On assessment of the client with otitis media, the nurse notes that the tympanic membrane is retracted and the landmarks visible. Which of the following is the priority nursing diagnosis for the client at this stage?
A. Acute Pain related to increased middle ear pressure
B. Risk for Infection related to presence of bacteria in the middle ear
C. Impaired Verbal Communication related to diminished hearing in affected ear
D. Risk for Imbalanced Fluid Volume related to potential nausea and vomiting
A
Acute pain accompanies otitis media and can be incapacitating. Antibiotics are required if a bac-terial cause is suspected. However, as the disease progresses to stage 3, with increased redness, bulging, and loss of landmarks, the ear is at risk for perforation. More aggressive intervention is required.
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