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 D
Explanation
Choice A reason: Limiting water intake is not recommended as adequate hydration is important, especially when sick.
Choice B reason: Checking blood glucose every 8-12 hours is not frequent enough; it should be monitored more often during illness.
Choice C reason: Drinking juice every hour is not necessary and could lead to hyperglycemia if not balanced with insulin.
Choice D reason: This is the correct choice. It is crucial to continue administering insulin as prescribed to manage blood glucose levels, even if the child is not eating as much.
Correct Answer is C
Explanation
Choice A reason: Feeding the toddler is a basic need and should be ensured, but it does not specifically address developmental appropriateness or encourage independence.
Choice B reason: Dressing the toddler is also a basic need, but it does not actively involve the toddler in the process, which is important for development.
Choice C reason: Offering the toddler a choice of clothing allows the child to make decisions, fostering a sense of autonomy and contributing to developmental milestones.
Choice D reason: Asking the toddler if he would like to take his medicine is important for involving the child in their care; however, it does not offer the same level of developmental engagement as making choices about personal preferences like clothing.
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