The physician orders a hypertonic crystalloid solution for the patient in critical care who has cerebral edema. The nurse hangs a bag of a hypotonic solution. What will the priority assessment by the nurse include?
1. Headache, irritability, and decreasing level of consciousness
2. Nausea, projectile vomiting, and pinpoint pupils
3. Confusion, hallucinations, and agitation
4. Hypertension, headache, and nausea
1
Rationale 1: A hypotonic solution will cause a fluid shift out of the plasma into the tissues and cells in the intracellular compartment. This will increase cerebral edema. Headache, irritability, and decreasing level of consciousness are signs of cerebral edema.
Rationale 2: Projectile vomiting and pinpoint pupils are not classical signs of cerebral edema.
Rationale 3: Confusion, hallucinations, and agitation are not classical signs of cerebral edema.
Rationale 4: Hypertension and nausea are not classical signs of cerebral edema.
Global Rationale: A hypotonic solution will cause a fluid shift out of the plasma into the tissues and cells in the intracellular compartment. This will increase cerebral edema. Headache, irritability, and decreasing level of consciousness are signs of cerebral edema. Confusion, hallucinations, and agitation are not classical signs of cerebral edema. Hypertension and nausea are not classical signs of cerebral edema. Projectile vomiting and pinpoint pupils are not classical signs of cerebral edema.
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