A nurse is assisting a neurosurgeon who is monitoring a client's intracranial pressure (ICP) in the intensive care unit. Which measure is most critical in monitoring the client's intracranial pressure?
A) Monitor and document the client's vital and neurologic signs.
B) Stop immediately if there is a break in the ICP monitoring system.
C) Avoid moving the client's head up or down without physician orders.
D) Observe the client's general appearance as well as mobility level.
C
Feedback:
The nurse should take care not to move the client's head up or down without specific orders from the physician. Monitoring and documenting the client's vital signs and neurologic signs are specifically important when assisting during a lumbar puncture; they are not specific measures during ICP monitoring. The nurse should report any break in an ICP monitoring system to the neurosurgeon immediately and not stop it on their own. Observing the client's general appearance and mobility level are important during neurologic nursing assessment, but not specific to ICP monitoring.
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