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. Hypertension (blood pressure of 136/92 mm Hg) in a child with acute pyelonephritis can indicate a severe condition that may lead to renal damage or worsening kidney function. Immediate intervention is necessary to manage high blood pressure and prevent complications.
B. A heart rate of 100 bpm is within normal limits for a 7-year-old and does not require immediate action.
C. Decreased urine output is concerning and needs monitoring, but hypertension is the more urgent issue.
D. Tea-colored urine suggests hematuria or concentrated urine, which is important but not as immediately life-threatening as high blood pressure.
Correct Answer is B
Explanation
Rationale:
A. A child recovering from nasopharyngitis could still be contagious, and since children with leukemia have compromised immune systems, they are at higher risk of infections.
B. A child with nephrotic syndrome, although potentially needing special care, does not pose the same infection risk as a child recovering from an infectious disease. Therefore, they are a more suitable roommate for a child with leukemia.
C. A child with gastroenteritis may still be infectious and could expose the child with leukemia to gastrointestinal pathogens.
D. A child with rheumatic fever does not have a contagious illness, but the specific needs of the child with leukemia and the potential for complications from infections make it less ideal compared to a non-infectious condition like nephrotic syndrome.