A 2-year-old child with a ventricular shunt has a temperature of 101.5°F (38.6°C), is irritable, and has a heart rate of 160 bpm.
Which of the following is the priority nursing action?
Notify the provider of a possible shunt infection.
Document findings as normal for age.
Administer antipyretics and reassess in 1 hour.
Encourage oral fluids and monitor output.
The Correct Answer is A
Choice A rationale
The constellation of fever (101.5°F or 38.6°C), irritability, and tachycardia (160 bpm, normal for a 2-year-old is ∼ 80-130 bpm) in a child with a ventricular shunt is highly suggestive of a shunt infection (ventriculitis or meningitis). A shunt infection can lead to septicemia and shunt malfunction, potentially causing rapidly increased intracranial pressure (ICP). Given the high morbidity, this finding requires immediate notification of the provider for prompt diagnostic workup (e.g., shunt tap) and empiric antibiotics.
Choice B rationale
While tachycardia and irritability can sometimes be non-specific symptoms, a fever of 101.5°F is abnormal. The presence of a ventricular shunt significantly raises the index of suspicion for shunt infection, a neurosurgical emergency, which is a life-threatening condition. Documenting and observing without immediate intervention is dangerously negligent given the clinical picture.
Choice C rationale
Administering antipyretics addresses only the fever, a symptom, and does not treat the underlying potentially fatal shunt infection. Delaying notification to reassess in one hour risks rapid neurological deterioration, as shunt infections can progress quickly to sepsis, severe ventriculitis, or uncompensated increased intracranial pressure (ICP). Immediate medical evaluation is the priority.
Choice D rationale
Encouraging oral fluids is a supportive measure for fever and dehydration, but it is not the priority for a child highly suspected of having a ventricular shunt infection. Oral fluid intake can be impaired due to irritability and potential nausea/vomiting associated with increased intracranial pressure, and this action delays definitive diagnosis and treatment of the infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The sweat chloride test is the gold standard diagnostic test for cystic fibrosis (CF). CF is caused by a mutation in the CFTR gene, which impairs chloride ion transport across epithelial cells. This defect leads to abnormally high chloride concentration in sweat, typically >60 mEq/L in children, which provides biochemical confirmation of the disease.
Choice B rationale
Pulmonary function tests (PFTs) measure lung volumes and airflow, typically revealing an obstructive pattern in CF due to chronic infection and inflammation. While they monitor disease progression and severity, PFTs are not diagnostic for the underlying genetic disorder that defines cystic fibrosis.
Choice C rationale
A Chest X-ray (CXR) may show characteristic findings of chronic lung disease in CF, such as bronchiectasis, hyperinflation, or atelectasis, reflecting the disease's pulmonary complications. However, the CXR is an imaging tool for assessing lung structure, not a diagnostic test for the systemic genetic condition itself.
Choice D rationale
Sputum cultures are used to identify the specific bacterial pathogens, such as Pseudomonas aeruginosa or Staphylococcus aureus, colonizing the airways of CF patients. While essential for guiding antibiotic therapy, a sputum culture only detects secondary infection and does not confirm the diagnosis of cystic fibrosis.
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale
Hypercyanotic spells, or "tet spells," result from a sudden decrease in pulmonary blood flow and increased right-to-left shunting, leading to profound hypoxemia. Administering oxygen helps by slightly increasing arterial oxygen tension, which acts as a mild pulmonary vasodilator, potentially reducing pulmonary vascular resistance and improving oxygen delivery to tissues. This aims to counteract the immediate hypoxemia.
Choice C rationale
Morphine administration is appropriate because of its central nervous system depressant effects. It helps to calm the infant, decreasing systemic oxygen demands and reducing the hyperpnea (rapid, deep breathing) that often accompanies the spell. Furthermore, morphine mildly vasodilates, which increases systemic vascular resistance, decreasing the right-to-left shunt flow.
Choice E rationale
Placing the infant in the knee-chest position significantly increases systemic vascular resistance (SVR) by compressing the major arteries in the lower extremities. The increased SVR reduces the pressure gradient driving the right-to-left shunt through the ventricular septal defect, thereby increasing pulmonary blood flow and improving oxygen saturation during the hypercyanotic event.
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