An infant who is developmentally delayed has a ventricular peritoneal (VP) shunt for hydrocephalus. The nurse makes a postoperative home visit to assess the child's progress. During the visit, the mother tells the nurse, "When the shunt is removed, the pressure in my baby's head will be gone." Which response should the nurse provide?

"Many infants outgrow the need for a shunt after the neonatal period."

"The shunt will be replaced as your child grows to reduce pressure in the brain."

"Other pathways in the brain will drain fluid after the shunt is removed."

"The shunt will have to be reinserted only if an infection or blockage develops."

Answer and Explanation

The Correct Answer is B

Choice A reason: "Many infants outgrow the need for a shunt after the neonatal period." is not a correct response that the nurse should provide. This statement is false, as most infants with hydrocephalus will need a shunt for life. Only a small percentage of infants with post-hemorrhagic hydrocephalus may outgrow the need for a shunt .

Choice B reason: "The shunt will be replaced as your child grows to reduce pressure in the brain." is the correct response that the nurse should provide. This statement is true, as the shunt will need to be adjusted or replaced as the child grows to accommodate the changes in the size and shape of the head and the amount of fluid drainage. The nurse should educate the mother about the signs and symptoms of shunt malfunction and the need for regular follow-up visits.

Choice C reason: "Other pathways in the brain will drain fluid after the shunt is removed." is not a correct response that the nurse should provide. This statement is false, as the shunt is not removed unless there is a serious complication or the child no longer needs it. The shunt is a permanent device that bypasses the blocked or impaired pathways in the brain and allows the fluid to drain into the abdomen. Without the shunt, the fluid will accumulate in the brain and cause increased pressure and damage.

Choice D reason: "The shunt will have to be reinserted only if an infection or blockage develops." is not a correct response that the nurse should provide. This statement is false, as the shunt is not removed and reinserted unless there is a serious complication or the child no longer needs it. The shunt is a permanent device that stays in place unless it malfunctions or becomes infected. The nurse should educate the mother about the signs and symptoms of shunt infection and the need for prompt treatment.

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Correct Answer is A

Explanation

Choice A reason: Arrested growth is a common outcome of renal osteodystrophy in children. It is caused by the impaired bone formation and mineralization that result from the abnormal calcium, phosphorus, vitamin D, and parathyroid hormone levels in chronic kidney disease. Arrested growth can lead to short stature, delayed puberty, and poor quality of life.

Choice B reason: Weight gain is not a specific outcome of renal osteodystrophy in children. It may be related to other factors, such as fluid retention, decreased physical activity, or increased appetite due to medications or hormonal imbalances. Weight gain can worsen the kidney function and increase the risk of cardiovascular complications.

Choice C reason: Low blood pressure is not a specific outcome of renal osteodystrophy in children. It may be caused by other factors, such as dehydration, blood loss, infection, or medications. Low blood pressure can affect the perfusion of vital organs and cause dizziness, fainting, or shock.

Choice D reason: Hypervitaminosis D is not a specific outcome of renal osteodystrophy in children. It may occur as a side effect of vitamin D supplementation, which is often prescribed to treat or prevent renal osteodystrophy. Hypervitaminosis D can cause hypercalcemia, which can lead to nausea, vomiting, constipation, confusion, or kidney stones.

A. Measure abdominal circumference. B. Gather supplies for an intravenous (IV) infusion. C. Monitor strict urinary output. D. Prepare for anorectal manometry.

Correct Answer is A

Explanation

Choice A reason: Measuring abdominal circumference provides immediate, objective data about the degree of abdominal distention, which is a key sign of intestinal obstruction in a neonate who hasn’t passed meconium and is vomiting bilious secretions. Establishing a baseline girth measurement guides further assessment, helps detect rapidly worsening distention, and informs decisions about decompression and imaging studies.

Choice B reason: Although initiating an IV infusion is critical for fluid and electrolyte replacement in any vomiting infant, securing intravenous access should follow a focused assessment. Prioritizing assessment ensures you understand the severity of the obstruction and tailor fluid resuscitation and other interventions appropriately.

Choice C reason: Monitoring strict urinary output is not the first action that the nurse should take. This is because urinary output is not the most sensitive indicator of fluid status in infants, especially those with renal insufficiency or oliguria. Monitoring urinary output may also delay more urgent interventions, such as fluid resuscitation and decompression.

Choice D reason: Preparing for anorectal manometry is not the first action that the nurse should take. This is because anorectal manometry is a diagnostic test that measures the pressure and function of the anal and rectal muscles. It is not indicated for infants with suspected meconium ileus, which is a mechanical obstruction of the bowel by thick and sticky meconium. Preparing for anorectal manometry may also delay more urgent interventions, such as fluid resuscitation and decompression.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a child with chronic kidney disease who is experiencing renal osteodystrophy. Which outcome should the nurse explain to the parents about the sequela for their child with renal osteodystrophy?

Correct Answer is A

Explanation

An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?

Correct Answer is A

Explanation

When providing care for a child who is in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?

The nurse is caring for an infant admitted with dehydration, irritability, signs of extreme hunger, and a palpable olive-like mass in the upper right abdominal quadrant. When feeding the infant, the nurse should monitor for which development?

The nurse is providing discharge instructions to the caregiver of an infant with recurrent otitis media. Which statement made by the caregiver should the nurse recognize as needing additional education about minimizing subsequent infections?

The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?

The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

A 9-year-old boy is diagnosed with type 1 diabetes mellitus (DM). Which stage of Erikson’s theory of psychosocial development is the nurse addressing when teaching this client about insulin injections?