The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe?
A red, dull, thick, and immobile tympanic membrane.
A transparent and clear tympanic membrane.
A pearly colored tympanic membrane.
A pink colored tympanic membrane.
The Correct Answer is A
A. Mastoiditis often results in inflammation and infection that extend to the middle ear, causing the tympanic membrane to appear red, dull, thickened, and immobile upon examination.
B. A transparent and clear tympanic membrane is typical in a healthy ear, not in cases of mastoiditis.
C. A pearly colored tympanic membrane is also indicative of a normal, healthy ear without infection.
D. A pink-colored tympanic membrane may suggest mild irritation but is not a characteristic finding of mastoiditis.
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Correct Answer is C
Explanation
A. Diplopia is a concerning symptom but does not indicate immediate deterioration in neurological status like a change in GCS does.
B. Ataxia is also significant but is less acute than a drop in GCS score.
C. A change in the Glasgow Coma Scale score from 13 to 11 indicates a worsening level of consciousness and necessitates immediate reporting, as it may suggest increased intracranial pressure or other complications.
D. A decrease in heart rate from 76 to 69 bpm is not significant enough in the context of TBI to warrant immediate reporting, as it remains within a normal range.
Correct Answer is A
Explanation
A. Hypertension with bradycardia is characteristic of autonomic dysreflexia due to the exaggerated sympathetic response causing increased blood pressure while the body compensates with bradycardia.
B. Hypotension with tachycardia is not indicative of autonomic dysreflexia; instead, it suggests different underlying issues.
C. While hypertension can occur in autonomic dysreflexia, it is typically accompanied by bradycardia, not tachycardia.
D. Hypotension with bradycardia does not correlate with autonomic dysreflexia and suggests other health complications.