The nurse is monitoring a child with hydrocephalus who received a repeat ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally?

The child has grown in height since the previous shunt placement.

The child is afebrile with normal vital signs postoperatively.

An intracranial pressure (ICP) monitoring probe is in place.

The child reports no evidence of continuous headaches.

Answer and Explanation

The Correct Answer is D

The absence of continuous headaches in the child indicates that the VP shunt is functioning normally. A VP shunt is used to treat hydrocephalus by draining excess cerebrospinal ﬂuid from the brain to the abdomen. If the shunt is functioning properly, it should relieve pressure on the brain and reduce symptoms such as headaches. The other options (A, B, and C) do not directly indicate whether the shunt is functioning normally or not.

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Correct Answer is C

Explanation

The nurse should recognize that the statement "high-calorie formula encourages increased growth" is an appropriate understanding of interventions for an infant with FTT. High-calorie formula can help infants who are not gaining weight adequately to increase their calorie intake and promote growth.

Breast milk provides adequate nutrition for most infants, but in cases of FTT, the infant may require a higher calorie intake than breast milk can provide. Regular syringe feedings and fruit juice are not recommended interventions for FTT. Syringe feedings can cause aspiration and fruit juice does not provide the appropriate balance of nutrients needed for an infant's growth and development.

A. Rebound tenderness in the left lower abdominal quadrant. B. Stool that consists of mucus and blood. C. Olive-size mass in the epigastric area. D. Frequent burping accompanied by poor feeding.

Correct Answer is C

Explanation

In a 5-week-old infant presenting with a history of projectile vomiting after feedings, the nurse should expect to assess an olive-size mass in the epigastric area. This finding is consistent with pyloric stenosis, a condition in which the muscle at the bottom of the stomach that controls the ﬂow of food into the small intestine becomes thickened and narrowed.

Rebound tenderness in the left lower abdominal quadrant, stool that consists of mucus and blood, and frequent burping accompanied by poor feeding are not typically associated with pyloric stenosis.

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The nurse is monitoring a child with hydrocephalus who received a repeat ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing nutrition education to the parents of an infant with failure to thrive (FTT). Which statement made by the parent should the nurse recognize as an appropriate understanding of interventions?

Correct Answer is C

Explanation

The nurse is caring for a 5-week-old infant presenting with a history of projectile vomiting after feedings. Which additional finding should the nurse expect to assess?

Correct Answer is C

Explanation

A 3-year-old boy in a daycare facility scratches his head frequently, and the nurse confirms the presence of head lice. The nurse washes the child's hair with permethrin shampoo and calls his parents. Which instruction should the nurse provide to the parents about treatment for head lice?

The nurse is caring for a child with hypoparathyroidism who demonstrates a carpal spasm when pressure is applied to the upper arm. Which laboratory value should the nurse review?

The nurse is caring for an infant who was recently diagnosed with a congenital heart defect. Which assessment finding is most important for the nurse to report to the healthcare provider?

While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?

The nurse is assessing the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?

The parents of a child with Wilms tumor ask the nurse why surgery is necessary before a biopsy is performed. Which information should the nurse provide?

The nurse is assessing a child with acute glomerulonephritis who presents with increased fatigue, facial puffiness, decreased appetite. The child's urine sample is dark yellow in color. Which additional finding should the nurse report to the healthcare provider?

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