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 A
Explanation
Choice A reason: Holding the buttocks together for 1-2 minutes after suppository insertion prevents expulsion, ensuring the medication is absorbed in a 3-month-old. This aligns with pediatric medication administration protocols, making it the correct intervention to assure effective delivery of the rectal suppository in this infant.
Choice B reason: Pre-warming the suppository is not standard, as it may soften excessively, complicating insertion. Holding the buttocks ensures retention, directly impacting absorption, making this less effective and incorrect compared to the critical step of preventing expulsion in a 3-month-old during suppository administration.
Choice C reason: Using the index finger is inappropriate for an infant, as the pinky finger is safer for their small rectum. Holding the buttocks ensures medication retention, making this unsafe and incorrect compared to the prioritized intervention for effective suppository administration in a 3-month-old child.
Choice D reason: Placing the child on the abdomen may aid positioning but does not ensure suppository retention like holding the buttocks. Retention is critical for absorption, making this less essential and incorrect compared to the direct intervention of securing the suppository in place post-insertion for the infant.
Correct Answer is B
Explanation
Choice A reason: Scoliosis screening is typically prioritized in older children (10-14 years), as curvature often appears during puberty. Vision and hearing screenings are critical for 6-8-year-olds to support learning, making this less urgent and incorrect for the prioritized screening in this elementary school age group.
Choice B reason: Vision and hearing screenings are critical for 6-8-year-olds, as deficits can impair academic performance and development. Early detection ensures timely intervention, aligning with pediatric school health guidelines, making this the prioritized screening for elementary students to support their educational and health needs.
Choice C reason: Assessing nutritional needs is important but less standardized as a routine screening compared to vision and hearing, which directly impact learning. These screenings take precedence, making this less critical and incorrect for the nurse’s priority in routine health checks for 6-8-year-olds.
Choice D reason: Reviewing immunization records ensures compliance but is administrative, not a health screening like vision and hearing, which detect active issues. These screenings are more urgent, making this incorrect compared to prioritizing assessments that directly affect the health of 6-8-year-old students.
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