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 C
Explanation
Rationale:
A. "Maintain the client in a supine position for 24 hours following surgery.": Prolonged supine positioning increases the risk of pulmonary complications such as atelectasis. Early mobilization and elevating the head of the bed help promote lung expansion and reduce postoperative risks.
B. "Expect the client to have a palpable distended bladder following surgery.": A distended bladder is not expected and may indicate urinary retention, a common complication after anesthesia. The nurse should assess and address it promptly, rather than consider it normal.
C. "Report bleeding that saturates the client's dressing.": Active bleeding that saturates a postoperative dressing may indicate hemorrhage and requires immediate intervention. Reporting this finding is critical to prevent further complications like hypovolemia or shock.
D. "Ensure the client's urinary output is no less than 20 mL per hour.": Urine output should be at least 30 mL per hour in adults. A rate below this may indicate hypoperfusion or renal impairment and should prompt further assessment and intervention.
Correct Answer is A
Explanation
Rationale:
A. Explain to the client they can change their mind at any time: Clients have the right to make or revoke decisions about resuscitation at any time. Informing the client of this autonomy supports informed consent and respects their evolving preferences and values regarding end-of-life care.
B. Obtain consent from the family for the change to the plan of care: The decision for a Do Not Resuscitate (DNR) order is made by the client, not the family, if the client is competent. Family involvement is supportive but does not override the client’s autonomy in this matter.
C. Discharge the client to hospice care: While hospice may be appropriate for end-stage disease, requesting a DNR does not automatically necessitate discharge. Clients can remain in the current care setting with appropriate adjustments to their goals of care.
D. Place a sign with "Do Not Resuscitate" outside the client's room: Displaying such signs can violate privacy and confidentiality. Instead, the DNR order should be documented clearly in the medical record and care plan, accessible to the healthcare team.
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