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 A
Explanation
Choice A reason: This is the correct choice. A respiratory rate of 48 is high for a 3-year-old, indicating that the croup is affecting his breathing.
Choice B reason: This choice is incorrect. A heart rate of 90 is within the normal range for a 3-year-old.
Choice C reason: This choice is incorrect. A blood pressure of 100/52 is within the normal range for a 3-year-old.
Choice D reason: This choice is incorrect. A temperature of 98.8°F (37.1°C) is within the normal range for a 3-year-old.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. A Hemoglobin A1C level of 6.2% is within the target range for most adults with diabetes and indicates good blood sugar control over the past 2 to 3 months.
Choice B reason: A fasting plasma glucose of 189 mg/dL is above the target range for fasting blood sugar levels, indicating that the client may not be adhering to the diabetic regimen.
Choice C reason: While an HDL of 40 mg/dL is at the lower limit of the normal range, it does not provide direct information about blood sugar control.
Choice D reason: A postprandial plasma glucose of 225 mg/dL is above the target range for after-meal blood sugar levels, suggesting that the client's diabetes is not well-controlled.
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