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 B
Explanation
Choice A reason: Chickenpox, caused by varicella-zoster virus, presents with a rash and fever, not the characteristic cough of pertussis. It is a distinct viral infection, unrelated to the bacterial respiratory pathology of pertussis, which is caused by Bordetella pertussis.
Choice B reason: Pertussis, caused by Bordetella pertussis, is commonly called whooping cough due to the distinctive whooping sound during coughing fits. This bacterial infection causes severe, prolonged coughing, particularly in children, making it the correct common name for the disease.
Choice C reason: Measles, caused by the rubeola virus, presents with rash, fever, and Koplik spots, not a whooping cough. It is a viral infection, distinct from the bacterial etiology of pertussis, making this an incorrect common name for the condition.
Choice D reason: Fifth disease, caused by parvovirus B19, causes a slapped-cheek rash, not a cough. It is a viral infection, unrelated to the bacterial respiratory symptoms of pertussis, making it an incorrect common name for this bacterial disease.
Correct Answer is D
Explanation
Choice A reason: A 99.5 ml/hour rate overestimates fluid needs for a 13.5 kg child with 20% burns. The Parkland formula (4 ml/kg/% burn) yields 1080 ml over 8 hours (540 ml first 8 hours ÷ 8 = 67.5 ml/hour), making this rate too high, risking fluid overload.
Choice B reason: A 35.5 ml/hour rate underestimates fluid resuscitation for a 13.5 kg child with 20% burns. The Parkland formula calculates 540 ml for the first 8 hours (4 × 13.5 × 20 ÷ 2), or 67.5 ml/hour, insufficient fluid risks hypovolemia and shock.
Choice C reason: A 33.8 ml/hour rate is too low for burn resuscitation in a 13.5 kg child with 20% burns. The Parkland formula gives 67.5 ml/hour (4 × 13.5 × 20 ÷ 2 ÷ 8), and under-resuscitation risks inadequate tissue perfusion, leading to organ failure.
Choice D reason: For a 13.5 kg child with 20% burns, the Parkland formula (4 ml/kg/% burn) calculates 1080 ml total (4 × 13.5 × 20), with half (540 ml) in the first 8 hours, or 67.5 ml/hour. This rate ensures adequate hydration, preventing shock while avoiding fluid overload.
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