A nurse is assessing a child with suspected otitis media.
Which aspect should the nurse evaluate regarding pain?
"I feel a sharp pain in my ear sometimes.”..
"My ear hurts all the time.”..
"The pain gets worse when I lie down.”..
"I have no pain in my ear.”..
The Correct Answer is C
"The pain gets worse when I lie down.”.
Choice A rationale:
"I feel a sharp pain in my ear sometimes.”.
This statement suggests intermittent ear pain, which can occur in otitis media when there is a sudden change in pressure in the middle ear.
It is a possible symptom, but it is not specific to otitis media as other ear conditions can also cause sharp ear pain.
Choice B rationale:
"My ear hurts all the time.”.
Constant ear pain is a common symptom of acute otitis media.
The pain is caused by inflammation and pressure in the middle ear.
This symptom is indicative of otitis media but does not provide specific information about the pain worsening when lying down, which is a crucial aspect to assess.
Choice C rationale:
"The pain gets worse when I lie down.”.
This statement is indicative of otitis media.
When the child lies down, the fluid in the middle ear can put additional pressure on the eardrum, causing increased pain.
This worsening of pain in specific positions helps differentiate otitis media from other ear conditions.
Choice D rationale:
"I have no pain in my ear.”.
Absence of ear pain is not consistent with otitis media.
Otitis media is characterized by ear pain, especially in acute cases when there is inflammation and pressure in the middle ear.
Lack of ear pain suggests the absence of this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Choice A rationale:
Redness of the tympanic membrane can indicate inflammation, which is a common sign of acute otitis media (AOM).
Inflammation causes increased blood flow to the area, leading to redness and often pain.
Choice B rationale:
Bulging of the tympanic membrane occurs when there is increased pressure behind the eardrum, often due to fluid accumulation.
In the context of acute otitis media, this bulging is caused by the buildup of pus or other fluids in the middle ear.
Choice C rationale:
Purulence (pus) observed in the ear canal is a definitive sign of acute otitis media.
The presence of pus indicates an active infection within the middle ear.
Choice D rationale:
Orange discoloration of the tympanic membrane is not a typical finding in acute otitis media.
The color change could be due to various factors but is not specific to this condition.
Choice E rationale:
Decreased mobility of the tympanic membrane can occur due to the accumulation of fluid in the middle ear, leading to impaired movement.
This decreased mobility is often observed in acute otitis media and contributes to the diagnosis.
Correct Answer is D
Explanation
Choice A rationale:
Age alone is not a risk factor for otitis media.
However, certain age groups, such as young children, are more susceptible to ear infections due to their developing immune systems and shorter Eustachian tubes.
Choice B rationale:
Season is not a direct risk factor for otitis media.
While certain respiratory infections might be more common in specific seasons, otitis media itself is not strongly influenced by seasonal changes.
Choice C rationale:
Allergies can contribute to ear infections, but they are not the most closely associated risk factor mentioned in the context.
Allergies can lead to inflammation and fluid buildup in the middle ear, making individuals more prone to infections.
However, in the given options, day care attendance is a more specific risk factor related to exposure to infectious agents.
Choice D rationale:
Day care attendance is closely associated with an increased exposure to infectious agents, including the bacteria that can cause otitis media.
Children in day care settings are in close contact with others, facilitating the spread of infections.
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