A 3-year-old child is diagnosed with hydrocephalus and is scheduled for a ventriculoperitoneal shunt in the morning. During the post-operative period, the nurse noticed the child to be restless and irritable. Suspecting an increasing ICP, the nurse should first:
Explanation
Answer: D - Behavioral changes such as irritability, restlessness, and lethargy are signs of an increasing intracranial pressure, which may indicate obstruction in the shunt. Initially, the head of the bed should be elevated to allow efficient flow of CSF. The physician should then be notified. The child is placed on the non-operated side. The nurse should be careful not to put the client in moderate or high bed positioning, as this could cause dangerous, rapid reduction in CSF. Vital signs should be monitored regularly, while head circumference should be measured daily.
