A client with intracranial pressure (ICP) is going to be ...

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A client with intracranial pressure (ICP) is going to be evaluated by a neurosurgeon. The nurse identifies which of the following as priority results to be present on the chart for review? (Select all that apply.)
 
  1. MRI result
   2. Complete blood count of the cerebrospinal fluid
   3. Arterial blood gases
   4. Bronchoscopy results
   5. Serum osmolality

Question 2

If a patient is more confused than yesterday, the best way to document this would be
 
  a. Patient is confused more today than yesterday.
  b. Patient is sleeping a lot.
  c. Patient is not able to state where he is, who he is, what time it is, what place he is in.
  d. Patient is hard to talk to.

[Jmfn03]

Answer to Question 1

1. MRI result
3. Arterial blood gases
5. Serum osmolality

Rationale:
Diagnosis of increased ICP is made on the basis of observation and neurologic assessment; even subtle changes can be clinically significant. Testing can include CT scan or MRI, serum osmolality, and arterial blood gases. Bronchoscopy and lumbar puncture are not performed.

Answer to Question 2

C
All communication must be objective, descriptive, and complete. The communication includes observations rather than opinions and is stated or written so that an accurate picture of the patient is conveyed.

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