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?
Exaggerated reflexes.
Muscle weakness.
Hypernatremia.
Weak pulses.
The Correct Answer is B
The correct answer is choice B: Muscle weakness.
Choice A rationale:
Exaggerated reflexes are not typically associated with water intoxication. They can be a sign of other neurological conditions but not specifically related to the administration of hypotonic IV fluids.
Choice B rationale:
Muscle weakness is a symptom of water intoxication, which can occur due to the dilution of electrolytes, including sodium, in the body when a hypotonic solution is administered.
Choice C rationale:
Hypernatremia, or high levels of sodium in the blood, is the opposite of what occurs in water intoxication. Water intoxication leads to hyponatremia, which is a low sodium concentration in the blood.
Choice D rationale:
Weak pulses are not a direct indicator of water intoxication. While they can be associated with various conditions, they do not specifically point to water intoxication following the administration of a hypotonic IV fluid bolus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. “A low-protein diet should be followed for 3 months prior to conception.”
Choice A rationale:
Monitoring serum bilirubin is not relevant for managing phenylketonuria (PKU) during pregnancy. PKU management focuses on maintaining low phenylalanine levels to prevent harm to the developing fetus.
Choice B rationale:
Diet sodas contain aspartame, which is high in phenylalanine and should be completely avoided by individuals with PKU, not just limited to two or three times per week.
Choice C rationale:
Breastfeeding does not prevent a baby from developing PKU. PKU is a genetic disorder, and breastfeeding does not influence the genetic makeup of the baby.
Choice D rationale:
Following a low-protein diet for 3 months prior to conception is crucial for women with PKU. This helps to ensure that phenylalanine levels are low, reducing the risk of birth defects and intellectual disabilities in the baby.
Correct Answer is A
Explanation
Choice A rationale:
Allowing the toddler to feed himself is an important aspect of promoting autonomy and developing fine motor skills. It encourages self-sufficiency and exploration of different food textures. However, close supervision is necessary to ensure the toddler's safety during feeding.
Choice B rationale:
Avoiding snacks between meals is not the most appropriate instruction for a toddler's nutritional needs. Toddlers have smaller stomach capacities and higher energy requirements due to their rapid growth. Healthy snacks can help meet their nutritional needs and prevent excessive hunger between meals.
Choice C rationale:
Providing different food for the toddler than the parents is not recommended. Ideally, toddlers should be exposed to the same nutritious foods that the family consumes. This practice helps establish healthy eating habits and exposes the toddler to a variety of foods.
Choice D rationale:
Setting meal times immediately after physical activity is not necessarily beneficial. While regular physical activity is important for toddlers, scheduling meals immediately after activity might lead to poor appetite or discomfort. It's generally better to ensure the toddler is well-rested and hungry before meals.
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