A nurse is assessing a 4-year-old child who is 2 days postoperative following insertion of a ventriculoperitoneal shunt. Which of the following findings is the nurse's priority?

Urine output of 50 mL in 2 hr

Lethargy

Respiratory rate 24/min

Absent Babinski reflex

Answer and Explanation

The Correct Answer is B

A. Urine output of 50 mL in 2 hr: This is within normal limits for a child and does not indicate an immediate concern.
B. Lethargy: Lethargy is a potential sign of increased intracranial pressure (ICP), which is a critical complication of VP shunt placement and requires immediate intervention.
C. Respiratory rate 24/min: This is within the normal range for a 4-year-old child.
D. Absent Babinski reflex: This is a normal finding in children over 2 years old, as the reflex typically disappears by that age.

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Correct Answer is C

Explanation

A. "I will cook foods that are low in fat and carbohydrates.": Children with cystic fibrosis often require a high-calorie, high-fat diet to meet their increased energy needs.
B. "My child can chew their enzyme medication with meals.": Enzyme medications should not be chewed as they can irritate the oral mucosa; they should be swallowed whole or sprinkled on soft food.
C. "I will give my child stool softeners for constipation." Constipation is a common issue in cystic fibrosis due to thickened intestinal secretions. Stool softeners help prevent this complication.
D. "My child will be excused from physical education class.": Physical activity is encouraged for children with cystic fibrosis to improve lung function.

A. Cough B. Recurrent emesis C. Inadequate weight gain D. Irritability

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

Cough

Hypertrophic Pyloric Stenosis: Pyloric stenosis typically causes forceful vomiting but does not cause coughing.
Gastroesophageal Reflux: Coughing can occur due to aspiration or irritation of the esophagus.

Recurrent Emesis

Hypertrophic Pyloric Stenosis: Projectile vomiting after feedings is a hallmark sign of pyloric stenosis.
Gastroesophageal Reflux: GER can also cause recurrent vomiting, though it is usually less forceful than in pyloric stenosis.

Inadequate Weight Gain

Hypertrophic Pyloric Stenosis: The inability to retain feedings can lead to poor weight gain.
Gastroesophageal Reflux: Reflux can also result in poor weight gain if feedings are frequently vomited.

Irritability

Hypertrophic Pyloric Stenosis: Hunger due to inadequate feeding can cause irritability.
Gastroesophageal Reflux: Discomfort from esophageal irritation can lead to irritability.

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A nurse is assessing a 4-year-old child who is 2 days postoperative following insertion of a ventriculoperitoneal shunt. Which of the following findings is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

A nurse is teaching the parent of a school-age child who has cystic fibrosis about home care. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is caring for a 4-month-old infant in the outpatient setting. Exhibits For each assessment finding, click to specify if the finding is consistent with hypertrophic pyloric stenosis or gastroesophageal reflux. Each finding may support more than one disease process.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

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The nurse is continuing to care for the infant. The nurse is providing teaching to the parents of the infant. For each instruction, click to specify if the instruction is appropriate or contraindicated for the infant.