A nurse is assessing a 4-year-old child who is 2 days postoperative following insertion of a ventriculoperitoneal shunt. Which of the following findings is the nurse's priority?
Urine output of 50 mL in 2 hr
Lethargy
Respiratory rate 24/min
Absent Babinski reflex
The Correct Answer is B
A. Urine output of 50 mL in 2 hr: This is within normal limits for a child and does not indicate an immediate concern.
B. Lethargy: Lethargy is a potential sign of increased intracranial pressure (ICP), which is a critical complication of VP shunt placement and requires immediate intervention.
C. Respiratory rate 24/min: This is within the normal range for a 4-year-old child.
D. Absent Babinski reflex: This is a normal finding in children over 2 years old, as the reflex typically disappears by that age.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["12.5"]
Explanation
Dose required per day = 50mg/kg/day × 40 kg = 2000 mg/day
Dose per administration = 2000mg4 doses= 500 mg/dose
Volume to administer:
200mg5ml=40mg/ml
500mg40mg/ml=12.5ml/dose
Correct answer =12.5mL/dose
Correct Answer is ["A","B","C"]
Explanation
A. "I should eat extra food on busy days when I am more active." Physical activity lowers blood glucose levels. Eating extra food prevents hypoglycemia during periods of increased activity.
B. "I should increase my intake of sugar-free fluids when I am sick." During illness, maintaining hydration is essential. Sugar-free fluids help prevent dehydration without causing hyperglycemia.
C. "I should eat a snack 30 minutes before my baseball game starts." A pre-activity snack helps maintain blood glucose levels during exercise, reducing the risk of hypoglycemia.
D. "I should wait 2 hours after eating before playing with my friends." There is no need to delay physical activity for 2 hours after eating unless instructed otherwise by a healthcare provider.
E. "I should have a 16-ounce glass of milk if I start feeling weak or shaky." A smaller portion of fast-acting carbohydrates, like 4 ounces of juice or 15 grams of glucose tablets, is recommended for treating hypoglycemia.
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