A patient exhibits confusion, disorientation, and an inability to focus on a conversation. Which of the following would be the most likely assessment finding? (Select one, all, or some).

A. Optimizing pain: While pain management is important in any patient care plan, acute kidney injury typically does not cause significant pain unless associated with another condition such as obstruction or infection. It is not a primary focus unless the patient reports discomfort requiring intervention.

B. Protecting from falls: Fall prevention is a general safety measure but is not a specific priority related to AKI management unless the patient has associated risks like altered mental status, weakness, or dialysis-related hypotension. It is not a primary priority in early AKI care planning.

C. Monitoring electrolyte levels: AKI commonly leads to imbalances in potassium, sodium, calcium, and phosphorus due to impaired renal clearance. Hyperkalemia in particular poses serious cardiac risks, making electrolyte monitoring a top priority to prevent complications such as arrhythmias.

D. Assessing fluid balance: AKI affects the kidneys’ ability to excrete or conserve fluid, resulting in potential fluid overload or dehydration. Accurate intake and output tracking, daily weights, and edema assessment are essential to guide treatment and prevent respiratory or cardiovascular compromise.

E. Promoting infection control: Infection is both a potential cause and a complication of AKI, especially in hospitalized or catheterized patients. Maintaining strict aseptic technique, monitoring for signs of infection, and preventing sepsis are critical components of AKI management.

A. Brain, blood, cerebrospinal fluid (CSF): These are the three main components within the cranial vault as described by the Monro-Kellie doctrine. The total volume of these components remains constant, and any increase in one must be offset by a decrease in another to prevent elevated ICP.

B. Cerebrospinal fluid (CSF), blood, oxygen: While CSF and blood are intracranial components, oxygen is not a physical substance occupying volume in the cranial cavity. It is transported within the blood and does not contribute to changes in ICP in terms of physical space.

C. Brain, cerebrospinal fluid (CSF), air: Air is not a normal component of the cranial cavity. The presence of air would indicate pathology, such as a skull fracture with pneumocephalus, which is abnormal and can contribute to increased ICP but is not a standard component.

D. Brain, blood, lymphatic fluid: While the brain and blood are correct components, the central nervous system, including the brain, does not have a conventional lymphatic system like other parts of the body. Waste products are primarily cleared by the glymphatic system, which utilizes CSF, rather than traditional lymphatic fluid.