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 D
Explanation
Choice A Reason:
Stretch the perineum taut when applying the bag. Taut stretching might cause discomfort or be unnecessary for applying the collection bag and could potentially disrupt the process.
Choice B Reason:
Apply lidocaine gel to the perineum before attaching the bag. Applying lidocaine gel isn't typically necessary for routine urine collection and might not be appropriate for this procedure in an infant without specific indications for its use.
Choice C Reason:
Place a snug-fitting diaper over the drainage bag. Placing a diaper over the collection bag might interfere with the collection process, cause the bag to shift, or create unnecessary pressure on the area.
Choice D Reason:
Position the opening of the bag over the urethra and the anus. Placing the opening of the collection bag over both the urethra and the anus increases the chances of capturing urine effectively. It allows for the collection of a clean catch urine sample while minimizing the risk of contamination from the anus.
Correct Answer is A
Explanation
Choice A Reason:
Type 1 diabetes mellitus is correct. Type 1 diabetes is considered a risk factor for cardiovascular disease due to its potential impact on blood vessels and the heart over time. Individuals with diabetes, especially poorly controlled diabetes, are at a higher risk of developing cardiovascular complications such as heart disease, stroke, and peripheral vascular disease.
Choice B Reason:
Orthostatic hypotension is incorrect. Orthostatic hypotension refers to a drop-in blood pressure when moving from a lying or sitting position to a standing position. While it can cause symptoms like dizziness or lightheadedness, it's not typically considered a direct risk factor for cardiovascular disease. However, it might be associated with other conditions or medications that could contribute to cardiovascular issues indirectly.
Choice C Reason:
BMI of 24 is incorrect. A BMI (Body Mass Index) of 24 falls within the normal weight range. While obesity (especially central obesity or higher BMIs) is a known risk factor for cardiovascular disease, having a BMI of 24 by itself is not considered a significant risk factor for developing cardiovascular issues.
Choice D Reason:
Family history of osteoporosis is incorrect. Osteoporosis is a condition characterized by weakened bones, not directly related to cardiovascular disease. A family history of osteoporosis doesn't inherently indicate an increased risk of cardiovascular disease unless there are other associated factors or conditions within the family history that contribute to cardiovascular issues.
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