The nurse is monitoring a child with hydrocephalus who received a 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 reports no evidence of continuous headaches
An intracranial pressure (ICP) monitoring probe is in place
The child is afebrile with normal vital signs postoperatively.
The Correct Answer is B
Choice B rationale
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.
Choice A rationale
While growth in height could be a positive sign of overall health and development, it does not specifically indicate that a VP shunt is functioning properly.
Choice C rationale
The presence of an intracranial pressure (ICP) monitoring probe does not indicate whether the shunt is functioning properly. The probe is a device used to measure ICP and does not provide information about the functionality of the shunt.
Choice D rationale
Being afebrile with normal vital signs postoperatively is a positive sign, but it does not specifically indicate that the shunt is functioning properly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While physical therapy can be beneficial for many pediatric patients, it may not be the most appropriate intervention for a newborn who has had gastroschisis repair and is on parenteral nutrition and continuous enteral feedings. The focus at this stage should be on promoting normal growth and development, and physical therapy may not directly contribute to this goal.
Choice B rationale
Offering a pacifier for non-nutritive sucking can be an effective strategy to promote normal growth and development in infants who have had gastroschisis repair. Non-nutritive sucking can help stimulate the sucking reflex, which is important for feeding and growth. Therefore, the nurse should include this action in the plan of care.
Choice C rationale
Confirming the placement of the enteral tube with an abdominal x-ray is an important part of care for infants on continuous enteral feedings. However, this action is more related to ensuring the safety and effectiveness of the feeding process rather than promoting the infant’s normal growth and development.
Choice D rationale
Using sterile technique during feedings is a standard practice to prevent infection, especially in infants who are on parenteral nutrition and continuous enteral feedings. However, this action does not directly promote the infant’s normal growth and development.
Correct Answer is ["1.8"]
Explanation
Step 1: Calculate the total dose of diazepam for this child by multiplying the child’s weight (30 kg) by the prescribed dose (0.3 mg/kg). This calculation gives a total dose of 9 mg (30 kg × 0.3 mg/kg = 9 mg).
Step 2: Divide the total dose (9 mg) by the concentration of the medication (5 mg/mL) to determine the volume to be administered. This calculation gives a volume of 1.8 mL (9 mg ÷ 5 mg/mL = 1.8 mL).
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