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 E,A,C,B,D

Explanation

Rationale:

A. Verbally remind the staff member of the expected behaviour changes: After the initial meeting, a verbal reminder reinforces expectations and gives the staff member an opportunity to improve without formal penalties.

B. Suspend the staff member from work for several days: Suspension is used when prior interventions have not resulted in improvement. It serves as a serious consequence, giving time for reflection before returning to work.

C. Give the staff member a written warning about the behavior: A written warning follows a verbal reminder if the unprofessional behavior continues. It creates a formal record and communicates the seriousness of the issue.

D. Dismiss the staff member from employment at the facility: Termination is the final step when all other corrective measures have failed and the behavior persists, ensuring workplace standards and safety are maintained.

E. Set up a meeting to speak with the staff member about the behavior: The first action is to meet privately to discuss the observed behavior, clarify expectations, and begin the progressive discipline process in a constructive manner.

A. Raise the side rails up when the client is in bed. B. Place the bedside table at the foot of the bed. C. Keep the television on during the night. D. Assist the client to the toilet frequently.

Correct Answer is D

Explanation

A. Raise the side rails up when the client is in bed: Full side rails can increase the risk of entrapment and injury for clients with dementia. They are not recommended as a routine safety measure unless individually assessed and ordered.

B. Place the bedside table at the foot of the bed: Placing furniture at the foot of the bed can create obstacles and increase the risk of trips and falls. The environment should be arranged to allow safe, unobstructed mobility.

C. Keep the television on during the night: Continuous noise, such as a TV, can cause agitation or confusion in clients with dementia, increasing the risk of disorientation and injury. Quiet, calming environments are preferred.

D. Assist the client to the toilet frequently: Clients with dementia are at increased risk for falls due to urgency, confusion, or impaired mobility. Frequent toileting assistance reduces the risk of incontinence-related hazards and falls, promoting safety and dignity.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is E,A,C,B,D

Explanation

A nurse in a long-term care facility is admitting a client who has dementia. Which of the following actions should the nurse take to reduce the risk for client injury?

Correct Answer is D

Explanation

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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.