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Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately?
- A. The malleus can be visualized during otoscopic examination.
- B. The tympanic membrane is pearly gray.
- C. Tenderness is reported by the patient when the mastoid area is palpated.
- D. Clear, watery fluid is draining from the patients ear.
Correct Answer: D
Rationale: Clear, watery ear drainage post-trauma suggests cerebrospinal fluid leak from a skull fracture, requiring immediate reporting. Visualizing the malleus or a pearly gray tympanic membrane is normal, and mastoid tenderness, while notable, is less urgent.
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The nurse is planning the care of a patient with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this patients care?
- A. Risk for disturbed sensory perception
- B. Risk for unilateral neglect
- C. Risk for falls
- D. Risk for ineffective health maintenance
Correct Answer: C
Rationale: Vertigo increases fall risk due to impaired balance, making this the priority nursing diagnosis. Other risks are less immediate.
On otoscopy, a red blemish behind the tympanic membrane is suggestive of what diagnosis?
- A. Acoustic tumor
- B. Cholesteatoma
- C. Facial nerve neuroma
- D. Glomus tympanicum
Correct Answer: D
Rationale: A red blemish behind the tympanic membrane is characteristic of glomus tympanicum, a vascular tumor. Acoustic tumors, cholesteatomas, and neuromas do not typically present this way.
An older adult with a recent history of mixed hearing loss has been diagnosed with a cholesteatoma. What should this patient be taught about this diagnosis? Select all that apply
- A. Cholesteatomas are benign and self-limiting, and hearing loss will resolve spontaneously.
- B. Cholesteatomas are usually the result of metastasis from a distant tumor site.
- C. Cholesteatomas are often the result of chronic otitis media.
- D. Cholesteatomas, if left untreated, result in intractable neuropathic pain.
- E. Cholesteatomas usually must be removed surgically.
Correct Answer: C,E
Rationale: Cholesteatomas, often caused by chronic otitis media, require surgical removal to prevent complications like bone erosion. They are not self-limiting, metastatic, or typically painful.
A 6-month-old infant is brought to the ED by his parents for inconsolable crying and pulling at his right ear. When assessing this infant, the advanced practice nurse is aware that the tympanic membrane should be what color in a healthy ear?
- A. Yellowish-white
- B. Pink
- C. Gray
- D. Bluish-white
Correct Answer: C
Rationale: A healthy tympanic membrane is pearly gray. Yellowish-white, pink, or bluish-white colors suggest inflammation or other pathology.
A patient is being discharged home after mastoid surgery. What topic should the nurse include in discharge teaching?
- A. Expected changes in facial nerve function
- B. The need for audiometry testing every 6 months following recovery
- C. Safe use of analgesics and antivertiginous agents
- D. Appropriate use of OTC ear drops
Correct Answer: C
Rationale: Teaching about analgesics and antivertiginous agents supports safe management of pain and vertigo post-mastoidectomy. Facial nerve changes are complications, audiometry is not routine, and OTC ear drops are not recommended.