A nurse is caring for a child who has otitis media with effusion. The nurse should identify which of the following manifestations indicates a tympanic membrane rupture.

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.

Choice A:In actual practice, log rolling is typically done every 2 hoursto align with standard nursing protocols for preventing complications such as pressure injuries, maintaining skin integrity, and ensuring patient comfort. Repositioning every 2 hours also helps promote better circulation and reduces the risk of complications like pneumonia and deep vein thrombosis (DVT).
as a unit without twisting or bending the spine. The nurse should use a draw sheet and at least two other staff
members to assist with log rolling.

Choice B: This intervention is incorrect, as keeping the head of the bed at a 30-degree angle can cause flexion of the spine and compromise spinal alignment. The head of the bed should be kept flat or slightly elevated, depending on the provider's orders and the client's comfort. The nurse should avoid raising or lowering the head of the bed without checking with the provider first.

Choice C: This intervention is unnecessary, as placing the client in protective isolation is not indicated for a client who is postoperative following scoliosis repair with Harrington rod instrumentation. Protective isolation is used for clients who have compromised immune systems and are at high risk of acquiring infections from others, such as transplant recipients, cancer patients, or patients receiving immunosuppressive therapy. The nurse should follow standard precautions and surgical site care to prevent infection in this client.

Choice D: This intervention is optional, as initiating the use of a PCA pump for pain control may or may not be appropriate for a client who is postoperative following scoliosis repair with Harrington rod instrumentation. A PCA pump is a device that allows the client to self-administer a preset dose of analgesic medication by pressing a button. A PCA pump can provide effective and individualized pain relief, but it requires careful monitoring and education. The nurse should assess the client's pain level, preference, and ability to use a PCA pump and consult with the provider before initiating it.