A nurse is doing a postoperative assessment on an infant who has ...

[fahad]

A nurse is doing a postoperative assessment on an infant who has just had a ventriculoperitonea l shunt placed for hydrocephalus. Which assessment would indicate a malfunction in the shunt?
 
  1. Incisional pain
  2. Movement of all extremities
  3. Negative Brudzinski's sign
  4. Bulging fontanel

Question 2

A child with myelomeningocele, corrected at birth,is now 5 years old. What is a priority nursing diagnosis for a child with corrected spina bifida at this age?
 
  1. Risk for Altered Nutrition
  2. Risk for Impaired TissuePerfusionCran ial
  3. Risk for Altered Urinary Elimination
  4. Risk for Altered Comfort

[kalskdjl1212]

Answer to Question 1

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

Answer to Question 2

Answer:3
Rationale: A child with spina bifida will continue to have a risk for altered urinary elimination because the bowel and bladder sphincter controls are affected. Urinary retention is a problem,so bladder interventions are initiated early to prevent kidney damage.Risk for Altered Nutrition,Impaired Tissue Perfusion, and Altered Comfort are not problems once surgery has been performed to close the defect.

[fahad]

Thank you

[kalskdjl1212]

Happy to help you