing loss, and a feeling of fullness in the ear, not acute drainage.
D. Mastoiditis is an infection of the mastoid bone, presenting with ear pain, swelling, redness, and fever. It does not typically cause sudden relief of pain followed by drainage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Morphine more commonly causes constipation due to decreased gastrointestinal motility, not diarrhea.
B. Hiccups are not a typical adverse effect of morphine administration.
C. Morphine can cause peripheral vasodilation and histamine release, which may lead to orthostatic hypotension, especially with IV administration. The nurse should monitor blood pressure closely.
D. Heartburn is not a recognized adverse effect of morphine. Gastrointestinal effects are more likely to include nausea, vomiting, and constipation.
Correct Answer is B
Explanation
Rationale:
A. Pain control is important, but in the immediate emergency phase of a major burn, airway, breathing, and circulation take priority over comfort measures.
B. A 30% total body surface area (TBSA) burn places the client at high risk for hypovolemic shock due to massive fluid shifts. Initiating IV fluid resuscitation (guided by the Parkland formula) is the priority intervention to maintain circulation and perfusion.
C. Wound care is important but must be delayed until the patient is stabilized hemodynamically.
D. A tetanus booster may be indicated with burn injuries, but it is not the first priority. Circulatory stabilization with fluids must occur first.
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