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. An oxygen saturation level of 85% is significantly below the normal range and indicates hypoxemia (low blood oxygen levels). This finding is concerning, especially in a child with cystic fibrosis, which can lead to respiratory complications such as airway obstruction, infection, or mucus plugging.

A. A blood glucose level of 140 mg/dL is within the normal range for children, so this finding would not typically require immediate reporting to the provider.

B. A serum sodium level of 156 mEq/L is significantly elevated and above the normal range. However, hypoxia is the priority.

C. A red blood cell (RBC) count of 3.2 million/µL falls within the normal range for children, so this finding would not typically require immediate reporting to the provider.

A. "Put an ice pack on the ankle, alternating 20 minutes on with 20 minutes off." B. "Wrap the ankle in an Ace bandage for support." C. "Keep the leg elevated when sitting" D. "Apply warm compresses to the ankle for the first 24 hours."

Correct Answer is D

Explanation

D. Warm compresses or heat therapy are not recommended for the initial management of a sprained ankle, especially within the first 24 hours. Heat can increase blood flow and exacerbate swelling and inflammation, which may worsen pain and delay healing.

A. Applying ice packs in this manner helps reduce inflammation and swelling, which are common after a sprain. Alternating ice application with periods of rest allows for effective cooling without causing tissue damage.

B. Wrapping the ankle in an Ace bandage can provide compression and support, which may help reduce swelling and stabilize the joint during the healing process. However, it's important not to wrap the bandage too tightly, as this can impair circulation.

C. Elevating the leg when sitting helps reduce swelling by promoting venous return and preventing fluid accumulation in the injured area. Keeping the ankle elevated above the level of the heart whenever possible is recommended for optimal swelling reduction.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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