12. 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 peritoneum. 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. ANS: A
Obstruction of CSF flow may require placing a shunt to reduce CSF pressure and prevent increased 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.PTS: 1 DIF: Cognitive Level: Comprehension REF: 543 OBJ: 3 (clinical) TOP: Hydrocephalus: V-P Shunt KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease13. Following a craniotomy for the removal of a brain tumor, the patient exhibits nuchal rigidity, rash on the chest, headache, and a positive Brudzinski sign. What do these assessment findings indicate to the nurse? Nuchal rigidity, skin rash, headache, and a positive Brudzinski sign are indicative of meningitis.PTS: 1 DIF: Cognitive Level: Comprehension REF: 543 OBJ: 10 (theory) TOP: Meningitis: Signs KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. The nurse is caring for a patient with bacterial meningitis. What interventions should the nurse include in the plan of care? The environment is kept quiet with minimal stimulation to reduce the possibility of seizure. The care is done with general precautions. Fluid intake is encouraged, as are daytime naps to preserve energy.PTS: 1 DIF: Cognitive Level: Application REF: 545 OBJ: 10 (theory) TOP: Meningitis: General Care KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
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- Fall '18
- Nursing Process Step, Cognitive Level, Seizure, Phenytoin, simple partial seizure, Med Surg Neuro