Author Question: The nurse has taught the parents of a 6-year-old child with a ventriculoperitoneal (VP) shunt to ... (Read 54 times)

shofmannx20 · **on:** Jul 22, 2018

The nurse has taught the parents of a 6-year-old child with a ventriculoperitonea l (VP) shunt to monitor the child for shunt malfunction.

The nurse determines that learning goals have been met when the parents state they will notify the physician if the child presents with which of the following? 1. Bulging soft spot
2. Expanding head size
3. Sunset eyes
4. Altered level of consciousness

Question 2

Which statement is least accurate regarding the evaluation step of the nursing process?

a. Evaluation brings closure to the nursing process.
b. Evaluation measures the patient's progress toward achievement of expected outcomes.
c. Evaluation promotes nursing accountability.
d. Evaluation serves as the basis for modifica-tion of the plan of care.

tennis14576 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

4. Altered level of consciousness

Rationale:
An altered level of consciousness would be a symptom of shunt malfunction for the older child and increasing intracranial pressure. In most children, by age 6, the cranial suture lines have fused, and the fontanelles are closed, so a bulging soft spot, expanding head size, or sunset eyes would not be common symptoms of shunt malfunction and an increase in intracranial pressure.

Answer to Question 2

A
The purposes of evaluation include determining the patient's progress toward achievement of expected outcomes, determining the effectiveness of nursing care, determining the overall quality of care provided, and promoting nursing accountability.