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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Administer antiemetics on a schedule. Antiemetics are medications used to prevent or relieve nausea and vomiting. By administering them on a schedule, the nurse can help manage and control the client's nausea more effectively.

Providing a snack 30 minutes before treatments is not an appropriate intervention for nausea associated with radiation therapy. In fact, eating before radiation therapy may worsen nausea in some individuals. It is generally recommended to have a light meal or snack a few hours before the treatment to avoid an empty stomach but also prevent overeating that can trigger nausea.

Ensuring foods are served hot is not a recommended intervention for nausea. In fact, hot foods may exacerbate nausea in some individuals. It is advisable to serve foods at a cooler or room temperature, as cooler foods may be better tolerated.

Serving low carbohydrate meals is not specific to managing nausea associated with radiation therapy. While some individuals may find low carbohydrate meals easier to digest, there is no strong evidence suggesting that they alleviate nausea specifically. The choice of meals should be based on the client's preferences, tolerance, and any dietary restrictions they may have.

A. "I like to drink a glass of warm milk before bed to help me sleep." B. "I try to follow a low-fat, high-protein diet to help me maintain my weight." C. "I stopped drinking caffeinated beverages several weeks ago." D. "I have recently stopped drinking alcohol."

Correct Answer is A

Explanation

The nurse should identify the statement "I like to drink a glass of warm milk before bed to help me sleep" as a contributing factor to gastroesophageal reflux disease (GERD). Consuming a glass of warm milk before bed can worsen GERD symptoms due to its high-fat content. High-fat foods, including dairy products, can relax the lower esophageal sphincter (LES) and delay gastric emptying, allowing stomach acid to flow back into the esophagus, leading to symptoms of GERD.

"I try to follow a low-fat, high-protein diet to help me maintain my weight": Following a low-fat, high-protein diet is actually beneficial for managing GERD. High-fat foods can worsen GERD symptoms by relaxing the LES and delaying gastric emptying, while a low-fat diet can help reduce symptoms.

"I stopped drinking caffeinated beverages several weeks ago": Avoiding caffeinated beverages is a positive step in managing GERD. Caffeine can stimulate acid production in the stomach and relax the LES, contributing to GERD symptoms.

"I have recently stopped drinking alcohol": Stopping alcohol consumption is also beneficial for managing GERD. Alcohol can relax the LES and increase acid production in the stomach, leading to GERD symptoms.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client who is receiving radiation therapy and is experiencing nausea. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse is caring for a client who reports manifestations of gastroesophageal reflux disease (GERD). Which of the following client statements should the nurse identify as a contributing factor to GERD?

Correct Answer is A

Explanation

A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take?

A nurse is providing teaching about a gluten-free diet to a client who has celiac disease. Which of the following foods should the nurse recommend the client include in his diet?

A nurse is teaching a group of parents about appropriate food choices for toddlers. Which of the following choices by the parents demonstrates an understanding of the teaching?

A nurse is caring for a client who follows a vegan diet. The nurse should identify that the client is at risk for which of the following deficiencies?

A nurse is providing discharge teaching for a client who has iron deficiency anemia. Which of the following information should the nurse include?

A nurse is reviewing blood glucose values for a client who is at risk for diabetes mellitus. Which of the following findings should the nurse report to the provider?

A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following actions should the nurse plan to take?

A nurse is teaching a client who is at 10 weeks of gestation about increasing folate in her diet. Which of the following food choices should the nurse recommend as the best source of folate?