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 A
Explanation
The correct answer is choice A. “Fish and poultry are primary sources of heme iron.”
Choice A rationale:
Fish and poultry are indeed primary sources of heme iron, which is the type of iron found in animal products.Heme iron is more easily absorbed by the body compared to non-heme iron, which is found in plant-based foods.
Choice B rationale:
Cooking in a stainless steel skillet does not significantly increase the amount of iron in the food.While cooking in cast iron skillets can add some iron to the food, stainless steel does not have the same effect.
Choice C rationale:
Drinking iced tea with meals can actually decrease the amount of iron absorbed.Tea contains tannins, which can inhibit the absorption of non-heme iron from plant-based foods.
Choice D rationale:
Drinking orange juice with iron supplements can actually increase absorption, not decrease it.Vitamin C, found in orange juice, enhances the absorption of non-heme iron.
Correct Answer is B
Explanation
Choice A rationale:
Caramel popcorn is not an appropriate choice for toddlers due to its high sugar content and potential choking hazard from hard or sticky pieces.
Choice B rationale:
Cooked spaghetti with sauce is an appropriate choice for toddlers. It provides carbohydrates for energy, and the sauce can contain vegetables and proteins, making it a balanced option.
Choice C rationale:
Steak cut into small pieces might not be suitable for toddlers, as it could be difficult for them to chew and may not provide the appropriate texture for their developing teeth.
Choice D rationale:
Hot dogs cut into fourths may pose a choking hazard for toddlers due to their cylindrical shape and potential difficulty in chewing. They are also processed meats, which are not the healthiest option for young children.
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