A nurse providing care to a child diagnosed with chronic otitis media with effusion (OME) will assess for which sign/symptom?

Fever as high as 40° C (104° F)

Severe pain in the ear

Nausea and vomiting

A feeling of fullness in the ear

Answer and Explanation

The Correct Answer is D

Chronic otitis media with effusion (OME) is a condition where fluid accumulates in the middle ear without signs of infection.

This can cause hearing loss, speech delay, and balance problems. The child may complain of a feeling of fullness or pressure in the ear.

Choice A is wrong because a fever as high as 40° C (104° F) is a sign of acute otitis media, which is an infection of the middle ear with inflammation and pus formation.

Choice B is wrong because severe pain in the ear is also a sign of acute otitis media, not chronic otitis media with effusion.

Choice C is wrong because nausea and vomiting are not typical symptoms of chronic otitis media with effusion. They may be associated with other conditions such as gastroenteritis or vestibular disorders.

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Correct Answer is ["C","D","E"]

Explanation

The parents should notify the physician if the infant has a temperature above 37.7° C (100° F), new frequent coughing, or turning blue or bluer

than normal. These are signs of infection, respiratory distress, or cyanosis, which could indicate complications after cardiac surgery.

Choice A is wrong because a respiratory rate of 36 breaths/minute at rest is within the normal range for an infant.

Choice B is wrong because an appetite slowly increasing is a positive sign of recovery and does not require immediate attention.

A. A normal finding B. An abnormal finding: the child needs referral to an ophthalmologist C. A sign of a possible visual defect; the child needs vision screening D. A sign of small hemorrhages, which usually resolve spontaneously

Correct Answer is A

Explanation

A brilliant, uniform red reflex in both eyes is a sign of a healthy retina and optic nerve. The red reflex is the reflection of light from the retina that varies in color depending on the patient’s skin tone. It can be seen by holding the ophthalmoscope directly in front of your eye and asking the patient to focus on a point in the distance.

Choice B is wrong because an abnormal finding would be an absent or asymmetric red reflex, which could indicate cataracts, retinal detachment, or other eye diseases.

Choice C is wrong because a possible visual defect would not affect the red reflex, but rather the visual acuity or field of vision of the patient.

A vision screening would involve testing the patient’s ability to read letters or numbers at different distances.

Choice D is wrong because small hemorrhages would not cause a brilliant, uniform red reflex, but rather dark spots or blotches on the retina that can be seen with the ophthalmoscope.

Hemorrhages can be caused by diabetes, hypertension, or trauma.

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A nurse providing care to a child diagnosed with chronic otitis media with effusion (OME) will assess for which sign/symptom?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting discharge and teaches parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician if the conditions occur. (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

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Correct Answer is A

Explanation

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