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 A
Explanation
A. Kawasaki disease is a systemic vasculitis that predominantly affects medium-sized arteries, including the coronary arteries of the heart. The inflammation of the blood vessels can lead to coronary artery aneurysms and other cardiovascular complications if not promptly treated.
B. The respiratory system is not primarily affected by Kawasaki disease. While Kawasaki disease is a systemic illness that can cause fever and inflammation, it primarily affects the cardiovascular system, with inflammation of blood vessels, particularly the coronary arteries.
C. The integumentary system (skin, hair, nails) is not primarily affected by Kawasaki disease. Although some children with Kawasaki disease may develop a rash, particularly in the acute phase of the illness, skin involvement is not the primary feature of the disease.
D. Gastrointestinal symptoms, such as abdominal pain, vomiting, or diarrhea, can occur in Kawasaki disease but they are not the primary focus of the disease. Kawasaki disease primarily affects the cardiovascular system, leading to inflammation of blood vessels and potential complications such as coronary artery aneurysms.
Correct Answer is D
Explanation
D The forward bending test, also known as the Adam's forward bend test, is commonly used to screen for idiopathic scoliosis. During this test, the child is instructed to bend forward from the waist with their arms hanging downward and palms touching or overlapping. This position allows the nurse to observe the child's back for asymmetry, rib humps, or other signs of spinal curvature characteristic of scoliosis.
A This position may be used for certain examinations, such as assessing the spine's curvature but it is not typically the position used for screening for idiopathic scoliosis.
B This instruction involves cervical spine movement and is not relevant to screening for idiopathic scoliosis. It may be part of a different examination, such as assessing cervical spine range of motion or neurological function, but it does not aid in detecting scoliosis.
C Turning to the side and remaining relaxed may not provide adequate visualization of the spine's curvature, which is essential for scoliosis screening. Additionally, this position does not allow for proper assessment of the spine's alignment.
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