A nurse in the emergency department is assessing a young adult client who was administered a hypotonic IV fluid bolus for rehydration after collapsing at an athletic event. Which of the following findings indicates the client is experiencing water intoxication?

Hypernatremia

Weak pulses

Exaggerated reflexes

Muscle weakness

Answer and Explanation

The Correct Answer is D

A) Hypernatremia refers to elevated sodium levels in the blood and is not consistent with water intoxication. In water intoxication, hyponatremia (low sodium levels) is more likely due to dilutional effects from excess water intake.

B) Weak pulses are not specific findings associated with water intoxication. While fluid overload can lead to cardiovascular complications, such as hypertension and bounding pulses, weak pulses are not typically indicative of water intoxication.

C) Exaggerated reflexes are not characteristic findings of water intoxication. Instead, neurological symptoms such as confusion, headache, and seizures may occur due to cerebral edema resulting from water intoxication.

D) Muscle weakness is a potential manifestation of water intoxication due to hyponatremia, which can lead to changes in osmolarity and cellular function. Hyponatremia can cause neurological symptoms such as muscle weakness, lethargy, and seizures. As water moves into cells, it can disrupt cellular function and lead to symptoms of cellular swelling. Therefore, muscle weakness is a concerning finding in the context of suspected water intoxication.

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Correct Answer is C

Explanation

A) Vitamin D: While vitamin D plays a crucial role in bone health and immune function, it may not directly contribute to wound healing unless the client has a deficiency. Vitamin D deficiency can impair immune function and delay wound healing, but routine supplementation may not be necessary unless deficiency is confirmed through laboratory testing.

B) Calcium: Calcium is essential for bone health and muscle function but is not directly involved in the wound healing process. While adequate calcium intake is important for overall health, supplementation specifically for wound healing is not typically recommended unless the client has a documented calcium deficiency.

C) Vitamin C: Vitamin C is essential for collagen synthesis, a critical component of wound healing. It promotes the formation of new connective tissue and helps strengthen the wound site. Adequate vitamin C intake is necessary for proper wound healing, and supplementation may be beneficial, especially for clients at risk of deficiency.

D) Potassium: Potassium is an electrolyte important for maintaining fluid balance and proper muscle function but is not directly involved in the wound healing process. Supplementation with potassium is typically recommended only for clients with documented potassium deficiencies or those at risk of deficiencies due to certain medical conditions or medications.

A. Blueberry muffins B. Graham crackers C. 2% milk D. Ground beef

Correct Answer is B

Explanation

A) Blueberry muffins are not typically recommended for a client with cholecystitis. They are likely to be high in fat, which can exacerbate symptoms such as pain and discomfort associated with cholecystitis. Foods high in fat can trigger gallbladder contractions, leading to pain and potentially worsening the condition.

B) Graham crackers are a suitable option for a client with cholecystitis. They are low in fat and gentle on the digestive system, making them less likely to exacerbate symptoms. Foods that are low in fat and easy to digest are often recommended for individuals with cholecystitis to minimize discomfort and reduce the risk of triggering symptoms.

C) 2% milk is not typically recommended for a client with cholecystitis. Dairy products, especially those with higher fat content like 2% milk, can stimulate gallbladder contractions and worsen symptoms in individuals with cholecystitis. Therefore, it is usually advised to opt for lower-fat or non-dairy alternatives.

D) Ground beef is not typically recommended for a client with cholecystitis. Beef is high in fat, which can exacerbate symptoms and trigger gallbladder contractions. Clients with cholecystitis are often advised to avoid or limit high-fat foods to reduce the risk of discomfort and complications.

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A nurse in the emergency department is assessing a young adult client who was administered a hypotonic IV fluid bolus for rehydration after collapsing at an athletic event. Which of the following findings indicates the client is experiencing water intoxication?

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