A child has an invasive intracranial pressure monitoring device in place. Which assessment finding indicates that goals for a priority nursing diagnosis have been met?
A.
Daily weight equals admission weight.
B.
Joints move freely during range of motion.
C.
No signs of infection are present at the insertion site.
D.
Skin is intact without redness or breakdown.
ANS: C
All indications show that goals for various nursing diagnoses have been met; however, the priority here would be preventing infection at the intracranial pressure monitoring site, which would have a direct route to the brain.
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