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 A
Explanation
Choice A Reason:
Continuous swallowing is correct. Continuous swallowing can be an indication of postoperative bleeding after a tonsillectomy and adenoidectomy. Increased swallowing may suggest blood trickling down the throat, prompting the child to swallow frequently. It's an important sign to observe for and could indicate a risk of hemorrhage.
Choice B Reason:
Heart rate 54/min. While a low heart rate (bradycardia) might be a concern in some cases, it's not a typical sign of hemorrhage after this specific surgery.
Choice C Reason:
Blood pressure 95/56 mm Hg. While a drop-in blood pressure could be concerning for hemorrhage, this blood pressure reading alone may not necessarily indicate postoperative bleeding. Monitoring trends and other signs are important for a comprehensive assessment.
Choice D Reason:
Flushing of the face. Facial flushing is not typically associated with hemorrhage after a tonsillectomy and adenoidectomy. It might be related to other factors but is not a specific indicator of bleeding following this surgery.
Correct Answer is C
Explanation
Correct answer: C
Choice A Reason:
Instructing the child to drink fluids through a straw should be avoided immediately after a tonsillectomy. The sucking motion required when using a straw can potentially disrupt the healing process and dislodge the blood clot at the surgical site, leading to bleeding. Therefore, this action is not recommended.
Choice B Reason:
Avoid milk products such as milk, icecream and pudding initially because they coat the throat, causing the child to cough to clear the throat.
Choice C Reason:
Placing the child in a side-lying position helps maintain an open airway and allows drainage of saliva and potential blood.
Choice D Reason:
Encouraging the child to deep breath and cough is generally a good practice to prevent respiratory complications post-anesthesia. However, immediate post-tonsillectomy, the focus might be more on airway patency and monitoring for signs of bleeding or adverse reactions rather than deep breathing and coughing.
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