What objective data should be collected when a client reports ear pain and discharge?
Inspect the tympanic membrane for bulging or rupture.
Ask the client about recent exposure to loud noises.
Inquire about current medication usage.
Obtain a swab of the discharge for laboratory testing.
The Correct Answer is A
Choice A reason: Otalgia associated with otorrhea (ear discharge) is highly suggestive of otitis media with effusion, acute otitis media with perforation, or otitis externa. Direct visualization using an otoscope to inspect the integrity and appearance of the tympanic membrane is the definitive objective assessment to differentiate between middle ear pathology and external canal infection.
Choice B reason: While exposure to loud noises is an important part of a clinical history for sensorineural hearing loss or tinnitus, it does not provide objective data relevant to the physical presence of ear pain and discharge, which are symptoms typically indicative of infectious or inflammatory processes rather than acoustic trauma.
Choice C reason: Inquiring about medication usage is a component of a subjective health history and medication reconciliation. While it provides context regarding systemic health or potential side effects, it does not constitute an objective clinical assessment of the current structural integrity or infectious state of the auditory canal and middle ear.
Choice D reason: While obtaining a culture from discharge can be useful in cases of chronic, recurrent, or resistant otitis externa, it is a diagnostic test rather than a primary physical assessment finding. The initial objective priority is to identify the source of the pathology through direct physical examination of the anatomy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Assessment of the posterior chest involves examining the back of the thorax. A straight spine and symmetrical chest expansion during inspiration are standard clinical findings documented during the posterior respiratory assessment, which allows the nurse to inspect the thoracic cage and lung excursion effectively without obstruction.
Choice B reason: The abdomen is the area inferior to the diaphragm. While abdominal movement (diaphragmatic breathing) is assessed during a physical exam, the description of a "straight spine" and "symmetrical movement upon inspiration" specifically pertains to thoracic cage landmarks and respiratory excursion rather than abdominal cavity structures.
Choice C reason: The anterior chest assessment focuses on the front of the thorax. While symmetry is also evaluated here, the "straight spine" is an anatomical landmark typically visible and assessed during the posterior chest examination, as the thoracic spine is a dorsal structure that is best inspected from the back.
Choice D reason: The lateral chest refers to the sides of the thoracic cavity. Assessment here focuses on lung sounds and chest wall excursion, but this is not the primary anatomical location for documenting the straightness of the spine, which is a posterior midline structure assessed for scoliosis or other deformities.
Correct Answer is C
Explanation
Choice A reason: A history of cigarette smoking is a significant risk factor for cardiovascular disease, chronic obstructive pulmonary disease, and peripheral vascular disease. However, it is an historical demographic factor and is not a clinical manifestation or symptom directly caused by or predictive of acute bradycardia.
Choice B reason: Hypoglycemia typically presents with sympathetic nervous system activation, resulting in tachycardia, diaphoresis, tremors, and anxiety as the body attempts to mobilize glucose stores. It is physiologically inconsistent with the manifestation of a heart rate of 56/min, which reflects parasympathetic dominance or conduction system pathology.
Choice C reason: A heart rate of 56/min is classified as bradycardia. When the heart rate is insufficient to maintain adequate cardiac output to meet systemic metabolic demands, cerebral perfusion may be compromised, resulting in symptoms such as dizziness, syncope, lightheadedness, fatigue, or altered mental status in symptomatic clients.
Choice D reason: Hyperthermia, defined as a temperature of 39° C, generally induces a physiological increase in the metabolic rate, leading to a compensatory tachycardia rather than bradycardia. The increase in body temperature stimulates the sinoatrial node, typically causing the heart rate to rise rather than fall below the normal range.
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