A nurse is caring for a child who has otitis media with effusion. The nurse should identify that which of the following manifestations indicates a tympanic membrane rupture?
Increased temperature.
Sudden pain relief.
Popping sensation when swallowing.
Green-blue discharge in the ear canal.
The Correct Answer is B
Rationale
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B. Sudden pain relief: The intense pain associated with otitis media is caused by the accumulation of fluid and pressure against the tympanic membrane. When the membrane ruptures, that pressure is instantaneously released, resulting in a sudden and dramatic decrease in pain. This is often followed by purulent (pus-filled) or serosanguineous (bloody) drainage in the external ear canal.
Why the others are incorrect
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A. Increased temperature: While a fever is a common sign of an acute infection (Acute Otitis Media), it is not a specific indicator that the eardrum has ruptured. In fact, systemic symptoms like fever may actually decrease once the pressure and infection are vented through a rupture.
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C. Popping sensation when swallowing: This sensation is typically associated with the opening and closing of the Eustachian tube as it attempts to equalize pressure in the middle ear. It is a common symptom of Eustachian tube dysfunction or fluid in the ear, but it indicates an intact eardrum rather than a ruptured one.
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D. Green-blue discharge in the ear canal: While drainage (otorrhea) occurs after a rupture, the color is typically clear, bloody, or yellowish-white (purulent). Green-blue discharge is more characteristic of Pseudomonas infections, often seen in otitis externa (swimmer's ear), rather than a standard tympanic membrane rupture from middle ear effusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While knowing if the client is taking any medications is important, it does not directly relate to diagnosing Guillain-Barré syndrome.
Choice B reason: Guillain-Barré syndrome often follows a recent infection, such as a respiratory or gastrointestinal infection. The immune response to the infection can trigger an autoimmune reaction that damages the peripheral nerves, leading to the symptoms of GBS. Therefore, asking about recent infections helps establish a potential cause for the syndrome.
Choice C reason: Travel history can be relevant for certain infectious diseases, but it is not a primary question for diagnosing GBS.
Choice D reason: A history of chronic alcohol abuse is more relevant to other neurological conditions, such as peripheral neuropathy, but not specifically to Guillain-Barré syndrome.
Correct Answer is A
Explanation
Choice A reason: A patient with a new-onset of confusion and restlessness is a priority because these symptoms could indicate a serious condition such as hypoxia, electrolyte imbalance, or a neurological event like a stroke. These changes in mental status need to be evaluated immediately to prevent further complications.
Choice B reason: Dizziness after receiving captopril (Capoten) can be a side effect of the medication due to its blood pressure-lowering effects. While it should be monitored, it is not as urgent as the new-onset confusion and restlessness seen in another patient.
Choice C reason: A patient requiring oxygen via nasal cannula with saturations of 97% is stable as the oxygen saturation is within normal limits. This patient does not need to be prioritized over others with more acute symptoms.
Choice D reason: A patient who has received digoxin and has a blood pressure of 100/56 should be monitored, especially for signs of digoxin toxicity. However, this situation is not as critical as the new-onset confusion and restlessness in another patient.
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