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학습 자료 둘러보기 →A high-pitched cry, lethargy, and vomiting in a child with a VP shunt represent a neurological emergency until proven otherwise. These symptoms indicate a rapid rise in intracranial pressure (ICP) from shunt failure.
The priority nursing action is immediate notification of the healthcare provider for urgent evaluation. Do not delay for extensive assessments like measuring head circumference, which tracks chronic changes, not acute deterioration.
Never administer antiemetics to control vomiting in a child with a shunt. This masks a critical sign of rising ICP and delays life-saving neurosurgical intervention. Vomiting in this context is often projectile and central in origin.
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