The nurse is monitoring a child with hydrocephalus who received a 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 reports no evidence of continuous headaches
An intracranial pressure (ICP) monitoring probe is in place
The child is afebrile with normal vital signs postoperatively.
The Correct Answer is B
Choice B rationale
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.
Choice A rationale
While growth in height could be a positive sign of overall health and development, it does not specifically indicate that a VP shunt is functioning properly.
Choice C rationale
The presence of an intracranial pressure (ICP) monitoring probe does not indicate whether the shunt is functioning properly. The probe is a device used to measure ICP and does not provide information about the functionality of the shunt.
Choice D rationale
Being afebrile with normal vital signs postoperatively is a positive sign, but it does not specifically indicate that the shunt is functioning properly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.8"]
Explanation
Step 1: Calculate the total dose of diazepam for this child by multiplying the child’s weight (30 kg) by the prescribed dose (0.3 mg/kg). This calculation gives a total dose of 9 mg (30 kg × 0.3 mg/kg = 9 mg).
Step 2: Divide the total dose (9 mg) by the concentration of the medication (5 mg/mL) to determine the volume to be administered. This calculation gives a volume of 1.8 mL (9 mg ÷ 5 mg/mL = 1.8 mL).
Correct Answer is B
Explanation
Choice A rationale
Dividing the gluteal area into quarters and giving the IM injection into the upper outer quadrant is not the recommended technique for a 16-month-old toddler. This site is not typically used until after the child has begun walking regularly and has developed sufficient muscle mass.
Choice B rationale
Administering the injection into the middle of the lateral aspect of the thigh is the recommended technique for a 16-month-old toddler. The vastus lateralis muscle in the thigh is usually the preferred site for IM injections in infants and young children.
Choice C rationale
Using a needle length of 1/2 inch (1.25 cm) to avoid deep tissue damage is not the recommended technique for a 16-month-old toddler. The needle length should be appropriate for the age and size of the child, and a 1/2 inch needle may not be long enough to reach the muscle tissue.
Choice D rationale
Giving the injection in the arm, one to 2 inches (2.5 to 5.0 cm) below the acromion process, is not the recommended technique for a 16-month-old toddler. The deltoid muscle in the arm is typically not used for IM injections until after the child is 3 years old.
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