A nurse is assessing an infant who has acute otitis media. Which of the following findings should the nurse expect? (Select all that apply.)
Enlarged subclavicular lymph node
Fever
Crying
Increased appetite
Restlessness
Correct Answer : B,C,E
Choice A Reason:
Enlarged subclavicular lymph node (A) is not a typical finding associated with acute otitis media. Enlarged lymph nodes in the neck area (cervical lymph nodes) might be observed due to the nearby infection, but the subclavicular lymph nodes are located below the clavicle and are not typically associated with ear infections.
Choice B Reason:
Fever: Infants with acute otitis media often present with a fever. Elevated body temperature is a common symptom of an infection, including ear infections.
Choice C Reason:
Crying: Ear pain is a common symptom of acute otitis media. Infants may express discomfort or pain by crying, especially when lying down due to increased pressure in the middle ear.
Choice D Reason:
Increased appetite is also not a common finding in acute otitis media. Generally, a decrease in appetite might occur due to feeling unwell or discomfort, but increased appetite is not a typical symptom of this condition.
Choice E Reason:
Restlessness: Due to discomfort or pain caused by the ear infection, infants with acute otitis media might exhibit restlessness or irritability.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
Choice A Reason:
Heat the formula to 39°C (102°F) prior to administration. Formula temperature should be warm, but heating it to a specific temperature like 39°C (102°F) is not typically necessary. Room temperature or slightly warm formula is often suitable.
Choice B Reason:
The supine position (lying flat on the back) is not recommended during enteral feedings. Infant should be placedin a semi-upright position (usually around 30 to 45 degrees)- this helps prevent aspiration and aids in proper digestion and passage of the feeding into the stomach.
Choice C Reason:
Offer the infant a pacifier during feedings. Offering a pacifier during enteral feedings could potentially interfere with the feeding process and may increase the risk of aspiration. It's generally not recommended during tube feedings.
Choice D Reason:
Instill the formula over a period of 30 to 45 minutes. Slowly administering the formula over this duration allows for proper digestion and reduces the risk of feeding-related complications.
Choice E Reason:
Check for residual volumes by aspirating stomach contents. Checking for residual volumes helps ensure the stomach is adequately emptying and can help prevent complications such as aspiration or feeding intolerance.

Correct Answer is D
Explanation
Choice A Reason:
"Encourage your partner to eat three large meals each day." In end-of-life care, the focus shifts from large meals to providing comfort and meeting the patient's nutritional needs, which might not involve large meals due to potential decreased appetite or difficulty swallowing.
Choice B Reason:
"We will use an electric blanket to keep your partner warm. “While keeping the patient warm is essential, the use of an electric blanket might not always be appropriate due to the risk of burns or changes in sensation that can occur in some conditions.
Choice C Reason:
"Opioids will be restricted if your partner develops respiratory distress. “This statement might not convey the full context of pain and symptom management in end-of-life care. Opioids are often used judiciously to manage distressing symptoms, including pain and respiratory distress, under careful monitoring rather than being strictly restricted.
Choice D Reason:
"Assume your partner can hear you, even if they do not respond." This statement emphasizes the importance of communication and connection with the partner who may be unresponsive. Research suggests that hearing may persist even when a person is unable to respond, so speaking to the person respectfully and with care can provide comfort and support during this time.
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