The nurse is monitoring a child with hydrocephalus who received a repeat ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally?

The child has grown in height since the previous shunt placement.

The child is afebrile with normal vital signs postoperatively.

An intracranial pressure (ICP) monitoring probe is in place.

The child reports no evidence of continuous headaches.

Answer and Explanation

The Correct Answer is D

The absence of continuous headaches in the child indicates that the VP shunt is functioning normally. A VP shunt is used to treat hydrocephalus by draining excess cerebrospinal ﬂuid from the brain to the abdomen. If the shunt is functioning properly, it should relieve pressure on the brain and reduce symptoms such as headaches. The other options (A, B, and C) do not directly indicate whether the shunt is functioning normally or not.

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Correct Answer is D

Explanation

Aortic stenosis is a narrowing of the aortic valve, which can cause decreased blood ﬂow from the left ventricle to the systemic circulation. In infants with aortic stenosis, the left ventricle must work harder to pump blood through the narrowed valve, which can lead to left ventricular hypertrophy, heart failure, and pulmonary edema. Bilateral fine crackles in both lung fields may indicate ﬂuid overload in the lungs, which is a common complication of heart failure. Hypotension and tachycardia may also be present due to decreased cardiac output.

Option A is not a typical finding associated with aortic stenosis.

Option B is not directly related to the infant's cardiac condition.

Option C is not a typical finding associated with heart failure.

A. Refer the child to the healthcare provider and schedule evaluation of blood pressure in two weeks. B. Measure the child's blood pressure three times during the visit and determine the highest of the readings. C. Conduct a head-to-toe assessment and omit repeated blood pressures during the examination. D. Take the blood pressure two more times during the visit and determine the average of the three readings.

Correct Answer is D

Explanation

If a child's systolic blood pressure is greater than the 90th percentile during a routine clinic visit, the nurse should take the blood pressure two more times during the visit and determine the average of the three readings. This will provide a more accurate assessment of the child's blood pressure. Referring the child to the healthcare provider and scheduling an evaluation of blood pressure in two weeks

A. may be necessary if the child's blood pressure remains elevated, but it is not the next action that should be taken. Measuring the child's blood pressure three times during the visit and determining the highest of the readings

B. is not recommended because it may overestimate the child's blood pressure. Conducting a head-to-toe assessment and omitting repeated blood pressures during the examination

C. is not appropriate because it does not provide an accurate assessment of the child's blood pressure.

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The nurse is monitoring a child with hydrocephalus who received a repeat ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. Which additional finding should the nurse expect to obtain?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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