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A nurse on a mental health unit is admitting a client.
Exhibits
Select the 3 client findings the nurse should recognize as manifestations of water intoxication.

A.

Activity level

B.

White blood cell count

C.

Sodium level

D.

Potassium level

E.

Hallucinations

Answer and Explanation

Correct Answer : A,C,E

A. Activity level: Restlessness, pacing, and inability to remain seated are early neurological manifestations of water intoxication, stemming from cerebral edema related to hyponatremia. These signs often precede more severe symptoms like seizures.

B. White blood cell count: A count of 9,100/mm³ is within normal limits and does not indicate water intoxication. This value is unrelated to the dilutional effects of excessive fluid intake.

C. Sodium level: A sodium of 130 mEq/L indicates hyponatremia, which is a hallmark laboratory finding in water intoxication due to dilutional effects from excess fluid intake. Low sodium can cause neurological changes and altered mental status.

D. Potassium level: A potassium of 3.6 mEq/L is within the normal range and does not support a diagnosis of water intoxication. Potassium is less affected by acute overhydration compared to sodium.

E. Hallucinations: Responding to unseen stimuli can occur when hyponatremia causes cerebral swelling, disrupting normal brain function. In clients with psychotic disorders, excess water intake can exacerbate hallucinations or make them more pronounced.


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Related Questions

Correct Answer is C

Explanation

Rationale:

A. "I don't think you understand the risks to your health.": This response is dismissive of the client’s autonomy and implies the nurse is questioning the client’s decision-making ability. It can create a defensive reaction rather than supporting informed consent.

B. "You should talk with your family about it first.": While family support can be helpful, the decision for surgery ultimately rests with the client. Suggesting family involvement at this point could undermine the client’s right to make an independent healthcare decision.

C. "I will notify your provider regarding this decision.": This response respects the client’s autonomy and ensures the healthcare team is promptly informed. It also facilitates further discussion between the provider and client about the decision, ensuring it is fully informed.

D. "Let me remind you of the benefits of the surgery.": While reviewing benefits can be part of informed consent, doing so after the client has expressed a clear decision not to proceed may be perceived as coercive rather than supportive.

Correct Answer is C

Explanation

Rationale:

A. Generativity vs self-absorption: This stage occurs in middle adulthood, typically between ages 40 and 65, when individuals focus on contributing to society, guiding the next generation, and creating a lasting legacy.

B. Trust vs mistrust: This is the first stage of Erikson’s theory, occurring in infancy (birth to 1 year). It centers on developing a sense of trust when basic needs are met consistently by caregivers.

C. Identity vs role confusion: This stage occurs during adolescence (approximately ages 12 to 18) and involves exploring personal values, beliefs, and goals to develop a stable sense of self. Success leads to identity formation, while failure results in role confusion.

D. Intimacy vs isolation: This stage takes place in young adulthood (approximately ages 20 to 40) and focuses on forming deep, committed relationships while balancing independence and emotional closeness.

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