A nurse is educating the parents of a pediatric patient who recently had a ventriculoperitoneal (VP) shunt placed to treat hydrocephalus. Which statement by the parents indicates the most critical understanding about care and potential complications?
We should limit physical activity and keep the child in bed to prevent dislodging the shunt.
If the child develops a fever, we can give over-the-counter fever reducers and only call the doctor if it persists more than 3 days.
We will need to flush the shunt regularly at home to keep it from clogging.
We will watch closely for sudden vomiting headache, or changes in behavior and notify the provider immediately if these occur.
The Correct Answer is D
A. Limiting physical activity and keeping the child in bed is incorrect because children with VP shunts do not need prolonged bed rest. Normal activity is encouraged as long as it is safe; the shunt is designed to withstand routine movement.
B. Managing fever with over-the-counter medications and waiting 3 days to call the provider is incorrect because fever may indicate a shunt infection, which is a medical emergency. Prompt assessment is essential for early intervention.
C. Flushing the shunt at home is incorrect because VP shunts should never be flushed by caregivers; doing so could cause serious injury or infection. Shunt function is monitored by observing for signs of malfunction, not by manual flushing.
D. Watching for sudden vomiting, headache, or changes in behavior and notifying the provider immediately is correct because these are key signs of shunt malfunction or increased intracranial pressure, which can be life-threatening. Early recognition and prompt medical evaluation are critical for preventing complications such as brain damage or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Visual Analog Scale (VAS) is incorrect because it requires the child to understand and mark a point on a line to represent pain intensity, which is often too complex for a 4-year-old, especially if they cannot verbalize pain reliably.
B. FLACC scale is correct. The FLACC (Face, Legs, Activity, Cry, Consolability) scale is an observational tool designed for children who cannot self-report pain. It assesses behavioral and physiological indicators of pain including facial expression, leg movement, activity level, crying, and consolability. Scores range from 0 to 10, allowing for objective assessment and monitoring of pain in young children, infants, or nonverbal patients.
C. Faces Pain Scale is incorrect because it relies on the child’s ability to understand and point to a facial expression that represents their pain. While appropriate for some preschoolers, a 4-year-old who cannot reliably verbalize or comprehend the scale may not use it accurately.
D. Numeric Rating Scale is incorrect because it requires the child to assign a number (0–10) to describe pain, which is generally suitable for children aged 7 and older who can understand abstract numerical concepts.
Correct Answer is A
Explanation
A. Ensure the weights hang freely and do not touch the floor to maintain proper traction force is correct. Proper skeletal traction depends on continuous, consistent force applied through the weights. If the weights touch the floor or are obstructed, the traction is disrupted, which can result in malalignment, delayed healing, increased pain, or neurovascular compromise. Maintaining correct traction mechanics is the highest priority to prevent serious complications.
B. Remove the traction weights every 6 hours is incorrect because weights should never be removed unless prescribed. Interrupting traction can cause muscle spasm, malalignment, or delayed fracture healing. Skin breakdown is addressed through regular skin care and positioning, not by removing weights.
C. Limit monitoring of pin sites to once every 24 hours is incorrect because pin sites require frequent assessment (at least every 4–8 hours) for signs of infection, inflammation, or loosening. Infrequent monitoring increases the risk of osteomyelitis or local infection.
D. Place the rope knot in contact with the pulley is incorrect because this would interfere with the smooth functioning of the traction system. The rope must move freely through the pulley to maintain proper tension and alignment.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.