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 ["1.5"]
Explanation
Volume= Desired dose/ concentration in mg/ml Concentration per ml= 10mg/ml
Desired dose= 15mg Volume= 15mg/10mg/ml Volume = 1.5ml
Therefore, the nurse should administer 1.5ml of morphine
Correct Answer is D
Explanation
D. Suctioning equipment and oxygen are essential items to have at the bedside for seizure precautions. Seizures can sometimes be associated with airway compromise, excessive secretions, or respiratory distress. Having suctioning equipment readily available allows for prompt removal of oral or airway secretions if necessary. Oxygen may be needed to support oxygenation during or after a seizure, especially if there are concerns about respiratory depression or hypoxemia.
A. A tracheotomy set is not typically needed at the bedside for seizure precautions. Tracheotomy sets are used in emergency situations to establish a surgical airway if there is a severe airway obstruction or respiratory distress.
B. An emergency cart contains essential supplies and medications needed for emergency situations, including resuscitation equipment, medications, and supplies for managing various medical emergencies. However, the cart is not placed bedside.
C. A padded tongue blade is not typically needed at the bedside for seizure precautions. Tongue blades are sometimes used during airway management to help visualize and manipulate the tongue, but padded tongue blades are not routinely included in seizure precautions.
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