Author Question: A nurse is conducting a postoperative assessment on an infant who has just had a ... (Read 27 times)

urbanoutfitters · **on:** Jun 28, 2018

A nurse is conducting a postoperative assessment on an infant who has just had a ventriculoperitonea l shunt placed for hydrocephalus. Which assessment finding would indicate a malfunction in the shunt?

1. Incisional pain
2. Movement of all extremities
3. Negative Brudzinski sign
4. Bulging fontanel

Question 2

A toddler-age client has a tonic-clonic seizure while in a crib in the hospital. The client's jaw is clamped. Which nursing action is the priority?

1. Place a padded tongue blade between the child's jaws.
2. Stay with the child and observe the respiratory status.
3. Prepare the suction equipment.
4. Restrain the child to prevent injury.

ndhahbi · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

Correct Answer: 4
Rationale: A bulging fontanel would be an abnormal finding and could indicate that the shunt is malfunctioning. Incisional pain, movement of all extremities, and negative Brudzinski sign are all normal findings after a ventriculoperitonea l shunt has been placed.

Answer to Question 2

Correct Answer: 2
Rationale: During a seizure, the nurse remains with the child, watching for complications. The child's respiratory rate should be monitored. Be sure nothing is placed in the child's mouth during a seizure. Suction equipment should already be set up at the bedside before a seizure begins. The child should not be restrained during a seizure.