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.

Activity level

White blood cell count

Sodium level

Potassium level

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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Correct Answer is C

Explanation

Rationale:

A. "Refrain from doing any exercises until your symptoms show improvement.": Completely avoiding exercise is not necessary for most people with asthma and can negatively impact cardiovascular health. The goal is to control symptoms so that safe activity is possible.

B. "Use your long-acting beta agonist inhaler after exercise-induced symptoms appear.": Long-acting beta agonists are used for maintenance therapy, not for quick relief. They are not appropriate for immediate symptom control before or after exercise.

C. "Use your short-acting beta agonist inhaler before exercising.": Short-acting beta agonists, such as albuterol, can be taken 5–20 minutes before exercise to prevent exercise-induced bronchospasm. This is the recommended approach for clients with exercise-triggered asthma.

D. "It is safe to exercise if your peak flow meter measures in the red zone.": The red zone indicates severe airway narrowing and poor asthma control, requiring immediate medical attention. Exercise in this state could worsen symptoms and lead to respiratory distress.

A. Set the suction source at 220 mm Hg. B. Repeat suctioning as needed up to five times. C. Hyperventilate the client with 100% oxygen before suctioning. D. Suction for 20 seconds with each pass.

Correct Answer is C

Explanation

Rationale:

A. Set the suction source at 220 mm Hg: This pressure is excessively high and can damage tracheal mucosa. Recommended suction pressure for an adult tracheostomy is typically 80–120 mm Hg to minimize tissue trauma while effectively clearing secretions.

B. Repeat suctioning as needed up to five times: Frequent suction passes increase the risk of hypoxia and mucosal injury. Generally, suctioning should be limited to a maximum of three passes per session, allowing adequate recovery and reoxygenation between attempts.

C. Hyperventilate the client with 100% oxygen before suctioning: Preoxygenating helps prevent hypoxemia during suctioning by increasing oxygen reserves. This is a standard safety measure, especially in clients with artificial airways, to maintain oxygenation during the procedure.

D. Suction for 20 seconds with each pass: Prolonged suctioning increases the risk of hypoxia, arrhythmias, and airway trauma. Each suction pass should be limited to 10–15 seconds for adults to reduce complications and promote safety.

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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.

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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.