# A nurse is caring for a client diagnosed with otitis externa. Which nursing intervention should the nurse implement first? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541680 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client diagnosed with otitis externa. Which nursing intervention should the nurse implement first? A 28-year-old client presents to the emergency department with severe ear pain, itching, and discharge from the right ear. The client reports recent swimming activities and states the pain worsens when the ear is touched. ## 보기 1. Administer prescribed antibiotic ear drops immediately 2. Irrigate the ear canal with warm saline solution 3. Apply a warm compress to the affected ear 4. Assess the client's pain level and hearing status **✔ 정답** **정답: 4** ## 해설 The nurse should first assess pain and hearing status to establish baseline data before interventions, as per the nursing process. Other interventions like ear drops or irrigation require prior assessment to avoid complications. ## 심화 해설 Understanding the Priority Setting Framework Before determining the correct intervention, it is essential to apply a clinical decision-making framework. In NCLEX-RN prioritization, the nursing process dictates that assessment must always precede implementation, unless the client is experiencing a life-threatening emergency. This question tests your ability to distinguish between an assessment action and an intervention action when a client presents with a non-life-threatening, acute condition. Pathophysiology and Clinical Presentation The client's history of recent swimming, severe ear pain that worsens with manipulation (tragus or pinna tenderness), itching, and discharge points directly to acute otitis externa, commonly known as swimmer's ear. This is an inflammatory condition of the external auditory canal, with or without infection [1]. The inflammation can cause significant discomfort, itching, and a sensation of fullness or impaired hearing due to edema and debris in the canal [1]. Understanding this pathophysiology helps you see why a thorough assessment is the critical first step: you need to establish a baseline for the severity of inflammation, the extent of hearing involvement, and the precise nature of the discharge before initiating any treatment that could alter these findings. Analysis of the Correct Answer (Option 4) The nurse should first assess the client's pain level and hearing status. This is the correct initial action because it aligns with the first step of the nursing process: assessment. Before you can evaluate the effectiveness of any intervention, you must have a baseline. Using a standardized pain scale quantifies the client's subjective experience of discomfort, a hallmark symptom of the condition [1]. Assessing hearing status, even grossly, documents the degree of conductive hearing loss that often accompanies canal occlusion from edema and discharge. This baseline data is vital for determining if the client's condition is improving or deteriorating after treatments like ear drops are initiated. Analysis of Incorrect Answers Option 1: Administer prescribed antibiotic ear drops immediately. While topical antibiotic drops are a mainstay of treatment for otitis externa [1], administration is an implementation step. It is premature to administer medication before performing a focused assessment. You must first evaluate the patency of the ear canal. If significant edema or debris is present, the drops may not reach the site of infection, rendering them ineffective. Furthermore, you need a baseline pain score to later judge the analgesic and therapeutic effect of the medication. Option 2: Irrigate the ear canal with warm saline solution. Ear canal irrigation is an intervention that is not a first-line nursing action without a direct order and a confirmed intact tympanic membrane. In the context of acute otitis externa, irrigation could cause further maceration of the already inflamed canal skin and introduce pathogens deeper into the tissue. More critically, the client's history does not rule out a tympanic membrane perforation, which is an absolute contraindication for irrigation. Assessment of the tympanic membrane by a qualified provider is required before this intervention can even be considered. Option 3: Apply a warm compress to the affected ear. Applying a warm compress is a comfort measure that can provide symptomatic relief for the pain associated with otitis externa. However, it is a non-pharmacological intervention. As with medication administration, the nurse must first assess the client's pain level to establish a baseline. Without this initial assessment, you cannot objectively measure whether the warm compress or any subsequent analgesic was effective in reducing the client's pain. The nursing process requires assessment before any comfort intervention.References (research sources) - [1]Interventions for acute otitis externa.Research articleKaushik V, Malik T, Saeed SR. (2010) · DOI: 10.1002/14651858.cd004740.pub2 ## 임상 시나리오 Otitis Externa: Initial Nursing PriorityAssessment Before Intervention The nursing process mandates that assessment precedes implementation for non-life-threatening conditions. For a client with suspected otitis externa, first establish a baseline of pain level and hearing status. Key assessment findings include tragus tenderness (pain with manipulation of the pinna), itching, and discharge. Document the character of any drainage and the degree of canal edema before initiating treatment. CautionNever irrigate the ear canal before confirming an intact tympanic membrane. Instilling ear drops or applying heat before a baseline pain assessment alters clinical findings and delays accurate diagnosis. ## 핵심 개념 - **Otitis Externa** — Inflammation of the external auditory canal, often caused by bacterial or fungal infection, commonly known as swimmer's ear. - **Nursing Process** — A systematic problem-solving framework (Assessment, Diagnosis, Planning, Implementation, Evaluation) where assessment always comes first unless a life-threatening emergency exists. - **Tragus Tenderness** — Pain elicited by pulling on the auricle or pressing on the tragus, a hallmark sign of otitis externa that helps differentiate it from otitis media. ## 같은 주제 문제 - [A 25-year-old client presents to the emergency department complaining of severe ear pain t…](https://mymerci.kr/pages/nclex_q.php?qn_id=541677) - [A nurse is assessing a client with suspected otitis externa. 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