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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: This is the correct choice. Congestive heart failure can occur in chronic renal failure due to fluid overload and the inability of the kidneys to manage fluid balance.
Choice B reason: Metabolic alkalosis is not typically a major complication of chronic renal failure; metabolic acidosis is more common due to the accumulation of acids in the body.
Choice C reason: Excessive excretion of blood urea nitrogen is not a complication; rather, in renal failure, the kidneys cannot excrete urea nitrogen effectively.
Choice D reason: Hypokalemia (low potassium) can occur, but it is not as major a complication as congestive heart failure in the context of chronic renal failure.

A. Pulmonary secretions are abnormally thick. B. Obstruction of the endocrine glands occurs. C. Elevated levels of potassium are found in the sweat. D. CF is an autosomal dominant hereditary disorder.

Correct Answer is A

Explanation

Choice A reason: This is the correct choice. Thick pulmonary secretions are a hallmark of cystic fibrosis and must be addressed in the care plan.
Choice B reason: While cystic fibrosis can affect various glands, the primary concern is the respiratory system.
Choice C reason: Elevated levels of chloride, not potassium, are found in the sweat of individuals with cystic fibrosis.
Choice D reason: Cystic fibrosis is an autosomal recessive disorder, not dominant. This is important for genetic counseling and understanding the inheritance pattern.

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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?

Nursing Test Bank

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