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 A
Explanation
Choice A: This response indicates an understanding of the teaching, as pancreatic enzymes are essential for a child who has cystic fibrosis (CF), which is a condition that causes thick mucus to block the pancreatic ducts and impair digestion and absorption of nutrients. Pancreatic enzymes help break down fats, proteins, and carbohydrates in food and prevent malnutrition, steatorrhea, or vitamin deficiencies. Pancreatic enzymes should be given with snacks and meals to ensure adequate digestion.
Choice B: This response indicates a lack of understanding of the teaching, as low-fat meals with limited protein are not recommended for a child who has cystic fibrosis (CF), which is a condition that causes thick mucus to block the pancreatic ducts and impair digestion and absorption of nutrients. Low-fat meals with limited protein can cause malnutrition, weight loss, or growth failure in a child who has CF. A high-calorie, high-protein diet is recommended for a child who has CF to meet their increased energy needs and promote growth and development.
Choice C: This response indicates a lack of understanding of the teaching, as limiting fluid intake is not recommended for a child who has cystic fibrosis (CF), which is a condition that causes thick mucus to block the airways and lungs and cause respiratory infections and complications. Limiting fluid intake can cause dehydration, thickening of mucus, or difficulty in expectoration in a child who has CF. Adequate fluid intake is recommended for a child who has CF to hydrate the body, thin out mucus, and facilitate clearance.
Choice D: This response indicates a lack of understanding of the teaching, as restricting salt intake is not recommended for a child who has cystic fibrosis (CF), which is a condition that causes excessive loss of salt through sweat due to abnormal chloride transport in cells. Restricting salt intake can cause hyponatremia, dehydration, or electrolyte imbalance in a child who has CF. Adequate salt intake is recommended for a child who has CF to replace the lost salt and maintain fluid and electrolyte balance.
Correct Answer is B
Explanation
Choice A: This information is incorrect, as the first dose of the diphtheria, tetanus, pertussis (DTaP) vaccine is usually given at 2 months of age, not 2 weeks. The DTaP vaccine protects against three serious bacterial diseases that can cause respiratory infections, nerve damage, or death. The DTaP vaccine is given in five doses at 2, 4, 6, 15 to 18 months, and 4 to 6 years of age.
Choice B: This information is correct, as the first dose of the hepatitis B vaccine is usually given within 24 hours of birth or prior to discharge from the hospital. The hepatitis B vaccine protects against a viral infection that can cause liver inflammation, cirrhosis, or cancer. The hepatitis B vaccine is given in three doses at birth, 1 to 2 months, and 6 to 18 months of age.
Choice C: This information is incorrect, as the first dose of the measles, mumps, rubella (MMR) vaccine is usually given at 12 to 15 months of age, not 6 months. The MMR vaccine protects against three viral diseases that can cause fever, rash, swelling of glands, or complications such as pneumonia, encephalitis, or deafness. The MMR vaccine is given in two doses at 12 to 15 months and 4 to 6 years of age.
Choice D: This information is incorrect, as the first dose of the pneumococcal conjugate (PCV13) vaccine is usually given at 2 months of age, not on the first birthday. The PCV13 vaccine protects against a bacterial infection that can cause pneumonia, meningitis, or sepsis. The PCV13 vaccine is given in four doses at 2, 4, 6, and 12 to 15 months of age.
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