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
Muscle weakness
Exaggerated reflexes
The Correct Answer is C
Choice A reason: Hypernatremia is not a sign of water intoxication, but rather the opposite condition. Hypernatremia means high sodium levels in the blood, which can occur when the body loses more water than sodium, such as in dehydration, diabetes insipidus, or excessive salt intake. Water intoxication causes hyponatremia, which means low sodium levels in the blood, due to excessive water intake or retention.
Choice B reason: Weak pulses are not a specific sign of water intoxication, but rather a general sign of poor perfusion or circulation. Weak pulses can have many causes, such as hypotension, shock, heart failure, or peripheral vascular disease. Water intoxication can cause hypotension, but it can also cause hypertension, depending on the volume status of the client.
Choice C reason: Muscle weakness is a sign of water intoxication, as it reflects the effect of low sodium levels on the neuromuscular system. Sodium is essential for nerve and muscle function, as it helps generate electrical impulses and contractions. When sodium levels drop too low, the nerves and muscles become less responsive and weaker. Other signs of water intoxication affecting the nervous system include confusion, headache, seizures, and coma.
Choice D reason: Exaggerated reflexes are not a sign of water intoxication, but rather a sign of hyperreflexia, which is a condition of overactive reflexes. Hyperreflexia can have many causes, such as spinal cord injury, stroke, multiple sclerosis, or electrolyte imbalance. Water intoxication can cause electrolyte imbalance, but it usually leads to hyporeflexia, which is a condition of reduced or absent reflexes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The client should not replace salt with soy sauce, as soy sauce is not kosher. Soy sauce is made from fermented soybeans and wheat, which are not allowed in a kosher diet. The client should use kosher salt or other kosher seasonings instead.
Choice B reason: The client's primary vegetables should not be squash and corn, as they are not considered kosher. Squash and corn are classified as kitniyot, which are legumes, grains, seeds, and other plant products that are not allowed in a kosher diet. The client should eat more leafy greens, root vegetables, and fruits, which are kosher.
Choice C reason: The client can eat meat and nondairy margarine together, as they are both kosher. Nondairy margarine is made from vegetable oils, which are pareve, meaning they are neither meat nor dairy. The client should avoid eating meat and dairy products together, as they are not kosher.
Choice D reason: The client does not need to use their right hand when eating food, as this is not a requirement of a kosher diet. This is a practice of some Muslims, who believe that the right hand is for eating and the left hand is for cleaning. The client should follow the rules of kashrut, which are the Jewish laws of kosher food.
Correct Answer is A
Explanation
Choice A reason: A low-protein diet is essential for clients who have PKU, as they cannot metabolize the amino acid phenylalanine. High levels of phenylalanine can cause intellectual disability and other neurological problems. A low-protein diet should be started before pregnancy and maintained throughout pregnancy to prevent fetal harm.
Choice B reason: Serum bilirubin is not related to PKU. It is a product of red blood cell breakdown and is elevated in conditions such as jaundice, liver disease, or hemolytic anemia. It does not need to be monitored routinely in clients who have PKU.
Choice C reason: Diet sodas are not recommended for clients who have PKU, as they often contain artificial sweeteners such as aspartame, which is a source of phenylalanine. Diet sodas should be avoided completely or consumed very sparingly by clients who have PKU.
Choice D reason: Breastfeeding will not prevent the baby from developing PKU, as PKU is a genetic disorder that is inherited from both parents. If both parents have PKU, the baby will have a 100% chance of having PKU. If one parent has PKU and the other is a carrier, the baby will have a 50% chance of having PKU. If one parent has PKU and the other is not a carrier, the baby will not have PKU but will be a carrier. Breastfeeding may provide some benefits for the baby, such as immunity and bonding, but it will not affect the baby's PKU status.
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