A nurse is collecting data from an infant who has otitis media. Which of the following findings should the nurse expect?
Bluish-green discharge from the ear canal
Erythema and edema of the affected auricle
Increase in appetite
Tugging on the affected ear lobe
The Correct Answer is D
Choice A rationale
Bluish-green discharge from the ear canal is not a typical finding in otitis media. This could suggest a different condition, such as an external ear infection or a ruptured eardrum.
Choice B rationale
Erythema and edema of the affected auricle (outer part of the ear) are not typical findings in otitis media. These symptoms are more commonly associated with conditions affecting the external ear, such as otitis externa.
Choice C rationale
An increase in appetite is not typically associated with otitis media. In fact, children with otitis media may have a decreased appetite due to discomfort or pain while swallowing.
Choice D rationale
Tugging on the affected ear lobe is a common sign of otitis media in infants and young children. This is often due to the pain and discomfort caused by the infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale
When a nurse notes the presence of bruises on a child’s arms and legs, the first action should be to obtain a detailed history. This can provide important context for the bruises and help determine whether they are likely the result of accidental injury or possible abuse.
Choice A rationale
Telling the child what will happen when the abuse is reported is not the first action a nurse should take. It is important to first gather all necessary information and report the suspected abuse to the appropriate authorities.
Choice B rationale
Requesting a social services referral is an important step when abuse is suspected, but it should come after obtaining a detailed history and reporting the suspected abuse.
Choice C rationale
Reporting the suspected abuse to the authorities is crucial when child abuse is suspected. However, it is important to first obtain a detailed history to provide as much information as possible to the authorities.
Correct Answer is B
Explanation
Choice A rationale
Gastroesophageal Reflux Disease (GERD) in infants is a condition where the stomach contents flow back into the esophagus causing discomfort. However, the symptoms described, such as projectile vomiting and constant hunger, are more consistent with Pyloric Stenosis.
Choice B rationale
Pyloric Stenosis is a condition in infants where the opening from the stomach to the small intestine narrows, preventing food from entering the small intestine. The symptoms described by the parents, such as projectile vomiting after every feeding and constant hunger, align with this condition. The infant’s lack of weight gain could be due to the fact that food is not being properly digested and absorbed. The nurse should refer the infant for a surgical consultation as the treatment for Pyloric Stenosis is usually surgical. The nurse should monitor the infant’s weight and frequency of vomiting to assess the infant’s progress.
Choice C rationale
Lactose Intolerance in infants is a condition where the infant has difficulty digesting lactose, a sugar found in milk and dairy products. Symptoms can include gas, bloating, and diarrhea.
However, the symptoms described by the parents do not align with this condition.
Choice D rationale
Milk Protein Allergy in infants is a condition where the infant’s immune system reacts negatively to the proteins in cow’s milk. Symptoms can include hives, itching, wheezing, difficulty breathing, constipation, and bloody diarrhea. However, the symptoms described by the parents do not align with this condition.
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