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 B
Explanation
The correct answer is choice B: Instruct the parent to avoid pressing on the abdominal area.
Rationale for each choice:
- Choice A: Schedule the child for an abdominal ultrasound. While an ultrasound may be necessary for further diagnosis, it is not the immediate priority. The child’s symptoms suggest a possible Wilms’ tumor, a type of kidney cancer that primarily affects children. An ultrasound can help confirm this diagnosis, but it should not be the first action.
- Choice B: Instruct the parent to avoid pressing on the abdominal area. This is the correct answer. If the child has a Wilms’ tumor, pressing on the abdominal area could potentially cause the cancer to spread. Therefore, it is crucial to avoid any unnecessary pressure on the abdomen until further medical evaluation can be performed.
- Choice C: Determine if the child is having pain. While assessing for pain is an important part of nursing care, it is not the immediate priority in this situation. The child’s symptoms need urgent medical attention, and assessing for pain will not provide the necessary information to guide immediate care.
- Choice D: Obtain a urine specimen for a urinalysis. Although a urinalysis can provide valuable information about a patient’s health, it is not the immediate priority in this situation. The child’s symptoms suggest a possible Wilms’ tumor, which requires immediate medical attention. A urinalysis may be part of the diagnostic process, but it should not be the first action taken.
Correct Answer is B
Explanation
Choice B rationale
Gelatin is part of a clear liquid diet. This type of diet is often prescribed before medical procedures or tests, or for patients with certain digestive issues. It consists of liquids and foods that are clear and liquid at room temperature.
Choice A rationale
Yogurt is not part of a clear liquid diet. It is a dairy product and is not clear or liquid at room temperature.
Choice C rationale
Strained soup might be allowed on a full liquid diet, but it is not part of a clear liquid diet. Only the broth of the soup, which is clear and liquid at room temperature, would be allowed.
Choice D rationale
Pureed fruit is not part of a clear liquid diet. While it is a liquid at room temperature, it is not clear.
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