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 B
Explanation
Choice A Reason:
Providing video games prior to bedtime might actually stimulate the child and make it harder for them to relax and fall asleep.
Choice B Reason:
Follow the child's home sleep routine to reduce anxiety. Maintaining consistency with the child's home sleep routine can provide familiarity and comfort, potentially reducing anxiety and promoting better sleep. This familiarity can help the child feel more secure and relaxed, aiding in the transition to sleep in an unfamiliar environment.
Choice C Reason:
Leaving the lights on in the child's room can disrupt the child's ability to achieve restful sleep as the environment may not be conducive to falling and staying asleep.
Choice D Reason:
Allowing the child to adjust their bedtime might not be the best approach in a hospital setting, as maintaining some routine and structure could be more beneficial for their recovery and overall well-being during the hospital stay.
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