You are the primary RN caring for patient in Diabetic Ketoacidosis (DKA). Which of the following symptoms would you expect to see in this patient?

A. Applying a tight cervical collar is correct as contraindicated because a tight or improperly fitted collar can increase ICPby restricting venous drainage from the brain. Proper spinal immobilization is important in trauma patients, but collars should be appropriately sized and not overly tight, and adjustments should be made to avoid raising ICP.

B. Monitoring ABGs is incorrect because assessing arterial blood gases is essentialin patients with increased ICP. ABGs help evaluate oxygenation and carbon dioxide levels, which directly affect cerebral blood flow and ICP.

C. Administering antipyretics for fever is incorrect because controlling fever is important; hyperthermia increases cerebral metabolism and can worsen ICP. Antipyretics help reduce metabolic demand and prevent ICP spikes.

D. Elevating the head of bed to 30 degrees is incorrect because head-of-bed elevation promotes venous drainagefrom the brain, which helps reduce ICP. This is a standard nursing intervention in patients with increased ICP.

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.