A 9-year-old patient has been complaining of headache, coughing, and an aching chest. The care provider makes a diagnosis of a viral infection. The child’s mother tells the nurse that when she first said she had a headache, the child’s father gave her half of an adult aspirin. The mother has heard of Reye syndrome and asks the nurse if her child could get this. Which statement would be the best response by the nurse?
“This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, stupor, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome.”
“This might or might not be a problem. Watch your daughter for signs of nasal discharge, sneezing, itching of the nose, or dark circles under the eyes. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome.”
“This is a serious problem. Aspirin is likely to cause Reye syndrome, and she should be admitted to the hospital for observation as a precaution.”
“This is unlikely to be a problem. Half an aspirin is not enough to cause harm. Reye syndrome generally only develops from prolonged use of aspirin in connection with a virus.”
The Correct Answer is A
Choice A reason: Half an aspirin with a viral infection poses a small Reye syndrome risk, warranting monitoring for symptoms like lethargy or vomiting. This aligns with pediatric safety guidelines, making it the best response to inform the mother while ensuring vigilance for the 9-year-old’s health.
Choice B reason: Nasal discharge and sneezing are unrelated to Reye syndrome, which involves neurological symptoms like stupor. Monitoring for lethargy or vomiting is correct, making this incorrect, as it lists irrelevant symptoms for the mother’s concern about Reye syndrome in her child.
Choice C reason: Admitting for observation overstates the risk, as a single half aspirin rarely causes Reye syndrome. Monitoring for specific symptoms is sufficient, making this alarmist and incorrect compared to the nurse’s balanced response to the mother’s concern about the viral infection.
Choice D reason: Downplaying the risk as unlikely ignores the potential, though rare, link between aspirin and Reye syndrome in viral infections. Monitoring for symptoms is prudent, making this dismissive and incorrect compared to advising vigilance for the 9-year-old’s safety post-aspirin use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Discussing anxiety and depression is relevant but premature without addressing the immediate issue of the child being alone and scared after school. After-school programs provide supervision and safety, making this less urgent and incorrect compared to resolving the primary concern of unsupervised time for the child.
Choice B reason: Preventing drug and alcohol use is important but not the priority for a 10-year-old scared and alone after school. After-school programs address immediate safety and social needs, making this secondary and incorrect compared to tackling the child’s current unsupervised and fearful situation at home.
Choice C reason: Emergency contact numbers are useful but do not resolve the ongoing issue of the child being alone and scared daily. After-school programs offer structured supervision, directly addressing the primary concern, making this less critical and incorrect for the nurse’s priority action for this family.
Choice D reason: Providing a list of after-school programs addresses the child’s fear and isolation by offering supervised, engaging activities, reducing unsupervised time at home. This prioritizes safety and emotional well-being, aligning with pediatric nursing goals for supporting relocated families, making it the correct action to assist them.
Correct Answer is A
Explanation
Choice A reason: Using tweezers to gently remove a tick without crushing it minimizes infection risk and ensures complete removal, reducing Lyme disease transmission. This aligns with pediatric infectious disease guidelines for tick removal, making it the best action for the caregiver to follow for the 4-year-old.
Choice B reason: Crushing the tick risks releasing pathogens into the bite site, increasing infection risk. Gentle tweezer removal is the standard, as it avoids dispersing tick contents, making this unsafe and incorrect for the proper method of removing a swollen tick from the child’s arm.
Choice C reason: Using a hot match to remove a tick is ineffective and risks burning the child or driving pathogens deeper. Tweezers ensure safe, complete removal, making this dangerous and incorrect compared to the recommended technique for tick removal in a child in a wooded area.
Choice D reason: Taking the child to a healthcare facility is unnecessary for a routine tick removal, which caregivers can perform with tweezers. This delays action and increases inconvenience, making it incorrect compared to the effective, immediate tweezer method for tick removal in this scenario.
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