A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider?

Irritability when being held

Heart rate 122/min

Hypoactive bowel sounds

Urine specific gravity 1.018

Answer and Explanation

The Correct Answer is A

A. Irritability when being held may indicate increased intracranial pressure or complications related to the VP shunt placement and should be reported to the provider.

B. A heart rate of 122/min is within the normal range for an infant and does not require reporting.

C. Hypoactive bowel sounds may occur postoperatively, especially if the infant has not been fed or has been under anesthesia, and is not an immediate concern.

D. A urine specific gravity of 1.018 is within normal limits for infants and does not indicate a need for reporting.

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Correct Answer is B

Explanation

A. While offering choices can promote autonomy, allowing clients to choose their own mealtimes may lead to avoidance of meals and is not a structured approach needed for clients with anorexia nervosa.

B. Supervision during and after eating is critical in managing clients with anorexia nervosa to ensure they consume the necessary nutrients and to monitor for any harmful behaviors, such as purging.

C. Although providing choices can support autonomy, it may not be suitable for clients with anorexia nervosa, as they might choose low-calorie or unhealthy options.

D. Encouraging casual conversation about food can sometimes increase anxiety or lead to fixation on eating behaviors, making it an inappropriate strategy for this population.

A. Bradycardia B. Wheezing C. Pale, Dry Skin D. Pink, frothy sputum

Correct Answer is D

Explanation

Bradycardia is not typically associated with pulmonary edema; instead, tachycardia is more common as the body tries to compensate for decreased oxygenation.

B. Wheezing may occur in certain respiratory conditions but is not a classic finding in pulmonary edema; instead, crackles or rales are more expected due to fluid accumulation.

C. Pale, dry skin is not characteristic of pulmonary edema; the client may present with cyanosis or clammy skin due to hypoxia.

D. Pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the alveoli and is often associated with acute heart failure.

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A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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