The nurse is monitoring the client with IICP who is on mannitol infusions every 6 hours. The nurse plans to monitor the client for:
1. edema around the ankles and decreased pedal pulses.
2. cold hands and feet.
3. jaundice and decreased bowel sounds.
4. poor skin turgor, sunken eye sockets, and cardiac arrhythmias.
Answer: 4
1. Edema around the ankles and decreased pedal pulses are signs of poor circulation, not of dehydration.
2. Cold hands and feet do not reflect dehydration.
3. Jaundice is seen in liver failure, and the client might have decreased bowel sounds from inactivity.
4. Poor skin turgor and sunken eye sockets are symptoms of dehydration, which can be caused by mannitol. Cardiac arrhythmias are a sign of imbalanced electrolytes caused by mannitol.
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