In caring for an infant who has had a ventriculoperitoneal (VP) shunt, the nurse will include in the plan of care: (Select all that apply.)
a. Taking daily head measurements
b. Taking daily abdominal measurements
c. Positioning on the stomach if fontanels are bulging
d. Positioning on the opposite side from surgery
e. Changing the position every 4 hours
A, B, D
The baby should have daily head and abdominal measurements to track whether the CSF is being drained from the head and absorbed in the abdomen. The child should be positioned on the side opposite the surgery unless the fontanels are bulging. In this event, the child is placed in a semi-Fowler's position to facilitate drainage. Position changes should occur every 2 hours.
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You are conducting a general assessment of a 6-years-old child. While the child is sitting on the examination table you assess his respiratory rate. You would begin by
a. first informing him of what you are doing. b. counting the number of respirations in 15 seconds and multiplying by 2. c. counting the respirations while measuring his pulse. d. placing the stethoscope on his chest so he does not know you are counting respirations.
The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? (Use all options.)
A) Palpation B) Inspection C) Auscultation D) Percussion
The experimental treatment initiated by a researcher can be described as what kind of variable?
a. Independent b. Dependent c. Extraneous d. Outcome
A terminally ill child is awake at 2 AM and continues to put on the call light. What should the nurse do regarding this child's behavior?
A) Provide with a sleeping aid. B) Encourage the child to sleep. C) Sit with the child until sleep comes. D) Put on the television and dim the lights.