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 B
Explanation
A. Offer the client to move to a quiet room first: Changing the environment may reduce distractions, but it does not directly support the client’s immediate attempt to communicate. The priority is to respond to the client’s active effort to speak in the moment.
B. Allow the client time to complete her sentence: Allowing extra time promotes autonomy, reduces frustration, and respects the communication process for clients with aphasia. It gives the client space to formulate thoughts without pressure or interruption, which supports language recovery and expression.
C. Pull up a chair and sit quietly with the client: Sitting quietly can offer emotional support, but it may be perceived as passive when the client is actively trying to communicate. The nurse should take a facilitative role by giving the client time to speak, rather than only offering silent presence.
D. Provide a list of phrases to express herself properly: Providing phrases may overwhelm or confuse the client, especially during spontaneous attempts to speak. Aphasia affects word retrieval, and prompting with choices may interrupt the client's cognitive effort.
Correct Answer is D
Explanation
A. Ask if the client is experiencing any change in bowel habits: Changes in bowel habits are not directly related to the confusion or memory loss seen in pernicious anemia. The concern here is primarily with vitamin B12 deficiency.
B. Determine if the client is taking iron and folic acid supplements: While iron and folic acid are important, they don't directly address the memory loss and confusion related to B12 deficiency. The immediate focus should be on the effects of the B12 treatment.
C. Encourage the husband to bring the client to the clinic for a complete blood count: A CBC can help monitor anemia, but it doesn't address the memory issues. The nurse should first explain the symptoms related to B12 deficiency.
D. Explain that memory loss and confusion are common with vitamin B12 deficiency:
Memory loss and confusion are known symptoms of vitamin B12 deficiency. These symptoms may take time to improve with treatment, and educating the husband helps alleviate concerns.
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