A nurse is assessing an infant who has acute otitis media. Which of the following findings should the nurse expect? (Select all that apply.)
Enlarged subclavicular lymph node
Fever
Crying
Increased appetite
Restlessness
Correct Answer : B,C,E
Choice A Reason:
Enlarged subclavicular lymph node (A) is not a typical finding associated with acute otitis media. Enlarged lymph nodes in the neck area (cervical lymph nodes) might be observed due to the nearby infection, but the subclavicular lymph nodes are located below the clavicle and are not typically associated with ear infections.
Choice B Reason:
Fever: Infants with acute otitis media often present with a fever. Elevated body temperature is a common symptom of an infection, including ear infections.
Choice C Reason:
Crying: Ear pain is a common symptom of acute otitis media. Infants may express discomfort or pain by crying, especially when lying down due to increased pressure in the middle ear.
Choice D Reason:
Increased appetite is also not a common finding in acute otitis media. Generally, a decrease in appetite might occur due to feeling unwell or discomfort, but increased appetite is not a typical symptom of this condition.
Choice E Reason:
Restlessness: Due to discomfort or pain caused by the ear infection, infants with acute otitis media might exhibit restlessness or irritability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Neck vein distention is incorrect. Neck vein distention is not a common symptom of aspirin poisoning. It might be seen in conditions like heart failure but is not typically associated with aspirin toxicity.
Choice B Reason:
Polyuria is incorrect. Excessive urination (polyuria) is not a typical symptom of acute aspirin poisoning. Aspirin toxicity more commonly presents with symptoms related to the central nervous system, respiratory distress, metabolic acidosis, and temperature dysregulation.
Choice C Reason:
Hyperpyrexia is correct. Acute aspirin poisoning can lead to an increased body temperature (hyperpyrexia) due to its effects on the central nervous system and interference with the body's temperature regulation mechanisms. Aspirin toxicity can result in alterations in the hypothalamus, leading to an elevated body temperature.
Choice D Reason:
Jaundice is incorrect. Jaundice, the yellowing of the skin and eyes, is not a characteristic finding of acute aspirin poisoning. It is more commonly associated with liver dysfunction or certain types of liver diseases but is not a typical manifestation of aspirin toxicity.
Correct Answer is D
Explanation
Choice A Reason:
Inserting an IV is not typically required for this specific test. The test involves applying a substance (pilocarpine) to the skin to stimulate sweat production in a localized area for sweat collection.
Choice B Reason:
Measuring protein in the urine over a 24-hour period is unrelated to the pilocarpine iontophoresis test for cystic fibrosis. Protein measurement in urine over a 24-hour period is a different diagnostic test used for various conditions, but not for cystic fibrosis diagnosis.
Choice C Reason:
Fasting for 8 hours prior to the test is not necessary for the pilocarpine iontophoresis test. There's no requirement for fasting before this particular test.
Choice D Reason:
"The test will measure the amount of chloride in your baby's sweat." Is correct. Pilocarpine iontophoresis testing is a diagnostic test used to measure the concentration of chloride in a person's sweat. Elevated chloride levels in sweat are a hallmark of cystic fibrosis, so this test helps in the diagnosis of the condition.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today