Which action should the nurse take when providing postoperative nursing care to a child after insertion of ventriculoperitone (VP) shunt?
Check the urine for glucose and protein
Administer narcotics for pain control
Test cerebrospinal (CSP) fluid leakage for protein
Monitor for increased temperature
The Correct Answer is D
A. Checking urine for glucose and protein is not directly related to the care of a child with a VP shunt. The focus is on monitoring the child for signs of complications related to the shunt.
B. Administering narcotics for pain control may be indicated if the child is in pain, but it is not the primary action and should be determined based on the child's pain assessment.
C. Testing cerebrospinal (CSF) fluid leakage for protein is not typically a nursing responsibility in the immediate postoperative period. Leakage of CSF should be reported to the healthcare provider, and diagnostic tests would be conducted by medical staff as needed.
D. Monitor for increased temperature.
Monitoring for an increased temperature is essential because postoperative fever could be an early sign of infection or complications related to the VP shunt. Infection and shunt malfunction are potential risks in the postoperative period.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Fever: Osteomyelitis is often associated with fever as it is an infectious process that can cause an elevated body temperature.
B. Unwillingness to move the affected extremity: Children with osteomyelitis may experience pain and discomfort, leading to a reluctance to move the affected limb.
C. A previous closed fracture of an extremity is not typically a direct assessment finding for osteomyelitis. Osteomyelitis is more commonly associated with infections that can spread to the bone, and a previous fracture may not always be present.
D. Redness and swelling at the site: Osteomyelitis can cause local inflammation, leading to redness and swelling at the affected area.
E. Severe pain: Pain is a common symptom of osteomyelitis, and it can be severe, leading to the child's unwillingness to move the affected extremity.
Correct Answer is C
Explanation
A. Continuing to offer a special formula to limit gagging is not a standard approach in the care of infants with cerebral palsy. The choice of formula should be based on the child's nutritional needs, and any feeding difficulties should be addressed by a healthcare professional.
B. Maintaining immobility of the limbs with splints is not recommended. Encouraging movement and mobility is important for the development and well-being of children with cerebral palsy.
C. Preserve muscle tone to prevent joint contractures.
Cerebral palsy is a condition that can lead to problems with muscle tone and movement. Preserving muscle tone is important to prevent joint contractures, which can limit mobility and cause pain. Physical therapy and exercises can help maintain muscle tone and joint flexibility in children with cerebral palsy.
D. Focusing on cognitive rather than motor skills is not appropriate. Motor skills are a crucial aspect of development for children with cerebral palsy. The approach should encompass both cognitive and motor skill development as appropriate for the child's age and abilities.
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