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 A
Explanation
Choice A Reason:
"I cannot confirm or deny that we have a client by that name." This response respects the patient's right to confidentiality under HIPAA (Health Insurance Portability and Accountability Act) regulations. It neither confirms nor denies the patient's presence in the hospital, preserving the patient's privacy and confidentiality.
Choice B Reason:
"I will tell him you called." This response doesn't uphold patient confidentiality. Revealing that the employer called could indirectly confirm the patient's presence in the hospital, potentially breaching confidentiality.
Choice C Reason:
"The client's condition is stable right now." Sharing any information about the patient's condition with someone who hasn't been authorized to receive it breaches patient confidentiality. Even sharing a seemingly benign statement about stability can indirectly disclose the patient's presence in the hospital.
Choice D Reason:
"He is here in the hospital, but I cannot tell you anything else. “While it refrains from divulging more information, it still confirms the patient's presence in the hospital, breaching confidentiality.
Correct Answer is A
Explanation
Choice A Reason:
Pad the side rails of the crib is correct. This intervention aims to ensure the infant's safety by preventing injury or entrapment in the crib. It's relevant to prevent accidental harm, especially if the infant is experiencing seizures or increased muscle tone due to meningitis.
Choice B Reason:
Keep the television on in the room to provide background noise is incorrect. Background noise might be distracting and uncomfortable for an infant with bacterial meningitis, especially if they're experiencing sensitivity to light and sound due to their condition. A quiet, calm environment is generally more conducive to their recovery.
Choice C Reason:
Place the infant in a semiprivate room is incorrect. Providing a quieter environment with fewer disturbances can be beneficial for an infant with bacterial meningitis. This measure promotes rest and minimizes exposure to potential infections from other patients.
Choice D Reason:
Provide frequent range of motion to the neck and shoulders is incorrect. In cases of bacterial meningitis, particularly when inflammation occurs in the meninges (the protective membranes covering the brain and spinal cord), excessive movement or manipulation of the head and neck might be painful and could exacerbate symptoms.
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