The nurse is caring for a one-week-old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which finding(s) indicate a postoperative complication? Select all that apply.
Reference Range:
White blood cells (WBC) [9,000 to 10,000/mm3 (9 to 10 x 10^9 /L)]
Leakage of cerebral spinal fluid from the incisional site.
Poor feeding and vomiting.
Abdominal distention.
WBC of 10,000/mm3 (10 x 10^ 9/L).
Hyperactive bowel sounds.
Correct Answer : A,B,C
A. Leakage of cerebral spinal fluid from the incisional site: Leakage of cerebrospinal fluid (CSF) from the incision site is a serious postoperative complication. It could indicate a shunt malfunction or infection, requiring immediate attention.
B. Poor feeding and vomiting: These symptoms may indicate increased intracranial pressure, which can result from a shunt malfunction or infection, both serious complications that need to be addressed immediately.
C. Abdominal distention: Abdominal distention in an infant with a VP shunt can indicate an issue with the peritoneal end of the shunt. This could be due to malabsorption of CSF in the peritoneal cavity, infection (peritonitis), or kinking/blockage of the catheter in the abdomen, leading to accumulation of fluid and distention.
D. WBC of 10,000/mm3 (10 x 10^9/L): A WBC count of 10,000/mm3 is within the normal range for a one-week-old infant. Therefore, this finding does not indicate infection or an inflammatory response and is not a concern in this case.
E. Hyperactive bowel sounds: Hyperactive bowel sounds are typically not associated with a VP shunt complication. This finding is generally indicative of gastrointestinal motility, which is not related to a shunt malfunction or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.6"]
Explanation
Rationale:
- Convert the client's weight from pounds (lb) to kilograms (kg).
Weight in kg = 154 lb / 2.2 lb/kg
= 70 kg.
- Calculate the total desired dose in units.
Desired dose (units) = Desired dose (units/kg) × Weight (kg)
= 200 units/kg × 70 kg
= 14000 units.
Available concentration of the medication = 25,000 units/mL.
- Calculate the volume in milliliters (mL) to administer.
Volume (mL) = Desired dose (units) / Available concentration (units/mL)
= 14000 units / 25000 units/mL
= 0.56 mL.
- Round the answer to the nearest tenth.
= 0.6.
Correct Answer is ["A","B"]
Explanation
A. History of hypertension: Although the client’s current blood pressure is controlled with atenolol, the need for medication confirms a history of hypertension. Hypertension is a major modifiable risk factor for coronary artery disease and warrants ongoing assessment.
B. Family health history: A strong family history of heart disease and diabetes, particularly in first-degree relatives, significantly increases the client’s risk for cardiovascular events. The genetic predisposition should be explored to assess early markers and implement prevention strategies.
C. Vegetarian diet: A vegetarian diet is generally associated with lower cardiovascular risk due to reduced intake of saturated fats and cholesterol. Unless the diet is poorly balanced or nutrient-deficient, it does not constitute a risk factor that requires further evaluation here.
D. Sexual history: Sexual history may be relevant in certain clinical contexts, such as evaluating HIV risk or sexually transmitted infections, but it is not directly related to the client's cardiac symptoms or concern about hereditary heart disease.
E. Excessive aerobic exercise: The client’s activity level (jogging) is not excessive and is generally healthy, unless it is associated with overtraining or extreme exertion. There is no indication here that excessive exercise is a concern, so further exploration is not needed based on this information.
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