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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) recommend that the first dose of MMR vaccine be given at 12-15 months of age.
A. 6 months is too early for the MMR vaccine.
D. 2 months is also too early for the MMR vaccine.
C. 24 months is slightly beyond the recommended range for the first dose of MMR vaccine, which is given between 12-15 months of age.
Correct Answer is A
Explanation
The nurse should report the findings of significant erythema and swelling in the scrotum immediately to the healthcare provider. The adolescent's symptoms may be indicative of testicular torsion, which is a medical emergency and requires prompt treatment to prevent loss of the testicle. Obtaining a swab of secretions from the penis and urethra or collecting a sterile urine sample for culture and sensitivity are not appropriate actions for this presentation. Providing a urinal for urinary hesitancy may be appropriate if the adolescent is experiencing difficulty urinating, but this should not take precedence over reporting the findings to the healthcare provider.
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