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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. "Place a pillow under your knees while in bed.": Elevating the knees with a pillow can compress blood vessels and restrict circulation, increasing the risk of venous stasis and deep vein thrombosis.
B. "Participate in range-of-motion exercises.": Performing range-of-motion exercises promotes blood flow in the extremities, prevents venous stasis, and reduces the risk of complications such as deep vein thrombosis, supporting postoperative circulation.
C. "Remain on bed rest for 24 hours following the procedure.": Prolonged immobility can impair circulation and increase the risk of blood clots. Early ambulation and movement are encouraged unless contraindicated by the provider.
D. "Use an incentive spirometer every hour”: While using an incentive spirometer is important for preventing respiratory complications, it primarily promotes lung expansion and does not directly enhance circulation.
Correct Answer is A
Explanation
Rationale:
A. Food exchange lists for meal planning from the American Diabetes Association: The ADA provides evidence-based, reliable resources for meal planning that help clients manage blood glucose levels and make informed dietary choices. These lists are tailored for diabetes management.
B. Food label recommendations from the Institute of Medicine: While the IOM provides general nutrition guidelines, they are not specifically designed for diabetes management and may not address individualized meal planning needs for blood glucose control.
C. Diabetes medication information from the Physicians' Desk Reference: The PDR contains medication details but is intended for healthcare professionals, not clients. It may be too technical for patient education purposes.
D. Personal blogs about managing the adverse effects of diabetes medications: Blogs may provide anecdotal information that is not evidence-based and could be inaccurate or misleading, making them an unreliable resource for client education.
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