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 ["A","B","D","E"]
Explanation
Choice A rationale
Calculating the safe dosage is a crucial step in administering medication to a toddler. This ensures that the child receives the appropriate amount of medication based on their weight and age.
Choice B rationale
Identifying the toddler by asking the caregiver is an important step to ensure that the correct medication is given to the correct child.
Choice C rationale
Telling the caregiver to administer the medication is not recommended. As a nurse, it is your responsibility to administer the medication to ensure it is done correctly.
Choice D rationale
Offering juice after the medication can help mask any unpleasant taste and make the medication administration process more tolerable for the toddler.
Choice E rationale
Asking the toddler to pick a toy to hold during administration can serve as a distraction and make the process less stressful for the child.
Correct Answer is A
Explanation
Choice A rationale
The statement “My baby will be placed under special lights if the test is elevated” indicates a need for further teaching. This statement is incorrect because phototherapy (special lights) is not used to treat phenylketonuria (PKU). PKU is a genetic disorder that results in the body’s inability to metabolize the amino acid phenylalanine. If left untreated, it can lead to intellectual disability and other serious health problems. The treatment for PKU involves a special diet that is low in phenylalanine. Therefore, the parent’s statement about using special lights for treatment indicates a misunderstanding about the nature of PKU and its treatment.
Choice B rationale
The statement “Sometimes the test is repeated in the doctor’s office at the 2-week check-up” is correct. PKU is usually diagnosed through a routine newborn screening test, and if the initial test results are positive or unclear, the test may be repeated.
Choice C rationale
The statement “My baby must take formula or breast milk before the test is done” is correct. For accurate results, the PKU test is done after the baby is 24 hours old and after the baby has had some protein in the diet.
Choice D rationale
The statement “This test checks for a genetic disorder that can be corrected by diet” is correct. PKU is a genetic disorder that can be managed with a special diet low in phenylalanine.
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