A nurse is caring for a child who has otitis media with effusion. The nurse should identify which of the following manifestations indicates a tympanic membrane rupture.
Popping sensation when swallowing
Green-blue discharge in the ear canal
Sudden pain relief
Increased temperature
The Correct Answer is C
Choice A: A popping sensation when swallowing is not a sign of a tympanic membrane rupture, as it is a normal phenomenon that occurs when the eustachian tube opens and closes to equalize the pressure between the middle ear and the atmosphere. A popping sensation when swallowing may be associated with otitis media with effusion, which is a condition that causes fluid accumulation behind the eardrum, but it does not indicate a rupture.
Choice B: Green-blue discharge could be indicative of infection but is not as directly related to the rupture event as the sudden pain relief is.
Choice C: The correct answer is sudden relief of pain. This is because the rupture of the tympanic membrane releases the pressure and fluid that has built up in the middle ear, leading to an immediate decrease in pain.
Choice D: An increased temperature is not a sign of a tympanic membrane rupture, as it is a nonspecific symptom that may indicate various conditions, such as inflammation, infection, or fever. An increased temperature may be associated with otitis media with effusion, which is a condition that causes fluid accumulation behind the eardrum, but it does not indicate a rupture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This choice is correct because providing a latex-free environment is an essential intervention for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac. Spina bifida is a congenital defect in which the spinal cord and its coverings do not close properly, resulting in a protrusion of the meninges (meningocele) or the meninges and spinal cord (myelomeningocele). Children who have spina bifida are at a high risk of developing a latex allergy, which can cause severe reactions such as anaphylaxis or death. Therefore, avoiding exposure to latex products such as gloves, catheters, balloons, or bandages is crucial to prevent complications.
Choice B reason: This choice is incorrect because initiating contact precautions is not necessary for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac. Contact precautions are infection control measures that prevent the transmission of microorganisms that can be spread by direct or indirect contact with the client or their environment. They may be indicated for clients who have multidrug-resistant organisms, clostridium difficile, or scabies, but they are not required for clients who have spina bifida unless they have a concurrent infection.
Choice C reason: This choice is incorrect because limiting visitors to immediate family members is not indicated for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac. Limiting visitors may be indicated for clients who have immunosuppression, isolation, or terminal illness, but it may not be beneficial for clients who have spina bifida. Allowing visitors may provide emotional and social support for the client and their family, as long as they follow standard precautions and do not pose any risk of infection or injury.
Choice D reason: This choice is incorrect because maintaining the infant in the supine position is not an appropriate intervention for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac.
Maintaining the infant in the supine position may cause pressure or trauma to the sac, which can lead to rupture, infection, or nerve damage. Therefore, positioning the infant in a prone or side-lying position with the hips flexed and knees abducted can help to protect the sac and prevent complications.
Correct Answer is B
Explanation
Choice A: A heart rate of 72/min is within the normal range for an adolescent, which is 60 to 100 beats per minute. A heart rate of 72/min does not indicate any signs of shock, hemorrhage, or cardiac injury. Therefore, this finding is not the nurse's priority.
Choice B: A blood pressure of 84/52 mm Hg is below the normal range for an adolescent, which is 110 to 120/70 to 80 mm Hg. A blood pressure of 84/52 mm Hg indicates hypotension, which can be a sign of shock, hemorrhage, or internal organ damage. Hypotension can lead to decreased tissue perfusion, organ failure, or death. Therefore, this finding is the nurse's priority and requires immediate intervention.
Choice C: An abdominal pain rated 4 on a scale of 0 to 10 is a moderate level of pain that can indicate inflammation, injury, or infection in the abdomen. However, pain is a subjective symptom that may vary depending on the individual and the severity of the condition. Pain can also be managed with analgesics or other measures. Therefore, this finding is not the nurse's priority.
Choice D: A respiratory rate of 20/min is within the normal range for an adolescent, which is 12 to 20 breaths per minute. A respiratory rate of 20/min does not indicate any signs of respiratory distress, hypoxia, or pulmonary injury. Therefore, this finding is not the nurse's priority.
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