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: Body image changes are the most common reaction for an adolescent who has scoliosis and requires surgical intervention, as scoliosis affects the appearance and shape of the spine and torso. Body image changes can lead to low self-esteem, social isolation, depression, or anxiety.
Choice B: Feelings of displacement are not the most common reaction for an adolescent who has scoliosis and requires surgical intervention, as displacement means feeling out of place or unwanted in a certain situation or environment. Feelings of displacement can occur due to hospitalization, separation from peers or family, or lack of control over one's life.
Choice C: Loss of privacy is not the most common reaction for an adolescent who has scoliosis and requires surgical intervention, as loss of privacy means having one's personal information or space exposed or invaded by others. Loss of privacy can occur due to frequent examinations, procedures, or interventions by health care providers or staff.
Choice D: Identity crisis is not the most common reaction for an adolescent who has scoliosis and requires surgical intervention, as identity crisis means having difficulty or confusion in defining one's self-concept or role in society. Identity crises can occur due to developmental changes, peer pressure, or cultural expectations.
Correct Answer is A
Explanation
Choice A: Using a pincer grasp indicates a need for further evaluation, as it is a developmental milestone that is usually achieved by 9 to 10 months of age. A pincer grasp is the ability to pick up small objects using the thumb and index finger. A 7-month-old infant should be able to use a raking grasp, which is the ability to scoop up objects using all fingers.
Choice B: Having a fear of strangers does not indicate a need for further evaluation, as it is a normal and expected behavior for a 7-month-old infant. A fear of strangers is a sign of attachment and recognition of familiar and unfamiliar faces. A 7-month-old infant may cry, cling, or turn away from strangers.
Choice C: Showing preferences towards foods does not indicate a need for further evaluation, as it is a normal and expected behavior for a 7-month-old infant. Showing preferences towards foods is a sign of individuality and taste development. A 7-month-old infant may accept or reject certain foods based on their flavor, texture, or appearance.
Choice D: Babbling one-syllable sounds does not indicate a need for further evaluation, as it is a normal and expected behavior for a 7-month-old infant. Babbling one-syllable sounds is a sign of language and communication development. A 7-month-old infant may make sounds such as "ba", "da", "ga", or "ma".
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