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?
Weak pulses
Hypernatremia
Muscle weakness
Exaggerated reflexes
The Correct Answer is C
Muscle weakness is a finding that indicates the client is experiencing water intoxication. Muscle weakness is a symptom of water intoxication because the excessive intake of water dilutes the sodium levels in the blood, causing hyponatremia. Sodium is an electrolyte that helps maintain the balance of fluids in and around cells and also regulates muscle contraction. When sodium levels are too low, the cells swell and the muscles lose their ability to function properly.
Weak pulses are not a specific finding for water intoxication, as they can be caused by other factors such as decreased blood volume or inadequate cardiac output.
Hypernatremia is the opposite of hyponatremia, meaning high sodium levels in the blood. This can occur due to dehydration, excessive salt intake, or certain medical conditions, but not water intoxication.
Exaggerated reflexes are not typically associated with water intoxication. They may be seen in conditions such as hyperreflexia or certain neurological disorders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
2 oz processed cheese: Processed cheese, including cheese slices or spreads, tends to have a higher sodium content compared to other dairy products. The processing methods used in the production of processed cheese often involve the addition of sodium-containing ingredients to enhance flavor and improve texture.
1/2 cup yogurt: Yogurt generally has a lower sodium content compared to processed cheese. However, the sodium content can vary depending on the brand and type of yogurt. It is advisable to choose plain or low-sodium yogurt to minimize sodium intake.
1 cup milk: Plain milk, such as cow's milk, typically has a lower sodium content compared to processed cheese. However, it is important to note that flavored or sweetened milk products may contain added sugars and other ingredients that can increase sodium content. Choosing unsweetened or low-sodium varieties is recommended.
4 oz vanilla pudding: While some commercial pudding mixes may contain sodium, the sodium content in vanilla pudding is generally lower compared to processed cheese. However, it is important to read food labels and choose lower sodium options or consider homemade versions to better control sodium intake.
Correct Answer is C
Explanation
"I should limit the amount of fiber in my diet": This statement demonstrates an understanding of the teaching. In Crohn's disease, certain types of fiber can be difficult to digest and may worsen symptoms such as abdominal pain, diarrhea, and bowel obstruction. Therefore, it is often recommended to limit the intake of high-fiber foods during active disease flares.
"I will need to take mild laxatives to help me have a bowel movement": Taking laxatives is not typically recommended for individuals with Crohn's disease unless specifically prescribed by a healthcare provider. Laxatives can further irritate the intestines and potentially worsen symptoms. Therefore, this statement does not demonstrate an understanding of the teaching.
"I am likely to gain weight due to this disease": Weight loss is a more common occurrence in individuals with Crohn's disease due to factors such as decreased appetite, malabsorption, and increased metabolism. Weight gain is not typically associated with the disease, so this statement does not indicate an understanding of the teaching.
"Avoiding glutamine will help me recover from this disease": Glutamine is an amino acid that plays a role in gut health and repair. It is often considered beneficial for individuals with Crohn's disease as it supports intestinal healing. Therefore, avoiding glutamine would not be recommended for recovery from the disease. This statement does not indicate an understanding of the teaching.
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