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 C
Explanation
Choice A reason: Fever is a concern, but it is not the most immediate sign of dehydration.
Choice B reason: While loose stools are a symptom of diarrhea, the frequency mentioned does not necessarily indicate an emergency.
Choice C reason: This is the correct choice. Lack of a wet diaper for 8 hours can indicate dehydration, which is an emergency in infants.
Choice D reason: Longer naps may not be directly related to diarrhea and do not warrant immediate contact with a pediatrician.
Correct Answer is D
Explanation
Choice A reason: While peer group acceptance is important, it is not the primary concern in this situation.
Choice B reason: Developing a sense of industry is part of Erikson's stages of psychosocial development but is not the primary nursing concern here.
Choice C reason: Whether the child can manage their own insulin and finger sticks is important, but safety is the primary concern.
Choice D reason: This is the correct choice. Ensuring the child's safety is paramount, as the school needs to be aware of the child's condition in case of a diabetes-related emergency.
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