A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider?
Irritability when being held
Heart rate 122/min
Hypoactive bowel sounds
Urine specific gravity 1.018
The Correct Answer is A
Rationale:
A. Irritability when being held may indicate increased intracranial pressure or complications related to the VP shunt placement and should be reported to the provider.
B. A heart rate of 122/min is within the normal range for an infant and does not require reporting.
C. Hypoactive bowel sounds may occur postoperatively, especially if the infant has not been fed or has been under anesthesia, and is not an immediate concern.
D. A urine specific gravity of 1.018 is within normal limits for infants and does not indicate a need for reporting.
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Correct Answer is B
Explanation
Rationale:
A. Dietary salt restriction is challenging but is a specific intervention that can be managed with education and support.
B. The absence of symptoms can significantly hinder compliance because clients may not perceive the need to adhere to a treatment plan if they do not feel unwell. This perception can lead to underestimating the importance of managing their blood pressure.
C. The addition of a new medication may pose some challenges, but clients often adapt to new medications with proper guidance.
D. A detailed plan of care can enhance understanding and compliance, making it less likely to be a barrier compared to the lack of symptomatic cues indicating a need for treatment.
Correct Answer is B
Explanation
Rationale:
A. Taking the medication 2 hours apart from calcium supplements is important, but the timing is not the primary instruction; the focus should be on the medication itself.
B. Levothyroxine should be taken on an empty stomach, ideally 30 to 60 minutes before breakfast, to enhance absorption.
C. Taking a double dose if a dose is missed can lead to toxicity; patients should be instructed to skip the missed dose and resume the regular schedule.
D. While taking the medication with a small sip of water is acceptable, it is not the most critical instruction for ensuring proper absorption and effectiveness of levothyroxine.