HYDROCEPHALUS
A nurse is doing a postop assessment on an infant who has just had a ventroperitoneal shunt placed for hydrocephalus. Which assessment would indicate a malfunction in the shunt? Select one: a. Bulging fontanelle b. Negative Brudzinski sign c. Incisional pain d. Movement of all extremities
a
What clinical manifestations would suggest hydrocephalus in a neonate? a. Bulging fontanel and dilated scalp veins b. Closed fontanel and high-pitched cry c. Constant low-pitched cry and restlessness d. Depressed fontanel and decreased blood pressure
a
What manifestations of increasing ICP in the hydrocephalic child should the nurse be aware of? (Select all that apply.) a. High-pitched cry b. Inequality of pupils c. Bulging fontanelles
a b c
The nurse is caring for an infant with hydrocephalus. What nursing action is most important for this nurse to implement? a. Carry the baby at all time b. Support the head. c. Schedule an operation d. Provide emotional support
b
The nurse is providing education to the parents of a 2-year-old boy with hydrocephalus who has just had a ventriculoperitoneal shunt placed. Which information is most important for the parents to be taught? a. "limit the amount of t.v. he watches" b. "watch for changes in his behavior or eating patterns" c. "call the doctor if he gets a headache." d. "always keep his head raised 30 degrees"
b
The nurse is caring for a child who has had a ventriculoperitoneal shunt (VP) for hydrocephalus and observes an increasing abdominal girth. What is the most appropriate response? a. Document, it is a normal finding b. Place the infant in semi-Fowler position c. Don't feed the baby d. Notify the charge nurse of possible malabsorption
d
The nurse observes that the infants anterior fontanelle is bulging after placement of a ventriculoperitoneal shunt. How should the nurse position this infant? a. Supine position b. High Fowlers position c. The head should be flexed d. In a semi-Fowlers position
d
What occurrence results from obstruction within the ventricles of the brain or inadequate reabsorption of cerebrospinal fluid? a. Meningitis b. Bell's palsy c. Brain tumor d. Hydrocephalus
d
What nursing action will the nurse implement after feeding an infant with hydrocephalus? a. Burp the infant b. Culture CSF fluid c. Leave the infant in a side-lying position. d. Give the infant back to their mother
c
A nurse is assessing an adolescent admitted for a severe ventroperitoneal shunt infection. Which of the following assessment findings would the nurse expect to see? Select one or more: a. Bulging fontanel b. Positive Babinski sign c. Vomiting d. Loss of coordination or balance e. Redness along the shunt tract
c d e
