A nurse is collecting data from an infant who has otitis media. Which of the following findings should the nurse expect?
Bluish-green discharge from the ear canal
Erythema and edema of the affected auricle
Increase in appetite
Tugging on the affected ear lobe
The Correct Answer is D
Choice A rationale
Bluish-green discharge from the ear canal is not a typical finding in otitis media. This could suggest a different condition, such as an external ear infection or a ruptured eardrum.
Choice B rationale
Erythema and edema of the affected auricle (outer part of the ear) are not typical findings in otitis media. These symptoms are more commonly associated with conditions affecting the external ear, such as otitis externa.
Choice C rationale
An increase in appetite is not typically associated with otitis media. In fact, children with otitis media may have a decreased appetite due to discomfort or pain while swallowing.
Choice D rationale
Tugging on the affected ear lobe is a common sign of otitis media in infants and young children. This is often due to the pain and discomfort caused by the infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Assessing fluid balance is the priority action when caring for a child with severe diarrhea. Diarrhea can lead to significant fluid and electrolyte loss, which can result in dehydration. Early recognition and treatment of dehydration are crucial to prevent further complications.
Choice B rationale
While maintaining fluid therapy is an important part of managing severe diarrhea, the first step should be to assess the child’s fluid balance.
Choice C rationale
Rehydration is a key part of the treatment for severe diarrhea, but it should be done after assessing the child’s fluid balance.
Choice D rationale
Introducing a regular diet is usually done after the acute phase of diarrhea has resolved and the child’s fluid balance has been restored.
Correct Answer is C
Explanation
Choice A rationale
While maintaining a saline-lock can be important for administering medications or fluids, it is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.
Choice B rationale
A no-salt-added diet may be recommended for some children with acute glomerulonephritis to help manage fluid balance and blood pressure. However, this is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.
Choice C rationale
This is the correct answer. Checking the child’s weight daily is a priority action because weight changes can indicate fluid retention or loss, which can affect kidney function. Regular weight checks can help guide treatment decisions and monitor the effectiveness of interventions.
Choice D rationale
Educating the parents about potential complications is important, but it is not the priority action. The nurse’s priority should be to assess the child’s condition and intervene to prevent complications.
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