The nurse reviews the plan of care for a child with Reye's syndrome. The nurse plans to monitor for which priority complication of this syndrome?
The presence of protein in the urine
Signs of increased intracranial pressure
Signs of hyperglycemia
Signs of a bacterial infection
The Correct Answer is B
B. Reye's syndrome is characterized by swelling of the brain (cerebral edema), which can lead to increased intracranial pressure (ICP). Monitoring for signs of increased ICP, such as changes in level of consciousness, headache, vomiting, and altered pupil size and reactivity, is crucial for early detection and intervention to prevent neurological deterioration.
A. Reye's syndrome primarily affects the liver and brain, leading to liver dysfunction and encephalopathy. While renal involvement can occur in some cases, the priority complication typically relates to liver dysfunction and neurological manifestations rather than renal impairment.
C. Hyperglycemia may be present due to liver dysfunction and altered glucose metabolism, but it is not the primary concern compared to neurological complications and hepatic failure.
D. Reye's syndrome is not caused by a bacterial infection; it is typically associated with viral illnesses, particularly influenza and varicella (chickenpox).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Muscle weakness and lack of coordination contribute to difficulties with balance and coordination, leading to frequent falls and clumsiness in children with DMD.
A. DMD typically presents with symptoms such as difficulty climbing stairs, a waddling gait, and calf muscle hypertrophy, rather than atrophy.
B. Delayed fine-motor development is not a typical manifestation of Duchenne muscular dystrophy. DMD primarily affects muscle strength and function rather than fine motor skills.
D. Ambulating by holding onto furniture is not typical in Duchenne muscular dystrophy. As the disease progresses, children with DMD typically experience difficulty walking and may eventually require the use of assistive devices such as wheelchairs or orthoses for mobility.
Correct Answer is D
Explanation
D. Place resuscitation equipment at the child's bedside. This is because epiglottitis can lead to a life- threatening emergency requiring immediate intervention, and having resuscitation equipment readily available is essential for rapid response.
A. Establishing intravenous access may be necessary for administering fluids and medications but it is not the nurse's priority action when caring for a child with suspected epiglottitis.
B. Droplet precautions help reduce the risk of transmission of respiratory pathogens to others. However, the priority is to address the child's respiratory distress and potential airway compromise.
C. Providing blow-by humidified oxygen can be beneficial in managing the child's respiratory status. However, securing the airway takes precedence over other interventions, as indicated by the guidelines for managing epiglottitis.
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