A child with a ventriculoperitoneal shunt complains of headache and blurry vision and now experiences irritability and sleeping more than usual. The parents ask the nurse what they should do. Select the nurse's best response.
Give her some acetaminophen and see if her symptoms improve. If they do not improve, bring her to the healthcare provider's office.
You should immediately take her to the emergency department because these may be symptoms of a shunt malfunction.
It is common for girls to have these symptoms, especially before beginning their menstrual cycle. Give her a few days and see if she improves.
You are probably worried that she is having a problem with her shunt. This is very unlikely because it has been working well for 9 years.
The correct answer is: b) You should immediately take her to the emergency department because these may be symptoms of a shunt malfunction.
The Correct Answer is B
Choice A reason: Administering acetaminophen may mask symptoms of shunt malfunction, such as headache, without addressing the underlying issue. Increased intracranial pressure from a blocked shunt can cause rapid neurological deterioration, requiring urgent evaluation to prevent brain damage or death, making this response inadequate.
Choice B reason: Headache, blurry vision, irritability, and lethargy suggest shunt malfunction, potentially causing increased intracranial pressure due to cerebrospinal fluid buildup. Immediate emergency department evaluation is critical to assess shunt function, prevent herniation, and initiate interventions like shunt revision to restore normal cerebrospinal fluid drainage.
Choice C reason: Attributing symptoms to menstrual cycles is inappropriate, as headache, blurry vision, and lethargy indicate possible shunt malfunction. Hormonal changes do not typically cause these neurological symptoms, and delaying care risks severe complications like brain herniation due to increased intracranial pressure.
Choice D reason: Dismissing symptoms because the shunt has functioned for 9 years is dangerous. Shunts can fail at any time due to blockage or infection, causing increased intracranial pressure. Symptoms like headache and blurry vision require urgent evaluation to prevent irreversible neurological damage or death.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Hypoglycemia is not an adverse effect of levothyroxine, which treats hypothyroidism by increasing thyroid hormone levels. It may increase metabolism, potentially raising glucose levels, but does not cause low blood sugar, making this an incorrect concern for monitoring.
Choice B reason: Hypertension is not a primary adverse effect of levothyroxine. While excessive doses may increase metabolism and heart rate, leading to secondary cardiovascular effects, palpitations are a more specific and common sign of overmedication, making this less critical to monitor.
Choice C reason: Palpitations are a potential adverse effect of levothyroxine, especially with excessive dosing, as it increases thyroid hormone levels, stimulating the heart. This causes tachycardia or irregular heartbeats, requiring monitoring to prevent cardiovascular complications in adolescents with hypothyroidism.
Choice D reason: Weight loss may occur with levothyroxine due to increased metabolism, but it is an expected therapeutic effect in hypothyroidism, not an adverse one. Palpitations indicate potential overmedication, making them a more critical adverse effect to monitor than weight changes.
Correct Answer is D
Explanation
Choice A reason: Contact precautions are used for infections like MRSA, spread by direct touch. Measles is transmitted via airborne droplet nuclei, not skin contact. Contact precautions would not prevent the spread of measles, as they do not address the respiratory transmission route of the virus.
Choice B reason: Droplet precautions are for infections like influenza, spread by larger respiratory droplets. Measles spreads via smaller airborne particles that remain suspended, requiring stricter airborne precautions. Droplet measures are insufficient to prevent transmission in shared air spaces over longer distances.
Choice C reason: A protective environment is used for immunocompromised patients, like those undergoing transplants, to prevent infection. Measles requires precautions to protect others from the patient, not vice versa, making this inappropriate. It does not address the airborne transmission of the measles virus.
Choice D reason: Measles, caused by the rubeola virus, spreads via airborne droplet nuclei, which can remain suspended for hours. Airborne precautions, including negative-pressure rooms and N95 masks, prevent transmission by containing infectious particles, protecting healthcare workers and other patients from this highly contagious virus.
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