A nurse is caring for a child who has acute otitis media. Which of the following classic assessment findings should the nurse expect?
Itching and tenderness when manipulating the affected ear lobe
Fullness in the ear and a clogged sensation without other systemic findings
Edema and erythema of the external canal only
Pulling on the affected ear, acute onset of fever and otalgia
The Correct Answer is D
A. Itching and tenderness when manipulating the affected ear lobe is more characteristic of an external ear infection (otitis externa) rather than acute otitis media.
B. Fullness in the ear and a clogged sensation might be experienced in acute otitis media, but it usually occurs with systemic signs of infection such as fever and pain.
C. Edema and erythema of the external canal only would indicate an external ear infection (otitis externa), not otitis media, which affects the middle ear.
D. Pulling on the affected ear, acute onset of fever, and otalgia (ear pain) are classic signs of acute otitis media. Children often pull or tug at the affected ear in response to pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Respiratory Syncytial Virus (RSV) is the most common cause of bronchiolitis, particularly in infants and toddlers.
B. Haemophilus influenzae type B causes epiglottitis and other respiratory infections but is not a leading cause of bronchiolitis.
C. Adenovirus can cause respiratory infections but is not the primary pathogen for bronchiolitis.
D. Rhinovirus causes the common cold but is not typically responsible for bronchiolitis.
Correct Answer is []
Explanation
Potential Condition: Viral Pneumonia
High fever (39.88°C/103.8°F), severe fatigue, chills, productive cough, and dyspnea suggest a respiratory infection. Bilateral lung consolidation on x-ray is consistent with viral pneumonia. Negative bacterial culture supports a viral rather than bacterial etiology. Elevated WBC count (12,300/mm³) is slightly above normal, which can occur with viral infections. Crackles in upper lobes, diminished breath sounds in lower lobes are common findings in pneumonia.
Actions to Take (Correct Choices)
Cluster client care to allow for rest: Viral pneumonia leads to fatigue and respiratory distress. Minimizing exertion conserves energy and improves recovery.
Administer prescribed antipyretic: Reduces fever, improves comfort, and helps decrease metabolic demand on the body.
Incorrect Actions and Rationale:
Replace pancreatic enzymes – This is necessary for cystic fibrosis, not viral pneumonia.
Maintain airborne precautions – Airborne precautions are required for tuberculosis (TB), not viral pneumonia. Pneumonia typically requires droplet precautions only if caused by a pathogen like influenza.
Obtain a peak respiratory flow rate – More relevant for asthma, not pneumonia.
Parameters to Monitor (Correct Choices)
Level of fatigue: Fatigue indicates worsening illness or improvement. Increasing exhaustion may suggest hypoxia or worsening pneumonia.
Oxygen saturation levels: 92% on room air is borderline low, requiring monitoring for worsening hypoxemia. Oxygen therapy may be needed if saturation drops further.
Incorrect Parameters:
Allergen triggers – Relevant for asthma, not viral pneumonia.
Diet high in protein and calcium – Important for cystic fibrosis, but not a primary concern for pneumonia management.
Blood glucose levels – More relevant for diabetes or steroid therapy, not viral pneumonia.
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