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.

Answer and Explanation

The Correct Answer is D

Choice A reason: Increased temperature is a common symptom of many infections, including otitis media, but it does not specifically indicate a tympanic membrane rupture. Fever may accompany the infection but is not a definitive sign of membrane rupture.

Choice B reason: Sudden pain relief can be an indicator of a tympanic membrane rupture in otitis media. This occurs because the pressure built up in the middle ear is suddenly released when the membrane ruptures. However, it is not the only definitive sign.

Choice C reason: A popping sensation when swallowing is a symptom associated with eustachian tube dysfunction rather than a tympanic membrane rupture. It indicates that there is a change in the pressure within the middle ear but not necessarily a rupture.

Choice D reason: Green-blue discharge in the ear canal is a classic sign of a tympanic membrane rupture. This discharge is usually pus mixed with blood from the middle ear and indicates that the membrane has ruptured, allowing the fluid to drain out. This finding is definitive and requires medical attention.

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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.

A. An expected side effect of the medication B. An allergic reaction to the nitroglycerin C. A sign that the medication should not be used again D. An indication of worsening cardiac condition

Correct Answer is A

Explanation

Choice A reason: A headache is a common and expected side effect of nitroglycerin. Nitroglycerin causes vasodilation, which can lead to increased blood flow to the head and result in headaches. It is important to inform the client that this is a known side effect and to manage it with appropriate measures, such as taking analgesics.

Choice B reason: An allergic reaction to nitroglycerin would typically present with symptoms such as rash, itching, swelling, or difficulty breathing. A headache alone does not indicate an allergic reaction.

Choice C reason: A headache does not mean the medication should not be used again. It is a common side effect, and the benefits of nitroglycerin in relieving chest pain usually outweigh the discomfort of the headache. The nurse should educate the client on managing the headache while continuing the medication.

Choice D reason: A headache is not an indication of a worsening cardiac condition. It is a common side effect of the vasodilatory effects of nitroglycerin.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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