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 reason: This choice is incorrect because 1 cup of cooked rice provides more than 1 oz of grains. According to the U.S. Department of Agriculture (USDA), one-ounce equivalent of grains equals one slice of bread, one cup of ready-to-eat cereal, or half a cup of cooked rice, pasta, or cereal. Therefore, 1 cup of cooked rice provides about 2 oz of grains.
Choice B reason: This choice is incorrect because 1/2 slice of white bread provides less than 1 oz of grains. As explained above, one-ounce equivalent of grains equals one slice of bread, so 1/2 slice of white bread provides only 0.5 oz of grains.
Choice C reason: This choice is correct because 1 cup of ready-to-eat cereal flakes provides exactly 1 oz of grains. As explained above, the one-ounce equivalent of grains equals one cup of ready-to-eat cereal, so 1 cup of ready-to-eat cereal flakes provides 1 oz of grains.
Choice D reason: This choice is incorrect because 1/2 white flour tortilla provides less than 1 oz of grains. According to the USDA, one-ounce equivalent of grains equals one small tortilla (6 inches in diameter), so 1/2 white flour tortilla provides only about 0.4 oz of grains.
Correct Answer is ["B","C"]
Explanation
Choice A: Clubbing of the nail beds is not a finding that the nurse should expect in a child who has aortic stenosis, which is a condition that causes narrowing of the aortic valve and obstructs blood flow from the left ventricle to the aorta. Clubbing of the nail beds is a sign of chronic hypoxia, which can occur in conditions that affect the lungs or the right side of the heart.
Choice B: Murmur is a finding that the nurse should expect in a child who has aortic stenosis, as it indicates turbulent blood flow through the narrowed valve. A murmur can be heard with a stethoscope over the chest and may vary in intensity, pitch, and duration. A murmur caused by aortic stenosis is typically systolic, loud, and harsh and radiates to the neck or back.
Choice C: Weak pulses are a finding that the nurse should expect in a child who has aortic stenosis, as they indicate reduced blood flow and pressure in the peripheral arteries. Weak pulses can be felt with palpation of the radial, brachial, femoral, or pedal arteries and may be difficult to detect or absent.
Choice D: Bradycardia is not a finding that the nurse should expect in a child who has aortic stenosis, as it indicates a slow heart rate, which is less than 60 beats per minute in children. Bradycardia can occur in conditions that affect the electrical conduction system of the heart or cause increased vagal tone. A child who has aortic stenosis may have tachycardia, which is a fast heart rate, as a compensatory mechanism to increase cardiac output.
Choice E:Hypertension is not typically associated with aortic stenosis in children; instead, the condition often results in reduced blood pressure distal to the valve.
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