Health Promotion and Maintenance
72. A nurse enters the room of a child following the placement of a ventriculoperitoneal shunt. The child is sitting up in bed, crying, and has vomited a small amount on the bed linens. What are the priority nursing actions?
Select all that apply.
. Complete a neurological assessment.
. Place the child in the supine position.
. Administer the antiemetic as ordered.
. Complete a pain assessment.
. Increase the child's IV rate.
Test-Taking Tip
The priority of care for children recovering from neurosurgery is monitoring and preventing increased ICP. Select the actions that will not increase ICP.
Content Area: Child Health, Neurological; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems
Health Promotion and Maintenance
. . .
Answer 1 is correct because the nurse should assess the child thoroughly to determine whether the child's neurological status has changed since the last assessment. Answer 2 is incorrect because this child should be placed with the head of bed elevated to prevent increase of ICP. Answer 3 is correct because nausea and vomiting are common following neurosurgery. The antiemetic should be administered because vomiting needs to be prevented since it increases intracranial pressure (ICP). Answer 4 is correct because determining the child's pain level should be part of the physical assessment. It is expected that the child may have pain from this surgery. Answer 5 is incorrect because increasing the child's IV rate could lead to increased ICP and should not be done without an order.