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
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).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Cerebral palsy is a chronic condition that affects muscle control and movement. It is caused by damage to or abnormal development of the parts of the brain that control movement, balance, and posture. This damage can occur before, during, or shortly after birth, and it results in difficulties with muscle coordination, balance, and motor skills.
A. Cerebral palsy is not caused by an infectious agent; it is a non-progressive neurological disorder that affects movement, posture, and muscle coordination. It is primarily caused by abnormal development or damage to the brain before, during, or shortly after birth, rather than by an infectious disease.
B. Cerebral palsy is not caused by inflammation of the brain due to a viral illness. While viral illnesses can lead to complications, such as encephalitis (inflammation of the brain), cerebral palsy itself is not caused by inflammation but rather by neurological damage or abnormal development.
D. Cerebral palsy primarily affects movement and muscle control but it does not necessarily result in intellectual disability. Intellectual disability can occur in some cases of cerebral palsy, but it is not a defining characteristic of the condition.
Correct Answer is ["B","C","D"]
Explanation
B. Wheezing is a common symptom of asthma exacerbation and can indicate airway obstruction. Wheezing may worsen during an asthma attack, suggesting deterioration in respiratory status.
C. Nasal flaring is a sign of increased respiratory effort and can occur during respiratory distress. In a child with asthma, nasal flaring may indicate worsening airway obstruction and increased work of breathing, suggesting deterioration in respiratory status.
D. Retraction of sternal muscles, also known as intercostal retractions, occurs when the muscles between the ribs are drawn inward during inspiration, indicating increased effort to breathe. Intercostal retractions are a sign of respiratory distress and can occur in children with asthma during exacerbations, particularly when airway obstruction is severe.
A. Warm extremities are not typically indicative of deterioration in respiratory status in a child with asthma. In fact, warm extremities may suggest adequate peripheral perfusion.
E. An oxygen saturation of 95% is within the normal range for most children and may not necessarily indicate deterioration in respiratory status. However, oxygen saturation should be interpreted in conjunction with other clinical signs and symptoms.
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