A nurse is providing discharge teaching to the parents of a school-age child following the placement of a ventriculoperitoneal shunt. The nurse should determine that the teaching was effective when the parents identify which of the following as an indicator that the shunt has been displaced?
Decreased urine output
Increased sleeping
Hyperactive bowel sounds
Elevated temperature
The Correct Answer is D
Choice A reason: Decreased urine output is not directly related to ventriculoperitoneal shunt displacement. It may indicate other issues such as dehydration or kidney problems.
Choice B reason: Increased sleeping is not a specific indicator of shunt displacement. While it may be a concern if there are significant changes in the child's sleep patterns, it is not a definitive sign of this complication.Choice C reason: Hyperactive bowel sounds are not associated with shunt displacement. They may indicate gastrointestinal issues but are not relevant to the function of a ventriculoperitoneal shunt.
Choice D reason: An elevated temperature can be an indicator of shunt displacement, as it may suggest an infection or other complications related to the shunt. Parents should be aware of this sign and seek medical attention if it occurs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Using a 20-gauge needle for injections in a 3-month-old infant is not appropriate as it is too large. A smaller gauge needle should be used to minimize pain and tissue trauma.
Choice B reason: Providing a pacifier coated with an oral sucrose solution prior to the injections is an evidence-based practice to reduce pain in infants. The sweet taste of sucrose has a soothing effect and can help to distract the infant from the discomfort of the injection.
Choice C reason: Injecting immunizations into the deltoid muscle is not recommended for a 3-month-old infant as their muscle mass is not yet fully developed. The anterolateral thigh is the preferred site for intramuscular injections in infants.
Choice D reason: Applying eutectic mixture of local anesthetics (EMLA) cream immediately before the injections can help to numb the skin and reduce pain. However, it needs to be applied at least one hour before the procedure to be effective.
Correct Answer is A
Explanation
Choice A reason: Avoiding raw fruits and vegetables is crucial for a child with neutropenia because these foods can harbor bacteria that may cause infection in a child with a weakened immune system. It is important to minimize the risk of infection by providing a diet that includes cooked or thoroughly washed fruits and vegetables.
Choice B reason: Administering vaccines prior to discharge may not be appropriate for a child with neutropenia, as live vaccines are contraindicated due to the risk of infection. Vaccination should be deferred until the child's immune system has recovered.
Choice C reason: Obtaining the child's rectal temperature once daily is not recommended for a child with neutropenia due to the risk of introducing bacteria into the body, which can lead to infection.
Choice D reason: Bathing the child every other day does not directly relate to the care of neutropenia. While personal hygiene is important, the frequency of bathing should be based on the child's needs and condition.
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