Answer to Question 1
2. Administer acetaminophen (Tylenol) to relieve discomfort
Rationale:
An infant with a bulging tympanic membrane because of acute otitis media will have pain. Acetaminophen (Tylenol) should be provided to relieve the discomfort associated with acute otitis media. A flat-lying position may exacerbate the discomfort. Elevating the head slightly is recommended. Decongestants are not recommended for treatment of acute otitis media. Placing infants to sleep with a pacifier may increase the incidence of otitis media.
Answer to Question 2
2. Risk for Trauma
Rationale:
The client's symptoms are seen in labyrinthitis or Mnire's disease, which disturbs all balance and coordination of motor skills related to gravitational pulls and is a disturbance of the inner ear. The risk for trauma is the top priority. With imbalance and altered sensory input/perception, the risk for falls is very high. Actions to prevent injury from falls and/or other trauma should be the highest priority in management of care. Imbalanced nutrition is not the top priority, although this is relative to the symptoms present. The symptoms of vertigo and tinnitus do alter the ability to rest and sleep effectively but should not be the first priority. Long-term sleep deficits can lead to major psychological disorders that do need to be assessed further, but safety is a more immediate problem for this client. Disturbed sensory perception is accurate for a client who has tinnitus, vertigo, nausea; however, the first priority is safety related to falls.
Nurse-patient interaction; nonveral communication
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Entry level nurse competencies
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Personal care setting.
Topic Media