A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse expect?
Tugging on the affected ear lobe
Erythema and edema of the affected ear
Pain when manipulating the affected ear lobe
Clear drainage from the affected ear
The Correct Answer is A
The correct answer is: A. Tugging on the affected ear lobe.
Choice A reason:
Tugging on the affected ear lobe is a common sign of discomfort in children with otitis media. This behavior indicates that the child is experiencing pain or pressure in the ear, which is a typical symptom of this condition. Children often cannot verbalize their discomfort, so they may tug or pull at their ears to express their pain.
Choice B reason:
Erythema and edema of the affected ear are more indicative of otitis externa (swimmer's ear) rather than otitis media. Otitis media involves inflammation and infection of the middle ear, which is not typically visible externally. The primary signs of otitis media are observed through otoscopic examination, showing a bulging or erythematous tympanic membrane.
Choice C reason:
Pain when manipulating the affected ear lobe is also more characteristic of otitis externa. In otitis media, the pain is usually deeper within the ear and not exacerbated by touching the outer ear. The pain in otitis media is due to the pressure and inflammation in the middle ear space.
Choice D reason:
Clear drainage from the affected ear is not typical of otitis media. If there is drainage, it is usually purulent (pus-like) and indicates a ruptured eardrum due to the infection. Clear drainage is more commonly associated with conditions like otitis externa or a perforated eardrum without infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Oliguria is a condition of reduced urine output, which can indicate dehydration, kidney failure, or urinary tract obstruction. It is not associated with a CNS infection, which affects the brain and spinal cord.
Choice B: A negative Brudzinski sign is a normal finding that indicates no meningeal irritation. It is elicited by flexing the neck of a supine patient and observing no involuntary flexion of the hips and knees. A positive Brudzinski sign, on the other hand, is a sign of meningitis, which is a type of CNS infection.
Choice C: A bulging fontanel is an abnormal finding that indicates increased intracranial pressure, which can be caused by a CNS infection, such as meningitis or encephalitis. A fontanel is a soft spot on the skull of an infant that allows for brain growth and development.
Choice D: Jaundice is a condition of yellowing of the skin and eyes, which can indicate liver disease, hemolytic anemia, or neonatal hyperbilirubinemia. It is not associated with a CNS infection, which affects the brain and spinal cord.
Correct Answer is C
Explanation
Choice A reason: This choice is incorrect because tying colorful latex balloons to the side of
the crib may pose a risk of choking or suffocation for the infant who is in a cast for DDH. Latex balloons are made of rubber that can break easily and form small pieces that can block the airway or lungs if swallowed or inhaled by
the infant. Therefore, avoiding latex products such as balloons, gloves, or bandages is important to prevent accidents or injuries.
Choice B reason: This choice is incorrect because following the doctor's instructions regarding activities and treatment plans is not a specific strategy to promote the infant's growth and development. Following
the doctor's instructions regarding activities and treatment plans is a general responsibility of the nurse that applies to any client who has any condition or procedure. It may help to ensure the safety and effectiveness of the care, but it does not address the developmental needs of the infant who is in a cast for DDH.
Choice C reason: This choice is correct because providing a small electronic toy is a specific strategy to promote
the infant's growth and development. Providing a small electronic toy can help stimulate the infant's senses, cognition, and motor skills by offering visual, auditory, or tactile feedback. It may also help to reduce boredom, frustration, or depression by providing entertainment, diversion, or comfort. Therefore, providing a small electronic toy can help to enhance the developmental outcomes of the infant who is in a cast for DDH.
Choice D reason: This choice is incorrect because changing the infant's diaper as soon as soiling occurs is not a specific strategy to promote the infant's growth and development. Changing the infant's diaper as soon as soiling occurs is a general hygiene measure that applies to any infant who wears a diaper. It may help to prevent skin irritation, infection, or odor by keeping the diaper area clean and dry, but it does not address the developmental needs of the infant who is in a cast for DDH.
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