In caring for a child with Reye's syndrome, what is the priority nursing intervention?

• A. Observe for petechiae.
• B. Prevent skin breakdown.
• C. Monitor intake and output.
• D. Do range-of-motion (ROM) exercises.

Answer: (C)

In Reye’s syndrome the priority is to prevent and detect complications from cerebral edema and hepatic dysfunction, with emphasis on maintaining fluid and electrolyte balance so that the brain is not further destabilized. Monitoring intake and output gives you a direct read on the child’s hydration status, kidney function, and potential electrolyte disturbances, all of which can influence cerebral edema and overall stability. By tracking fluids and output, you can intervene early if dehydration or overload occurs, adjust fluids as ordered, and help maintain a stable metabolic state that supports neurologic status and recovery.

Observing for petechiae can indicate coagulopathy related to liver dysfunction, which is important but not the immediate priority when the goal is to stabilize fluid and electrolyte balance to protect brain function. Preventing skin breakdown and performing ROM exercises are less pertinent to the acute, life-threatening priorities of this condition.