The nurse is caring for a child with suspected Reye syndrome.
Which symptom is most concerning?
Projectile vomiting and confusion.
Fever and cough.
Mild headache.
Muscle aches.
The Correct Answer is A
Choice A rationale
Projectile vomiting and confusion are highly concerning symptoms in a child with suspected Reye syndrome. Projectile vomiting indicates increased intracranial pressure, and confusion reflects encephalopathy, both of which are hallmark signs of the severe neurological involvement in Reye syndrome.
Choice B rationale
Fever and cough are common symptoms of many childhood illnesses, particularly respiratory infections. While Reye syndrome can sometimes follow a viral illness, fever and cough alone are not specific indicators of this condition.
Choice C rationale
Mild headache is a relatively non-specific symptom and can be associated with various conditions. While headache may occur in the early stages of some illnesses, it is not the most concerning symptom suggestive of Reye syndrome.
Choice D rationale
Muscle aches can be associated with viral infections, which sometimes precede Reye syndrome. However, muscle aches alone are not as concerning as the neurological symptoms of confusion and increased intracranial pressure indicated by projectile vomiting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The epidermis is the outermost layer of the skin, providing a protective barrier against the external environment. A first-degree burn, characterized by redness and pain without blisters, affects only this superficial layer. The heat causes vasodilation in the dermal blood vessels beneath the epidermis, resulting in the visible redness.
Choice B rationale
The dermis is the layer of skin beneath the epidermis, containing structures like hair follicles, sweat glands, and nerve endings. Second-degree burns extend into the dermis, causing damage to these structures and leading to blister formation due to fluid leakage from damaged blood vessels within this layer.
Choice C rationale
The subcutaneous tissue (hypodermis) is the deepest layer of the skin, composed mainly of fat and connective tissue. Third-degree or full-thickness burns extend into this layer, damaging or destroying it along with the epidermis and dermis.
Choice D rationale
Muscle tissue lies beneath the subcutaneous tissue and is not typically directly affected in a superficial burn that only causes redness without blisters. Burns that reach muscle tissue are very deep and would present with significant tissue damage and likely charring.
Correct Answer is A
Explanation
Choice A rationale
Cryptorchidism is the medical term for the failure of one or both testicles to descend into the scrotum. The scenario describes a 2-year-old male with one non-palpable testicle, which is the hallmark of cryptorchidism. Risk factors include prematurity and low birth weight.
Choice B rationale
An inguinal hernia is a protrusion of abdominal contents through the inguinal canal. While it can present as a swelling in the groin area, it is distinct from a missing testicle in the scrotum. Examination would typically reveal a palpable mass that may reduce with gentle pressure.
Choice C rationale
A hydrocele is a collection of fluid within the tunica vaginalis, the sac surrounding the testicle. It typically presents as a painless swelling of the scrotum. The testicle is usually palpable within the fluid-filled sac.
Choice D rationale
Testicular torsion is a medical emergency involving the twisting of the spermatic cord, which cuts off blood supply to the testicle. It presents with sudden, severe scrotal pain, swelling, and often nausea and vomiting. The examination would reveal a tender, firm, and retracted testicle. .
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