A nurse is caring for a toddler in the outpatient setting.
Complete the following sentence by using the lists of options.
The nurse recognizes the toddler has likely developed
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Rationale for Correct Choices:
- Reye's syndrome: The toddler's worsening condition including vomiting, lethargy, and altered consciousness after a viral illness (influenza A) is consistent with Reye’s syndrome, which affects the liver and brain. The progression from mild viral symptoms to neurologic decline without respiratory compromise further supports this diagnosis.
- Aspirin administration: Giving aspirin during a viral illness in children is a well-known precipitant of Reye’s syndrome. The caregivers' report of alternating aspirin with acetaminophen confirms the exposure necessary to trigger the condition in a susceptible child.
Rationale for Incorrect Choices:
- Gastroenteritis: While vomiting is a feature of gastroenteritis, the absence of diarrhea and the presence of neurologic changes like lethargy and poor responsiveness make this unlikely. Additionally, the clear vomiting and lack of fluid intake without prior GI focus suggest another etiology.
- Bronchitis: Bronchitis typically causes a productive cough with wheezing, chest discomfort, and possible fever. This toddler's lungs are clear with a nonproductive cough, and neurologic signs are not typical of bronchitis.
- Acetaminophen administration: Acetaminophen is safe and commonly used to treat fever in toddlers. It is not associated with hepatic encephalopathy or neurologic complications seen in this scenario.
- Oseltamivir administration: Though oseltamivir may cause gastrointestinal side effects like nausea or vomiting, it does not explain the altered mental status and lethargy. It is also unlikely to cause such a significant clinical deterioration on its own.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Collect 4 mL/kg of blood in a 24-hr period: This volume exceeds safe limits for blood collection in small children. The guideline is not to exceed 3 mL/kg over 24 hours unless clinically necessary, as excessive draws can lead to anemia or hemodynamic instability.
B. Apply lidocaine cream 30 min prior to collecting the specimen: While lidocaine-prilocaine cream can be helpful, it typically requires at least 60 minutes to achieve adequate dermal analgesia. Applying it for only 30 minutes may not be sufficient to reduce pain effectively.
C. Ask the parents to leave the room prior to collecting the blood specimen: Parents are often a source of comfort and reassurance for preschoolers. Unless their presence is disruptive, involving them in the process can help calm the child and improve cooperation.
D. Demonstrate the use of the equipment to the child: Preschoolers benefit from age-appropriate explanations and demonstrations. Showing them the equipment reduces fear and anxiety by promoting familiarity and a sense of control in an unfamiliar situation.
Correct Answer is ["A","C","E","F"]
Explanation
Rationale:
A. Blood pressure: The reading of 162/112 mm Hg meets the criteria for severe hypertension in pregnancy, which increases the risk of complications such as preeclampsia, placental abruption, and stroke.
B. Urine ketones: Ketones are negative, which rules out dehydration or starvation ketosis. Ketones would be more concerning if elevated alongside hyperemesis or gestational diabetes.
C. Fetal activity: Decreased fetal movement at 31 weeks may indicate fetal hypoxia or distress and requires urgent evaluation with nonstress testing or biophysical profiling.
D. Respiratory rate: The client’s respiratory rate of 16/min is within the normal range (12–20/min) and does not indicate respiratory distress or a complication.
E. Report of headache: A severe, persistent headache that is unrelieved by acetaminophen is a classic warning sign of central nervous system involvement in preeclampsia and may precede seizures (eclampsia).
F. Urine protein: The presence of 3+ proteinuria indicates significant renal involvement, supporting a diagnosis of preeclampsia, particularly when paired with hypertension and neurologic symptoms.
G. Gravida/parity: While a history of preterm birth is a known risk factor, her current symptoms point toward preeclampsia rather than complications directly linked to her obstetric history.
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