The nurse has taught the parents of a school-aged child with a newly placed ventriculoperitoneal (VP) shunt to monitor for early signs of shunt malfunction. The nurse determines the parents understand the instructions if they understand they should notify the provider if the child develops which early manifestation?
Lethargy
Seizure activity
Rapid weight gain
Disinterest in attending school
The Correct Answer is A
Rationale:
A. Lethargy is an early sign of increased intracranial pressure (ICP) due to possible shunt malfunction and requires immediate medical attention.
B. Seizure activity can be a late sign of shunt malfunction and is also concerning but lethargy typically appears earlier.
C. Rapid weight gain is less directly related to shunt malfunction and more associated with conditions like hypothyroidism or edema.
D. Disinterest in school could suggest general malaise but is not a specific or early sign of shunt malfunction.
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Correct Answer is A
Explanation
Rationale:
A. Myelomeningocele is a type of spina bifida where there is a protrusion of the meninges and spinal cord through a defect in the vertebrae. This condition can result in partial to complete paralysis in the lower extremities due to the involvement of the spinal cord.
B. A unilateral port-wine birthmark is typically associated with conditions like Sturge-Weber syndrome, not myelomeningocele.
C. A protruding sac containing abdominal contents is characteristic of omphalocele, not myelomeningocele.
D. Fusion of cranial suture lines is not associated with myelomeningocele but rather with craniosynostosis.
Correct Answer is D
Explanation
Rationale:
A. Increasing fluid intake is important for overall health but is not the primary concern in the initial management of bladder exstrophy.
B. Inserting a catheter may be necessary but is not the first priority in managing bladder exstrophy.
C. Prone positioning is generally not recommended for infants with bladder exstrophy; supine positioning may be preferable to prevent pressure on the exposed bladder.
D. Preventing skin breakdown is critical due to the constant exposure of the bladder and surrounding skin to urine, leading to a high risk of irritation and infection.