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 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.
Correct Answer is C
Explanation
Choice A reason: This choice is incorrect because constructing a model airplane is not an appropriate activity for a 4- year-old child who requires airborne precautions. Airborne precautions are infection control measures that prevent the transmission of microorganisms that can be spread by small droplets that remain suspended in the air, such as tuberculosis, measles, or chickenpox. They involve placing the child in a negative-pressure room with a HEPA filter, wearing a respirator mask, and limiting movement outside the room. Constructing a model airplane may involve small parts that can be choking hazards, sharp edges that can cause injury or glue that can cause irritation or allergy. Therefore, this activity may not be safe or suitable for the child.
Choice B reason: This choice is incorrect because pulling a wagon with toys in the hallway is not an appropriate activity for a 4-year-old child who requires airborne precautions. As explained above, airborne precautions involve limiting movement outside the room to prevent exposure and transmission of microorganisms. Pulling a wagon with toys in the hallway may violate these precautions and increase the risk of infection for the child and others.
Therefore, this activity may not be allowed or advisable for the child.
Choice C reason: This choice is correct because putting a large-piece puzzle together is an appropriate activity for a 4-year-old child who requires airborne precautions. Putting a large-piece puzzle together can help to stimulate the child's cognitive, visual, and fine motor skills by requiring them to match shapes, colors, and patterns. It can also help to reduce boredom, frustration, or anxiety by providing entertainment, diversion, or achievement. Therefore, this activity may be beneficial and enjoyable for the child.
Choice D reason: This choice is incorrect because watching a video game in the playroom is not an appropriate activity for a 4-year-old child who requires airborne precautions. As explained above, airborne precautions involve limiting movement outside the room to prevent exposure and transmission of microorganisms. Watching a video game in the playroom may violate these precautions and increase the risk of infection for the child and others.
Therefore, this activity may not be permitted or recommended for the child.
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