I think illusion or distraction
The nurse is caring for a patient with a head injury who is receiving a 5 5w infusion at 100 ml/hr. The statement by the patient that requires immediate action by the nurse is My headache is getting worse.
Why does this statement require immediate action?
A worsening headache could indicate cerebral edema. the hypotonic solution would increase fluid shifts into the cells, causing this to occur
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