The nurse has taught the parents of a 6-year-old child with a ventriculoperitoneal (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
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.
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