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Question 1 of 5

While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and the light reflex is not visible. The most likely cause is:

Correct Answer: B

Rationale: The correct answer is B: acute otitis media. In this case, the presentation of a bright red tympanic membrane and absence of the light reflex are indicative of inflammation and fluid accumulation in the middle ear, which are classic signs of acute otitis media. This condition commonly occurs in young children, especially after a recent upper respiratory infection. Incorrect choices: A: Fungal infection is less likely in this case as the symptoms are more consistent with acute bacterial infection seen in otitis media. C: Rupture of the drum would typically present with sudden relief of pain and discharge from the ear, which is not described in the scenario. D: Blood behind the drum (hemotympanum) is uncommon in children with acute otitis media and would usually be associated with trauma or barotrauma.

Question 2 of 5

During an examination of a 3-year-old child, the nurse notes a bruit over the left temporal area. What should the nurse do?

Correct Answer: D

Rationale: The correct answer is D because a bruit in a 3-year-old child, especially over the temporal area, is not a normal finding and could indicate a serious underlying issue such as an arteriovenous malformation or other vascular abnormality. Stopping the examination and notifying the physician is crucial for further evaluation and management. A: Continuing the examination is not appropriate as the bruit should prompt further investigation. B: Checking again in 1 hour is unnecessary delay in addressing a potentially serious issue. C: Notifying the parents alone without medical intervention may delay necessary evaluation and treatment.

Question 3 of 5

The nurse is performing middle ear assessment on a 15-year-old patient who has a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and visible landmarks. The nurse should:

Correct Answer: B

Rationale: The correct answer is B: know that these are scars caused from frequent ear infections. The presence of dense white patches on the tympanic membrane in a patient with a history of chronic ear infections indicates scarring from previous infections. This is a common finding in individuals who have experienced recurrent middle ear infections. The other choices are incorrect because: A) Fungal infections typically present with different characteristics such as discoloration or debris in the ear canal, not dense white patches on the tympanic membrane. C) Blood in the middle ear would manifest as redness or hemorrhage, not white patches. D) While scarring may affect hearing, the description of the tympanic membrane in this case does not suggest any immediate concern for hearing loss.

Question 4 of 5

The nurse is assessing a 16-year-old patient with head injuries from a recent motor vehicle accident. Which of the following statements indicates the most important reason for assessing for any drainage from the canal?

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Bloody or clear watery drainage can indicate a basal skull fracture. 2. Basal skull fractures can cause cerebrospinal fluid leakage, leading to clear watery drainage. 3. Blood in the ear canal can suggest a temporal bone fracture. 4. Assessing for drainage helps identify potential serious head injuries. Summary: A. Incorrect. Purulent drainage indicates infection, not related to head injuries. C. Incorrect. Increased cerumen is not the priority in assessing head injuries. D. Incorrect. Foreign bodies in the canal are not the primary concern in this scenario.

Question 5 of 5

While assessing the tonsils of a 30-year-old, the nurse notes that they look involuted and granular, and appear to have deep crypts. What is the correct follow-up to these findings?

Correct Answer: B

Rationale: The correct answer is B: Nothing, this is the appearance of normal tonsils. In a 30-year-old, tonsils commonly appear involuted, granular, and have deep crypts due to natural aging and exposure to infections. This is considered a normal variant and does not typically require further intervention. Referral to a specialist (Option A) is unnecessary as these findings are within the normal range. Continuing the assessment (Option C) may not yield significant abnormal findings related to the tonsils. Throat culture for strep (Option D) is not indicated unless there are specific symptoms or signs of infection.

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