A nurse is conducting a comprehensive assessment of a child with otitis media.
Select all the appropriate assessment findings the nurse should consider.
Whisper test results.
Response to sounds.
Temperature measurement.
History of hearing problems.
Lip reading skills.
Correct Answer : A,B,D
Choice A rationale:
The nurse should consider the results of the whisper test when assessing a child with otitis media.
A whisper test helps to assess hearing acuity and can indicate if there is a hearing impairment in the child.
If the child does not respond appropriately to the whisper test, it could suggest hearing problems related to otitis media.
Choice B rationale:
Assessing the child's response to sounds is crucial in evaluating their hearing abilities.
Children with otitis media may have difficulty hearing soft sounds or may not respond appropriately to auditory stimuli.
This assessment finding can provide valuable information about the child's hearing status and potential issues related to otitis media.
Choice D rationale:
Considering the child's history of hearing problems is essential in understanding the overall context of their ear health.
A history of recurrent ear infections or hearing difficulties can indicate a chronic issue, such as otitis media, which the nurse needs to address and monitor closely.
Past hearing problems can influence the current assessment and guide appropriate interventions.
Choice C rationale:
Temperature measurement is not directly related to assessing a child with otitis media.
Otitis media primarily affects the middle ear, leading to symptoms such as ear pain, hearing loss, and sometimes drainage from the ear.
Monitoring the child's temperature is important for assessing fever, which could be a sign of infection, but it is not specific to otitis media assessment.
Choice E rationale:
Lip reading skills are not typically assessed in the context of otitis media.
Otitis media primarily affects the auditory system, leading to hearing difficulties.
While lip reading skills might be relevant for individuals with profound hearing loss, it is not a standard assessment for children with otitis media, especially during a comprehensive assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A"]
Explanation
"Difficulty locating sounds or following directions.”.
Choice A rationale:
Difficulty locating sounds or following directions is a common sign of hearing loss in children with otitis media.
Hearing loss can affect a child's ability to hear and process sounds, leading to problems in locating the source of sounds or following instructions.
This manifestation is indicative of conductive hearing loss, which is commonly associated with otitis media.
Children may have trouble understanding speech, especially in noisy environments.
Choice B rationale:
Ringing or buzzing sound in the ear, also known as tinnitus, is not a typical manifestation of hearing loss in otitis media.
Tinnitus can occur due to various reasons, but it is not a specific indicator of hearing loss associated with otitis media.
Choice C rationale:
Severe, pulsating ear pain is a symptom of acute otitis media, but it is not directly indicative of hearing loss.
Ear pain is caused by the buildup of fluid and pressure in the middle ear, leading to discomfort and pain.
However, it does not necessarily mean the child has hearing loss.
Choice D rationale:
Vertigo and nystagmus are symptoms associated with inner ear disorders, such as vestibular labyrinthitis or Meniere's disease, but they are not typical manifestations of hearing loss in otitis media.
These symptoms involve problems with balance and coordination and are not directly related to hearing loss.
Choice E rationale:
Inconsolable crying due to discomfort is a general symptom that can occur in children with various illnesses, including otitis media.
While it indicates the child is in pain or discomfort, it is not a specific sign of hearing loss.
Children may cry due to ear pain, but this symptom alone does not confirm hearing loss.
Correct Answer is ["B","D"]
Explanation
and "Balance problems result from serous fluid in the ear canal.”.
Choice A rationale:
The statement that "The ear pain is usually mild and intermittent" is incorrect.
Ear pain associated with acute otitis media (AOM) is often severe and continuous, causing discomfort and distress to the affected individual.
Choice B rationale:
Irritability, manifested as crying or fussiness, is a common symptom of AOM.
Ear pain and pressure can cause considerable discomfort, leading to irritability and changes in behavior, especially in children.
Choice C rationale:
The statement "Hearing loss in AOM is typically severe" is incorrect.
While hearing loss can occur in AOM, it is not always severe.
The degree of hearing impairment can vary based on the severity of the infection and the presence of fluid in the middle ear.
Choice D rationale:
Balance problems resulting from serous fluid in the ear canal are correct.
Serous fluid buildup in the middle ear can affect the balance mechanisms, leading to balance issues and dizziness, especially in children.
This fluid buildup can cause pressure changes, impacting the normal functioning of the inner ear.
Choice E rationale:
Otorrhea, which refers to discharge from the ear, is not a common symptom of AOM.
Otorrhea is more commonly associated with chronic ear infections or other ear conditions but not necessarily with acute otitis media.
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