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 C
Explanation
The correct answer is Choice C.
Choice A rationale
Puberty might be delayed if scrotal changes have not occurred by the age of 13½ to 14 years, not 11 years.
Choice B rationale
Changes in the voice occur during puberty but do not signal its beginning. Enlargement of the testicles is the first sign of puberty in boys.
Choice C rationale
Growth spurts in height typically occur toward the end of mid-puberty, making this the correct answer.
Choice D rationale
Gynecomastia, or the development of breast tissue in boys, commonly occurs during mid- puberty, not late puberty. .
Correct Answer is ["C","E"]
Explanation
Choice A rationale:
Evaluating the infant’s pain level using the FACES Scale is not appropriate for infants. The FACES Scale is typically used for children aged 3 years and older.
Choice B rationale:
Offering the infant small, frequent feedings of thickened liquids is not recommended in this scenario. The infant is on NPO (nothing by mouth) status due to the forceful vomiting and risk of aspiration.
Choice C rationale:
Measuring the infant’s head circumference is important to assess for any signs of increased intracranial pressure or hydrocephalus, which can be associated with vomiting.
Choice D rationale:
Implementing contact precautions is not necessary unless there is a known or suspected infectious cause for the vomiting.
Choice E rationale:
Weighing the infant is crucial to monitor for any significant weight loss, which can indicate dehydration or other underlying issues.
Choice F rationale:
Planning to administer a plain water enema to the infant is not appropriate in this scenario. The primary concern is the forceful vomiting, and an enema would not address this issue.
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