The nurse is caring for a 2-year-old child that has a ventriculoperitoneal shunt placed yesterday. Her current vital signs are T 100.5 temporal, Pulse 62, Respiratory rate 14. She vomited this morning and is awake and responsive. She voided 100ml this morning. Which assessment findings should the LPN report immediately?
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Rationale for correct choices:
• Vomiting, pulse, resp: The child recently had a ventriculoperitoneal (VP) shunt placed and now demonstrates vomiting, bradycardia (pulse 62), and decreased respirations (14). These findings are concerning for increased intracranial pressure or shunt malfunction. In a 2-year-old child, bradycardia and depressed respirations are late neurologic signs that require immediate reporting and intervention.
• Neurological assessment: Following recognition of possible increased intracranial pressure, the priority assessment is neurologic evaluation. The nurse should assess level of consciousness, pupil response, motor function, irritability, responsiveness, and additional signs of shunt malfunction or neurologic deterioration.
Rationale for incorrect choices:
• Temperature, vomiting: A mild postoperative temperature elevation may occur after surgery and is less concerning than the combination of vomiting with abnormal pulse and respirations indicating possible neurologic compromise.
• Temperature, pulse, output: Urinary output of 100 mL is acceptable for a 2-year-old child and is not the priority concern. Bradycardia with vomiting and respiratory depression is more urgent.
• Output, respirations, vomiting: Although respirations and vomiting are concerning, urinary output is not abnormal enough to warrant immediate reporting compared with signs suggesting increased intracranial pressure.
• Gastrointestinal assessment: Vomiting may occur with increased intracranial pressure, but gastrointestinal assessment does not address the primary neurologic concern related to VP shunt complications.
• Cardiovascular assessment: Bradycardia is significant, but a focused neurologic assessment takes priority because the cardiovascular changes are likely secondary to increased intracranial pressure.
• Genitourinary assessment: The child’s urinary output is adequate and does not suggest an immediate genitourinary complication requiring priority assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Traction in pediatric femoral fractures requires vigilant monitoring for neurovascular compromise, compartment syndrome, vascular perfusion deficits, and peripheral nerve injury. Children are at increased risk due to smaller limb compartments and rapid progression of ischemic damage when circulation is impaired under immobilization devices.
Rationale:
A. Abdominal assessment evaluates gastrointestinal function and possible distension but is not the priority in traction care. It does not directly reflect limb perfusion or detect complications related to skeletal immobilization.
B. Listening to breath sounds assesses respiratory status, which is important in general nursing care but not directly related to traction complications. There is no immediate indication of respiratory compromise in this scenario.
C. PERRLA and hand grasps assess neurologic function of the upper extremities and cranial nerves, which are not directly affected by femoral traction. These findings do not provide information about lower limb vascular integrity.
D. Neurovascular checks assess circulation, sensation, movement, capillary refill, and pulses in the affected extremity. This is the highest priority because traction can impair blood flow and nerve function, leading to ischemia, tissue damage, and potential limb-threatening complications if not detected early.
Correct Answer is A
Explanation
Meningitis is an acute inflammation of the meninges typically caused by bacterial or viral infection, leading to increased intracranial pressure, cerebral irritation, and systemic toxicity. Classic pediatric signs include irritability, high-pitched cry, poor feeding, fever, and meningeal irritation due to central nervous system involvement.
Rationale:
A. Meningitis presents with meningeal inflammation causing irritability, poor feeding, and a high-pitched cry in young children due to increased intracranial pressure and cerebral irritation. These are early pediatric signs before classic neck stiffness becomes evident.
B. Lyme disease primarily causes erythema migrans, arthritis, and later neurologic complications. It does not typically present acutely with a high-pitched cry or severe irritability suggestive of intracranial infection in toddlers.
C. Reye syndrome is associated with hepatic dysfunction and cerebral edema following viral illness and aspirin use. It typically presents with vomiting and altered consciousness rather than a high-pitched cry and early irritability in this presentation.
D. Febrile seizures involve transient convulsions associated with fever but do not cause persistent irritability, poor feeding, or a shrill cry between episodes, making them inconsistent with the ongoing neurologic irritation described.
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