The nurse is assessing a client with increased extracellular fluid (ECF) osmolality. Which of the following assessment areas is the priority assessment for the nurse to obtain?
A)Skin turgor
B)Heart sounds
C)Mental status
D)Capillary refill

Question

Quizplus · Accepted Answer

Changes in ECF osmolality lead to swelling or shrinking of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by ECF osmolality changes and resultant fluid shifts, these are signs that occur later and do not have as immediate an impact on client outcomes.

The Nurse Is Assessing a Client with Increased Extracellular Fluid