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 is appropriate, as it informs the parent that reporting suspected child abuse is a legal and ethical obligation for nurses, regardless of their personal opinions or feelings. This response also shows respect and honesty by acknowledging the parent's concern and explaining the reason for the nurse's action.
Choice B: This response is not appropriate, as it deflects responsibility and avoids answering the parent's question. This response also shows disrespect and dishonesty by implying that the provider is more qualified or authorized to explain the situation than the nurse.
Choice C: This response is not appropriate, as it denies information and creates confusion for the parent. This response also shows indifference and avoidance by suggesting that the nurse does not want to deal with the issue or communicate with the parent.
Choice D: This response is not appropriate, as it shifts blame and undermines trust between the nurse and the parent. This response also shows defensiveness and insecurity by implying that the nurse did not make the decision or take accountability for their action.
Correct Answer is C
Explanation
Choice A: Tremors are not a typical sign of hyperglycemia, which is a high blood glucose level. Tremors are more likely to occur in hypoglycemia, which is a low blood glucose level.
Choice B: Pallor is also not a typical sign of hyperglycemia. Pallor can indicate anemia, shock, or hypoxia, which are
not related to blood glucose levels.
Choice C: Lethargy is a common sign of hyperglycemia, as the body is unable to use glucose as an energy source. Lethargy can also lead to ketoacidosis, which is a life-threatening complication of hyperglycemia.
Choice D: Shallow respirations are not a sign of hyperglycemia, but rather a sign of respiratory distress or acidosis.
Shallow respirations can reduce the oxygen delivery to the tissues and worsen the condition of the child.
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