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: This response indicates an understanding of the teaching, as pancreatic enzymes are essential for a child who has cystic fibrosis (CF), which is a condition that causes thick mucus to block the pancreatic ducts and impair digestion and absorption of nutrients. Pancreatic enzymes help break down fats, proteins, and carbohydrates in food and prevent malnutrition, steatorrhea, or vitamin deficiencies. Pancreatic enzymes should be given with snacks and meals to ensure adequate digestion.
Choice B: This response indicates a lack of understanding of the teaching, as low-fat meals with limited protein are not recommended for a child who has cystic fibrosis (CF), which is a condition that causes thick mucus to block the pancreatic ducts and impair digestion and absorption of nutrients. Low-fat meals with limited protein can cause malnutrition, weight loss, or growth failure in a child who has CF. A high-calorie, high-protein diet is recommended for a child who has CF to meet their increased energy needs and promote growth and development.
Choice C: This response indicates a lack of understanding of the teaching, as limiting fluid intake is not recommended for a child who has cystic fibrosis (CF), which is a condition that causes thick mucus to block the airways and lungs and cause respiratory infections and complications. Limiting fluid intake can cause dehydration, thickening of mucus, or difficulty in expectoration in a child who has CF. Adequate fluid intake is recommended for a child who has CF to hydrate the body, thin out mucus, and facilitate clearance.
Choice D: This response indicates a lack of understanding of the teaching, as restricting salt intake is not recommended for a child who has cystic fibrosis (CF), which is a condition that causes excessive loss of salt through sweat due to abnormal chloride transport in cells. Restricting salt intake can cause hyponatremia, dehydration, or electrolyte imbalance in a child who has CF. Adequate salt intake is recommended for a child who has CF to replace the lost salt and maintain fluid and electrolyte balance.
Correct Answer is D
Explanation
Choice A reason: This choice is incorrect because the radial artery is not an ideal site to assess the heart rate in an infant. The radial artery is located on the thumb side of the wrist, and it can be palpated by placing two fingers over it. It may be used for adults or older children who have a strong pulse, but it may be difficult to locate or feel in an infant who has a small or weak pulse.
Choice B reason: This choice is incorrect because the carotid artery is not an ideal site to assess the heart rate in an infant. The carotid artery is located on either side of the neck, and it can be palpated by placing two fingers over it. It may be used for adults or older children who have a cardiac arrest or shock, but it may be risky to use in an infant who has a fragile neck or airway.
Choice C reason: This choice is incorrect because the brachial artery is not an ideal site to assess the heart rate in an infant. The brachial artery is located on the inner side of the upper arm, and it can be palpated by placing two fingers over it. It may be used for infants or young children who have a blood pressure measurement, but it may be uncomfortable or inaccurate to use for a heart rate assessment.
Choice D reason: This choice is correct because the apex of the heart is an ideal site to assess the heart rate in an infant. The apex of the heart is located at the fifth intercostal space on the left midclavicular line, and it can be auscultated by placing a stethoscope over it. It may be used for infants or young children who have a regular and strong heartbeat, and it may provide the most accurate measurement of the heart rate.
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