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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Muscular dystrophy is not an example of a neural tube defect, but rather a group of genetic disorders that cause progressive weakness and loss of muscle mass. Muscular dystrophy affects the skeletal muscles that control movement and may also affect the heart, lungs, or other organs. Muscular dystrophy is caused by mutations in genes that encode proteins that protect muscle fibers from damage.
Choice B: Spina bifida is an example of a neural tube defect, which is a birth defect that occurs when the neural tube, which is the structure that develops into the brain and spinal cord, does not close completely during the first month of pregnancy. Spina bifida causes an opening in the spine that exposes the spinal cord and nerves and may result in physical and mental disabilities. Spina bifida can be prevented by taking folic acid before and during pregnancy.
Choice C: Hydrocephalus is not an example of a neural tube defect, but rather a condition that causes accumulation of cerebrospinal fluid (CSF) in the brain. Hydrocephalus can increase the pressure inside the skull and damage the brain tissue and function. Hydrocephalus can be caused by congenital defects, infections, injuries, tumors, or bleeding in the brain.
Choice D: Cerebral palsy is not an example of a neural tube defect, but rather a group of disorders that affect movement, balance, and posture. Cerebral palsy is caused by damage to the developing brain before, during, or after birth. Cerebral palsy can affect muscle tone, coordination, reflexes, or speech. Cerebral palsy can be caused by infections, injuries, lack of oxygen, or genetic mutations.
Correct Answer is A
Explanation
Choice A: This response is appropriate, as it indicates urgency and concern for the infant's condition. Projectile vomiting immediately after eating can be a sign of pyloric stenosis, which is a condition that causes the narrowing of the pylorus, which is the opening between the stomach and the small intestine. Pyloric stenosis can prevent food from passing through and cause dehydration, electrolyte imbalance, or weight loss. The infant needs to be evaluated by a provider as soon as possible and may need surgery to correct the problem.
Choice B: This response is not appropriate, as it does not address the underlying cause of the infant's condition. Oral rehydration solution can help replace fluids and electrolytes lost through vomiting, but it does not treat pyloric stenosis or prevent further vomiting. Oral rehydration solution may also be vomited out by the infant if given too soon or too much.
Choice C: This response is not appropriate, as it does not address the underlying cause of the infant's condition. Burping the baby more frequently during feedings can help release air bubbles and prevent gas or colic, but it does not treat pyloric stenosis or prevent further vomiting. Burping may also trigger vomiting by increasing pressure on the stomach.
Choice D: This response is not appropriate, as it does not address the underlying cause of the infant's condition. Switching to a different formula can help if the infant has an allergy or intolerance to certain ingredients in their current formula, but it does not treat pyloric stenosis or prevent further vomiting. Switching formulas may also cause diarrhea or constipation by changing the infant's bowel flora.
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