The nurse is caring for a patient with brain tumor–related hydrocephalus who is scheduled to undergo placement of a ventriculoperitoneal (V-P) shunt
Which information is most important for the nurse to include when explaining the purpose of the procedure?
a. A V-P shunt redirects the cerebrospinal fluid (CSF) from the ventricles to the pe-ritoneum.
b. A V-P shunt stimulates ventricles to reabsorb excess CSF.
c. A V-P shunt channels excess CSF to the left atrium.
d. A V-P shunt provides a port from which excess CSF can be aspirated.
A
Obstruction of CSF flow may require placing a shunt to reduce CSF pressure and prevent in-creased intracranial pressure (ICP). A shunt is a tube placed in a ventricle and attached to a small manual pump that moves excess CSF fluid from the ventricles to the peritoneal cavity or into the atrium of the heart, so that it may be absorbed.
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While assessing a patient the nurse notes that the patient's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best respond to this assessment finding?
A) Assess the patient's use of over-the-counter dietary supplements. B) Implement interventions relevant to arterial narrowing. C) Encourage the patient to increase intake of foods high in vitamin K. D) Adjust the patient's activity level to accommodate decreased coronary output.
A client with mild dementia who lives in a board-and-care-home is getting worse and needs more care. Which of the following would be the next level of housing appropriate for this client?
A) Supervised group home B) Congregate housing C) Senior apartment complex D) Hospice care
The nurse cautions the older adult who is taking the protein-bound drug warfarin (Coumadin) that, with age-related reduced plasma protein levels, the risk of an adverse reaction is high because:
a. unbound active drug molecules continue to circulate in the bloodstream. b. the bleeding and clotting time will decrease, as evidenced by the PT and INR. c. the drug becomes ineffective and does not deliver its intended therapeutic action. d. renal damage can occur from the altered drug molecules.
The laboring client's fetal heart rate baseline is 120 beats per minute (bpm). Accelerations are present to 135 bpm. During contractions, the fetal heart rate gradually slows to 110, and is at 120 by the end of the contraction
What nursing action is best? 1. Document the fetal heart rate. 2. Apply oxygen via mask at 10 liters. 3. Prepare for imminent delivery. 4. Assist the client into Fowler's position.