The nurse is caring for a child who has had a ventriculoperitoneal shunt (VP) for hydrocephalus and observes an increasing abdominal girth.
What is the most appropriate response?
Notify the charge nurse of possible malabsorption.
Check bowel sounds.
Record retention of feeding.
Elevate the child’s head.
The Correct Answer is A
Choice A rationale
An increasing abdominal girth in a child with a VP shunt may be indicative of malabsorption of the cerebrospinal fluid (CSF) that is being shunted to the peritoneum. This is because the VP shunt is a soft, flexible tube which is inserted into a lateral ventricle and acts as a drainpipe, to give the CSF a way to flow out of the ventricles. The tube is connected to a valve, which regulates the flow of CSF. The end of the shunt is placed within the abdominal cavity (tummy area), where the CSF will be reabsorbed. Therefore, if the CSF is not being properly absorbed in the peritoneum, it could lead to an increase in abdominal girth. This is a serious concern that needs immediate attention, hence the charge nurse should be notified.
Choice B rationale
Checking bowel sounds is a common nursing intervention for assessing gastrointestinal function. However, in the context of a child with a VP shunt and increasing abdominal girth, it is less likely to be directly related to the issue at hand. While bowel sounds can provide information about the functioning of the digestive system, they do not provide direct information about the functioning of the VP shunt or the absorption of CSF in the peritoneum.
Choice C rationale
Recording retention of feeding could be relevant in cases where there are concerns about the child’s nutritional status or digestive function. However, in this case, the primary concern is related to the functioning of the VP shunt and the absorption of CSF in the peritoneum. Therefore, while it’s always important to monitor feeding in a child, it is not the most appropriate response in this specific situation.
Choice D rationale
Elevating the child’s head is often done to reduce intracranial pressure, especially in patients with conditions affecting the brain or spinal cord. However, in the context of a child with a VP shunt and increasing abdominal girth, elevating the head would not address the underlying issue of potential malabsorption of CSF in the peritoneum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Measuring from the back of the head to the forehead is not the correct method for measuring head circumference in an infant. The measurement should be taken around the widest part of the head, which is typically above the eyebrows and ears.
Choice B rationale
Placing the measuring tape above the eyebrows and around the widest part of the head is the correct method for measuring head circumference in an infant. The tape should be wrapped around the head at the points just above the eyebrows, above the ears, and around the back where the head slopes up prominently from the neck.
Choice C rationale
Measuring from the chin to the top of the head is not the correct method for measuring head circumference in an infant. The measurement should be taken around the widest part of the head, which is typically above the eyebrows and ears.
Choice D rationale
Wrapping the measuring tape tightly around the neck is not the correct method for measuring head circumference in an infant. The measurement should be taken around the widest part of the head, which is typically above the eyebrows and ears.
Correct Answer is D
Explanation
Choice A rationale
While the genitourinary system can be affected in individuals with Down syndrome, it is not the most commonly affected body system. Down syndrome is a genetic condition where a person is born with an extra chromosome. This can affect how their brain and body develop, leading to both physical and mental challenges.
Choice B rationale
The reproductive system is not the most commonly affected body system in individuals with Down syndrome. While individuals with Down syndrome can have reproductive health issues, these are not as common as issues with other body systems.
Choice C rationale
The gastrointestinal system can be affected in individuals with Down syndrome, but it is not the most commonly affected body system. Some individuals with Down syndrome may experience gastrointestinal issues such as constipation or gastroesophageal reflux disease.
Choice D rationale
The cardiovascular system is the most commonly affected body system in individuals with Down syndrome. Almost half of babies with Down syndrome have congenital heart disease (CHD), the most common type of congenital anomaly. CHD can lead to high blood pressure in the lungs, an inability of the heart to effectively and efficiently pump blood, and cyanosis (blue-tinted skin caused by reduced oxygen in the blood)3.
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.