The caregiver of a toddler is concerned about the frequency of ear infections and states, "The pediatrician said my child's ear tubes are small and short. What can I do about this?" Which action should the nurse take?

Refer the caregiver to an audiologist.

Explain to the caregiver this a normal finding.

Discuss the importance of prophylactic antibiotics.

Schedule the toddler for a tympanostomy procedure.

Answer and Explanation

The Correct Answer is B

A. Refer the caregiver to an audiologist: Referral to an audiologist is indicated if there are concerns about hearing loss, not for normal anatomical variations of the eustachian tubes.

B. Explain to the caregiver this is a normal finding: In toddlers, the eustachian tubes are naturally shorter and more horizontal, which predisposes them to ear infections. Educating the caregiver about this normal anatomy helps them understand the cause without unnecessary concern.

C. Discuss the importance of prophylactic antibiotics: Routine prophylactic antibiotics are not recommended for preventing recurrent ear infections due to normal eustachian tube anatomy, as overuse can lead to resistance.

D. Schedule the toddler for a tympanostomy procedure: Tympanostomy tubes are only considered for children with recurrent or persistent otitis media with effusion causing hearing loss or complications, not for normal anatomical predisposition alone.

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Correct Answer is A

Explanation

A. Argumentativeness and use of profanity: These behaviors may indicate escalating agitation and a risk for violence. Monitoring for verbal aggression is essential because it can quickly progress to physical aggression, making safety the priority concern.

B. Periodic sighing and shaking the head: These are signs of frustration or discouragement but are less concerning than overt verbal aggression. They do not immediately signal a risk of harm to others.

C. Decreased activity level and change in affect: A decline in activity or affect may suggest depression or withdrawal but does not indicate an acute risk of violent escalation like pacing and scowling combined with verbal aggression.

D. Repeated requests for attention from the nurse: Frequent requests may reflect anxiety or dependency but do not typically indicate imminent aggression. While they should be addressed, they are not the most critical behaviors to monitor in this scenario.

A. Maintain strict intake and output. B. Monitor blood glucose level. C. Assess warmth of extremities. D. Keep head of bed raised 45 degrees.

Correct Answer is A

Explanation

A. Maintain strict intake and output: In septic shock, monitoring fluid balance is critical because clients are at high risk for hypovolemia, organ dysfunction, and multi-organ failure. Accurate intake and output measurements guide fluid resuscitation and help evaluate response to therapy.

B. Monitor blood glucose level: Hyperglycemia can occur in sepsis and should be monitored, but it is secondary to maintaining adequate perfusion and fluid balance. Glucose monitoring supports overall care but is not the immediate priority in shock management.

C. Assess warmth of extremities: Extremity warmth or coolness provides information about perfusion and circulatory status but is observational. It does not actively intervene to reverse the pathophysiologic processes of septic shock.

D. Keep head of bed raised 45 degrees: Elevating the head of the bed may reduce aspiration risk, but it does not address the urgent need to manage hypoperfusion, organ perfusion, and fluid status in septic shock.

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The caregiver of a toddler is concerned about the frequency of ear infections and states, "The pediatrician said my child's ear tubes are small and short. What can I do about this?" Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the nurse to monitor?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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