Advanced Health Assessment Practice Exam

Which characteristic feature of the tympanic membrane should a nurse expect in a client with acute otitis media?

1. Red, bulging, with an absent light reflex

2. Clear, flat, with a visible light reflex

3. Pearly gray, normal tension, with a prominent cone of light

4. Yellow, retracted, with a visible blood vessel pattern

The correct answer is: Red, bulging, with an absent light reflex

In a client with acute otitis media, the tympanic membrane typically presents with specific characteristics indicative of the underlying infection and inflammation. Redness and bulging of the tympanic membrane occur due to increased pressure within the middle ear, resulting from the accumulation of fluid and pus. This process occurs as a direct response to infection, leading to inflammation and altering the normal appearance of the membrane. The absence of the light reflex is another key feature to note, as the light reflex usually appears as a bright cone of light on the membrane when it is healthy. In the case of acute otitis media, the distortion of the tympanic membrane due to swelling often obscures this normal reflex, making it absent in affected individuals. Therefore, recognizing these specific signs—redness, bulging, and an absent light reflex—is crucial for assessing the tympanic membrane in the context of acute otitis media and understanding the implications for the patient's condition. This knowledge helps inform treatment interventions and patient education on the disease process.