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. Teach the client relaxation techniques: Teaching coping strategies is helpful but does not address the immediate need to understand the client’s perception of the crisis. It should follow assessment.

B. Confirm the client's perception of the event: The first step in crisis intervention is to assess and understand the client’s view of the situation. Clarifying perception allows the nurse to accurately prioritize interventions and provide appropriate support.

C. Notify the client's support person: Contacting support is beneficial for ongoing assistance but should occur after assessing the client’s understanding and emotional state.

D. Help the client identify personal strengths: Identifying strengths promotes coping and resilience, but it is a secondary intervention that should follow assessment and clarification of the client’s perception.

Rationale for correct choices:

• Reye’s syndrome is a rare but serious condition that can develop after a viral illness when aspirin is given to children. The toddler’s symptoms—lethargy, persistent vomiting, and difficulty rousing—align with signs of increased intracranial pressure associated with Reye’s syndrome.

• Aspirin administration during a recent influenza A infection is a known trigger for Reye’s syndrome, as it can cause acute encephalopathy and liver dysfunction in pediatric patients.

Rationale for incorrect choices:

• Bronchitis would present with prominent lower respiratory symptoms such as productive cough, wheezing, and abnormal lung sounds, which are not noted here.

• Gastroenteritis is characterized by vomiting and diarrhea with signs of dehydration; this child has no diarrhea, and the neurological decline suggests CNS involvement rather than a purely GI process.

• Acetaminophen administration is not linked to Reye’s syndrome; toxicity causes liver injury but does not present with acute encephalopathy following viral illness in the same way.

• Cough finding is unrelated to the primary cause of the neurological changes and persistent vomiting; the cough has been present but is not the trigger for the current complication.