The nurse has taught the parents of a school-aged child with a newly placed ventriculoperitoneal (VP) shunt to monitor for early signs of shunt malfunction. The nurse determines the parents understand the instructions if they understand they should notify the provider if the child develops which early manifestation?
Lethargy
Seizure activity
Rapid weight gain
Disinterest in attending school
The Correct Answer is A
A. Lethargy is an early sign of increased intracranial pressure (ICP) due to possible shunt malfunction and requires immediate medical attention.
B. Seizure activity can be a late sign of shunt malfunction and is also concerning but lethargy typically appears earlier.
C. Rapid weight gain is less directly related to shunt malfunction and more associated with conditions like hypothyroidism or edema.
D. Disinterest in school could suggest general malaise but is not a specific or early sign of shunt malfunction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["23"]
Explanation
To calculate the IV fluid rate, first, convert the infant's weight from pounds and ounces to kilograms. There are 2.2 pounds in one kilogram. The infant weighs 16 pounds and 8 ounces, which is 16.5 pounds or approximately 7.5 kilograms when converted (16.5 pounds ÷ 2.2 pounds per kilogram). Next, multiply the infant's weight in kilograms by the prescribed amount of IV fluid, which is 6 mL/kg. This results in 45 mL (7.5 kg × 6 mL/kg). Since the fluid is to be infused over 2 hours, divide the total volume of 45 mL by 2 hours to find the rate per hour. The IV pump should be set to deliver approximately 22.5 mL/hr. After rounding to the nearest whole number, the IV pump should be set to deliver 23 mL/hr.
Correct Answer is D
Explanation
A. Monitoring for infection is important, but the white blood cell count is within normal limits, so it is not the immediate priority.
B. Although the hemoglobin is slightly low, it is not critically low, so transfusion of packed red blood cells is not immediately necessary.
C. Intravenous immunoglobulins are not indicated based on the current lab values.
D. The platelet count is critically low, placing the client at high risk for bleeding. Initiating bleeding precautions is the priority to prevent hemorrhage.
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