A nurse is assessing a client who reports ear pain for the past three 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?

Ménière's disease

Mastoiditis

Perforated tympanic membrane

Acoustic neuroma

Answer and Explanation

The Correct Answer is C

Choice A reason: Ménière's disease typically presents with vertigo, tinnitus, and hearing loss, not sudden resolution of ear pain with otorrhea.

Choice B reason: Mastoiditis may cause ear pain and drainage, but it is usually accompanied by fever and tenderness over the mastoid bone, not sudden pain resolution.

Choice C reason: A perforated tympanic membrane can lead to the sudden resolution of ear pain followed by drainage, as the pressure causing the pain is relieved when the eardrum ruptures.

Choice D reason: Acoustic neuroma typically presents with progressive hearing loss and tinnitus, not ear pain or otorrhea.

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Correct Answer is C

Explanation

The correct answer is: c. Prepare the client for intubation.

Choice A: Prepare to administer a vasopressor

Reason: Vasopressors are typically used to manage hypotension (low blood pressure) and are not a standard treatment for myasthenic crisis. Myasthenic crisis primarily involves respiratory muscle weakness, which can lead to respiratory failure, rather than issues with blood pressure.

Choice B: Administer an anticholinesterase medication

Reason: While anticholinesterase medications like pyridostigmine are used to manage myasthenia gravis, they are generally not recommended during a myasthenic crisis. During a crisis, the focus is on stabilizing the patient, often requiring more immediate interventions such as intubation and mechanical ventilation.

Choice C: Prepare the client for intubation

Reason: Intubation is a critical intervention in a myasthenic crisis due to the risk of respiratory failure. The crisis is characterized by severe muscle weakness, including the muscles that control breathing. Intubation ensures that the airway is protected and that the patient can receive adequate ventilation.

Choice D: Instruct the client to perform pursed lip breathing

Reason: Pursed lip breathing is a technique used to improve breathing efficiency in conditions like chronic obstructive pulmonary disease (COPD). However, it is not appropriate for managing a myasthenic crisis, where the primary issue is severe muscle weakness leading to respiratory failure.

A. Metabolic Alkalosis, Partially Compensated B. Respiratory Acidosis, Partially Compensated C. Respiratory Alkalosis, Uncompensated D. Metabolic Alkalosis, Uncompensated

Correct Answer is D

Explanation

Choice A reason: This choice is incorrect. Partial compensation would typically involve a change in PaCO2 to counterbalance the elevated bicarbonate, which is not observed here.

Choice B reason: This choice is incorrect. Respiratory acidosis is characterized by a low pH and an elevated PaCO2, which is not consistent with the given values.

Choice C reason: This choice is incorrect. Respiratory alkalosis would present with a low PaCO2 due to hyperventilation, which is not the case here.

Choice D reason: This is the correct choice. The elevated pH and HCO3 with a normal PaCO2 indicate metabolic alkalosis without respiratory compensation. Persistent vomiting can lead to loss of stomach acid, which causes metabolic alkalosis.

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A nurse is assessing a client who reports ear pain for the past three 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse suspects a client with myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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