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 rationale
Tugging on the affected ear lobe is a common sign of otitis media in children. This behavior is often observed because the child is experiencing discomfort or pain in the ear, and tugging or pulling on the ear lobe is a way to express or alleviate that discomfort.
Choice B rationale
Erythema and edema of the affected ear are not typical findings in otitis media. These symptoms are more commonly associated with external ear infections, such as otitis externa.
Choice C rationale
Pain when manipulating the affected ear lobe is more indicative of otitis externa rather than otitis media. Otitis media involves the middle ear, and manipulation of the ear lobe does not typically cause pain.
Choice D rationale
Clear drainage from the affected ear is not a typical finding in otitis media. If there is drainage, it is usually purulent (pus-like) and indicates a more severe infection or a ruptured eardrum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["83"]
Explanation
Step 1: Calculate the infusion rate. 1,000 mL ÷ 12 hr = 83.33 mL/hr Step 2: Round to the nearest whole number. 83.33 mL/hr ≈ 83 mL/hr.
The nurse should set the IV pump to deliver 83 mL/hr.
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale
Sitting on a nurse’s lap leaning forward is a position that can be used for postural drainage in infants with cystic fibrosis. This position helps drain secretions from the upper lobes of the lungs.
Choice B rationale
The supine position (lying on the back) is also used for postural drainage to target different areas of the lungs. It is not contraindicated for infants with cystic fibrosis.
Choice C rationale
Sitting on a nurse’s lap leaning backward is another position that can be used for postural drainage. This position helps drain secretions from the lower lobes of the lungs.
Choice D rationale
The Trendelenburg position (lying flat on the back with the feet elevated higher than the head) is contraindicated for infants with cystic fibrosis. This position can increase the risk of gastroesophageal reflux and aspiration, which can worsen respiratory symptoms.
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