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 ["260"]
Explanation
Sure, let’s calculate the total fluid intake step by step.
Step 1: Convert ½ cup of juice to mL.
- 1 cup = 240 mL
- ½ cup = 240 mL ÷ 2 = 120 mL
- Result: 120 mL
Step 2: Convert 3 oz of gelatin to mL.
- 1 oz = 30 mL
- 3 oz = 3 × 30 mL = 90 mL
- Result: 90 mL
Step 3: Convert 1 oz of an ice pop to mL.
- 1 oz = 30 mL
- 1 oz = 30 mL
- Result: 30 mL
Step 4: Ginger ale is already in mL.
- Result: 20 mL
Step 5: Add all the mL values together.
- 120 mL (juice) + 90 mL (gelatin) + 30 mL (ice pop) + 20 mL (ginger ale) = 260 mL
- Result: 260 mL
The nurse should record the child’s fluid intake as 260 mL.
Correct Answer is A
Explanation
Choice A: This action is appropriate for a 10-year-old child who will be hospitalized for an extended period of time, as it meets their psychosocial needs according to Erikson's stage of industry versus inferiority. In this stage, which occurs from age 6 to 12 years, children develop a sense of competence and achievement by mastering skills and tasks that are valued by society. Encouraging the client to complete school work can help them maintain their academic progress and self-esteem.
Choice B: This action is not appropriate for a 10-year-old child who will be hospitalized for an extended period of time, as it does not meet their psychosocial needs according to Erikson's stage of industry versus inferiority. In this stage, which occurs from age 6 to 12 years, children need consistency and structure to develop a sense of competence and achievement. Varying the child's schedule each day can cause confusion and stress for them.
Choice C: This action is not appropriate for a 10-year-old child who will be hospitalized for an extended period of time, as it does not meet their psychosocial needs according to Erikson's stage of industry versus inferiority. In this stage, which occurs from age 6 to 12 years, children need opportunities to master skills and tasks that are valued by society. Providing a daily session with a play therapist can help them cope with their emotions and fears, but it does not help them develop their competence and achievement.
Choice D: This action is not appropriate for a 10-year-old child who will be hospitalized for an extended period of time, as it does not meet their psychosocial needs according to Erikson's stage of industry versus inferiority. In this stage, which occurs from age 6 to 12 years, children need social support and peer interaction to develop a sense of competence and achievement. Discouraging visits from the client's friends can cause isolation and depression for them.
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