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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
Choice A reason: Bradycardia, or a slower than normal heart rate, is not typically an indication of infection. It can be related to other health issues or medication effects.
Choice B reason: An increase in platelets, or thrombocytosis, can occur in response to various conditions, but it is not a specific indicator of infection in diabetic foot pain.
Choice C reason: An increase in RBCs, or erythrocytosis, is generally not associated with infection. It could indicate other conditions such as polycythemia vera.
Choice D reason: Localized edema, or swelling, can be a sign of infection, especially if accompanied by other symptoms such as redness, warmth, and pain.
Choice E reason: An increase in neutrophils, a type of white blood cell, often indicates the body's response to an infection. Neutrophils are part of the immune system's first line of defense against pathogens.
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.
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