Which of the following lab findings do you expect to see in a patient with diabetic ketoacidosis (DKA)?

A. Make sure patient is laying flat is incorrect because the head of the bed should generally be elevated to 30 degreesto promote venous drainage and reduce ICP. Laying flat may actually increase intracranial pressureand does not ensure an accurate ICP waveform reading.

B. Close the drain to stop CSF drainage for 6 minutes is correct because when the ventriculostomy is open to drain CSF, the ICP reading may not reflect true intracranial pressure, as CSF is continuously leaving the ventricles. To obtain an accurate ICP waveform, the nurse temporarily clamps or closes the drain for a short period (typically 5–10 minutes)while monitoring the patient, then documents the reading. This ensures the waveform reflects actual intracranial pressure rather than the pressure altered by ongoing drainage.

C. Empty drainage tube is incorrect because draining CSF from the collection chamber does not directly affect ICP waveform accuracy. The waveform represents ventricular pressure, and emptying the tube does not change the measurement as long as the system remains patent.

D. Check patient's vital signs is incorrect because while vital signs are important for overall assessment and detecting signs of increased ICP, they do not ensure an accurate ICP waveform reading. Vital signs can indicate changes secondary to ICP but are not a substitute for waveform assessment.

A. BP of 90/65 is incorrect because blood pressure is a vital sign that can be influenced by many systemic factors. While hypotension or hypertension may affect cerebral perfusion, it is not the most reliable indicator of neurological status.

B. Cranial nerve testing is incorrect because cranial nerve assessment provides useful information about specific neurological functions, but it does not give a global view of the patient’s overall neurological status.

C. PERRLA (pupils equal, round, reactive to light and accommodation) is incorrect because pupil response is an important component of neurological assessment, but changes can be delayed or affected by medications, eye trauma, or other factors. It does not reflect overall brain function as reliably as level of consciousness.

D. Change in level of consciousness is correct because level of consciousness is the most sensitive and reliable indicator of neurological status. Alterations in consciousness often precede other signs of neurological deterioration, making it a key parameter in assessing patients with increased intracranial pressure or other acute neurological conditions. Nurses use tools like the Glasgow Coma Scale to quantify changes in consciousness and detect early deterioration.