A nurse is conducting a postoperative assessment on an infant who has just had a ventriculoperitoneal shunt placed for hydrocephalus. Which assessment finding would indicate a malfunction in the shunt?
Movement of all extremities.
Negative Brudzinski sign.
Incisional pain.
Bulging fontanel.
The Correct Answer is D
Choice A reason: Movement of all extremities is expected and does not indicate a shunt malfunction.
Choice B reason: A negative Brudzinski sign is a normal finding and does not suggest a shunt malfunction.
Choice C reason: While incisional pain is common after surgery, it is not a specific indicator of shunt malfunction.
Choice D reason: This is the correct choice. A bulging fontanel can indicate increased intracranial pressure, which may suggest a shunt malfunction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Severe fatigue is a symptom that can be associated with many conditions and is not specific to Wilms tumor.
Choice B reason: This is the correct choice. A palpable abdominal mass is often the first sign of a Wilms tumor that prompts medical evaluation.
Choice C reason: Seizures are not typically associated with Wilms tumor.
Choice D reason: Hematuria can occur with Wilms tumor, but it is not as common as the presentation of an abdominal mass.
Correct Answer is D
Explanation
Choice A reason: This statement is correct; early treatment for clubfoot is essential for the best outcomes.
Choice B reason: The parent's understanding of the need for long-term follow-up care until skeletal maturity is accurate.
Choice C reason: Regular visits for new casts are part of the standard treatment protocol for clubfoot.
Choice D reason: This statement indicates a misunderstanding. Clubfoot treatment typically involves a series of casts changed more frequently than 8-10 weeks apart, not a single spica cast for that duration. Further teaching is needed to correct this misconception.
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