The nurse reviews the plan of care for a child with Reye's syndrome. The nurse plans to monitor for which priority complication of this syndrome?

The presence of protein in the urine

Signs of increased intracranial pressure

Signs of hyperglycemia

Signs of a bacterial infection

Answer and Explanation

The Correct Answer is B

B. Reye's syndrome is characterized by swelling of the brain (cerebral edema), which can lead to increased intracranial pressure (ICP). Monitoring for signs of increased ICP, such as changes in level of consciousness, headache, vomiting, and altered pupil size and reactivity, is crucial for early detection and intervention to prevent neurological deterioration.

A. Reye's syndrome primarily affects the liver and brain, leading to liver dysfunction and encephalopathy. While renal involvement can occur in some cases, the priority complication typically relates to liver dysfunction and neurological manifestations rather than renal impairment.

C. Hyperglycemia may be present due to liver dysfunction and altered glucose metabolism, but it is not the primary concern compared to neurological complications and hepatic failure.

D. Reye's syndrome is not caused by a bacterial infection; it is typically associated with viral illnesses, particularly influenza and varicella (chickenpox).

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Correct Answer is D

Explanation

D. This is the correct action to take. A neurovascular check involves assessing the circulation, sensation, and movement in the affected limb. This check helps monitor for complications such as impaired circulation, nerve damage, or compartment syndrome, which can occur after the application of a plaster cast. Regular neurovascular checks are essential for early detection of any issues and appropriate intervention if necessary.

A. Using a hair dryer on a hot setting can cause burns to the skin under the cast. It can also cause the cast material to heat up and potentially cause discomfort or injury to the patient.

B. It's essential to follow the healthcare provider's instructions regarding weight-bearing restrictions, but completely discouraging ambulation can lead to complications such as muscle atrophy, decreased circulation, and increased risk of blood clots.

C. Keeping the client's leg in a dependent position means positioning it lower than the heart. This can increase swelling and exacerbate pain, potentially leading to complications such as compartment syndrome.

A. A private room with contact/droplet precautions B. A semi-private room with an infant who has croup C. A private room with protective isolation D. A semi-private room with a toddler who has pneumonia

Correct Answer is A

Explanation

A. This option is the most appropriate choice for an infant with respiratory syncytial virus (RSV). RSV is highly contagious and primarily spreads through respiratory secretions. Placing the infant in a private room helps to minimize the risk of transmission to other patients. Contact and droplet precautions should be implemented to further prevent the spread of the virus.

B. This choice is not ideal because both RSV and croup are respiratory infections that can spread easily among infants. Placing an infant with RSV in a semi-private room with another infant increases the risk of transmission of both infections to each other.

C. While isolating the infant in a private room is appropriate for preventing the spread of RSV, the term "protective isolation" typically refers to a type of isolation used for patients who have compromised immune systems.

D. Placing the infant with RSV in a semi-private room with a toddler who has pneumonia is not recommended. Both RSV and pneumonia are respiratory infections that can spread easily among patients, especially infants and young children who are more susceptible to complications.

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The nurse reviews the plan of care for a child with Reye's syndrome. The nurse plans to monitor for which priority complication of this syndrome?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is assisting with the admission of an infant who has respiratory syncytial virus (RSV). Which of the following rooms should the nurse assign the infant?

Correct Answer is A

Explanation

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The nurse reviews the plan of care for a child with Reye's syndrome. The nurse plans to monitor for which priority complication of this syndrome?