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 B
Explanation
Choice A reason: This choice is incorrect because limiting intake of high-protein foods is not a method of preventing iron deficiency anemia. High-protein foods are foods that contain a large amount of protein, such as meat, poultry, fish, eggs, dairy products, beans, nuts, or seeds. Protein is a nutrient that helps to build and repair body tissues and support immune function. It may also provide iron, which is a mineral that helps to produce hemoglobin, the protein that carries oxygen in red blood cells. Therefore, limiting intake of high-protein foods may reduce iron intake and increase the risk of iron deficiency anemia.
Choice B reason: This choice is correct because mom should continue prenatal vitamins if breastfeeding or formula with an iron supplement is a method of preventing iron deficiency anemia. Prenatal vitamins are supplements that contain various vitamins and minerals that are essential for pregnant or lactating women and their babies. They may include iron, which helps to prevent maternal and infant anemia. Formula with an iron supplement is a type of infant formula that contains added iron to meet the nutritional needs of infants who are not breastfed or partially breastfed. Therefore, mom should continue prenatal vitamins if breastfeeding or formula with an iron supplement can help to provide adequate iron intake and prevent iron deficiency anemia.
Choice C reason: This choice is incorrect because administering fat-soluble vitamins daily is not a method of preventing iron deficiency anemia. Fat-soluble vitamins are vitamins that dissolve in fat and can be stored in the body, such as vitamins A, D, E, and K. They have various functions such as maintaining vision, bone health, skin health, and blood clotting. They do not have a direct role in preventing iron deficiency anemia.
Choice D reason: This choice is incorrect because including fluoridated water in the toddler's diet is not a method of preventing iron deficiency anemia. Fluoridated water is water that contains fluoride, which is a substance that helps to prevent tooth decay and cavities. It does not have a direct role in preventing iron deficiency anemia.
Correct Answer is A
Explanation
Choice A: This statement indicates an understanding of the teaching, as washing all recently used clothing, bedding, and towels in hot water can help eliminate lice and nits (eggs). Lice and nits can survive on fabrics for up to two days and can spread from one person to another through direct or indirect contact. Washing items in hot water can kill lice and nits by exposing them to high temperatures.
Choice B: This statement indicates a lack of understanding of the teaching, as nits will not always be present after treatment. Nits are tiny white or yellow oval-shaped eggs that are attached to the hair shaft near the scalp. Nits can hatch into nymphs (young lice) within seven to ten days and mature into adult lice within nine to twelve days. Nits can be removed by using a fine-toothed comb or by applying products that loosen their grip on the hair.
Choice C: This statement indicates a lack of understanding of the teaching, as treating all family members may not be necessary or effective. Treating all family members can expose them to unnecessary chemicals or medications that may have side effects or cause resistance. Treating all family members may also not prevent reinfestation if there are other sources of exposure such as school or daycare. Only family members who have evidence of lice or nits should be treated.
Choice D: This statement indicates a lack of understanding of the teaching, as throwing out toys that can't be dry cleaned or washed may not be required or practical. Throwing out toys can cause emotional distress or financial burden for the child or the parents. Throwing out toys may also not prevent reinfestation if there are other sources of exposure such as clothing or bedding. Toys that can't be dry cleaned or washed can be sealed in plastic bags for two weeks to suffocate the lice and nits.
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