A nurse is caring for a child who has otitis media.
Which of the following assessment findings should the nurse expect?
Tugging on the affected ear lobe.
Erythema and edema of the affected ear.
Pain when manipulating the affected ear lobe.
Clear drainage from the affected ear.
The Correct Answer is A
The correct answer is A. Tugging on the affected ear lobe.
Choice A rationale
Tugging on the affected ear lobe is a common sign of otitis media in children. This behavior is often observed because the child is experiencing discomfort or pain in the ear, and tugging or pulling on the ear lobe is a way to express or alleviate that discomfort.
Choice B rationale
Erythema and edema of the affected ear are not typical findings in otitis media. These symptoms are more commonly associated with external ear infections, such as otitis externa.
Choice C rationale
Pain when manipulating the affected ear lobe is more indicative of otitis externa rather than otitis media. Otitis media involves the middle ear, and manipulation of the ear lobe does not typically cause pain.
Choice D rationale
Clear drainage from the affected ear is not a typical finding in otitis media. If there is drainage, it is usually purulent (pus-like) and indicates a more severe infection or a ruptured eardrum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale
Blood pressure is not the most reliable indicator of fluid loss in infants. Blood pressure can remain normal until dehydration is severe.
Choice B rationale
Respiratory rate can be affected by many factors and is not the most reliable indicator of fluid loss.
Choice C rationale
Body weight is the most reliable indicator of fluid loss in infants. A significant decrease in body weight indicates significant fluid loss and helps guide appropriate fluid replacement therapy.
Choice D rationale
Skin integrity can be affected by many factors and is not the most reliable indicator of fluid loss.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
Placing the child in a knee-chest position helps increase systemic vascular resistance, which reduces the right-to-left shunt and improves oxygenation during a cyanotic spell in children with Tetralogy of Fallot.
Choice B rationale
Having the child lie supine with the head turned to one side does not help in managing a cyanotic spell and may not improve oxygenation.
Choice C rationale
Lying prone does not specifically address the cyanotic spell and may not be the most effective position for improving oxygenation.
Choice D rationale
Placing the child in a semi-Fowler’s position in an infant seat does not specifically address the cyanotic spell and may not be the most effective position for improving oxygenation.
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