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
A. "The nurse will initiate acupuncture when I arrive at the unit.": Acupuncture must be performed by a trained and licensed practitioner, not a bedside nurse. While it can be used for labor pain, it is not typically initiated by nursing staff upon admission.
B. "I can use my ultrasound picture as a focal point during contractions.": Focal point techniques, such as concentrating on a meaningful object like an ultrasound picture, help distract from pain and promote relaxation.
C. "A transcutaneous electrical nerve stimulator will help with pelvic pressure.": TENS units are primarily effective for back pain in early labor rather than pelvic pressure. They work by stimulating sensory nerves to reduce pain perception but are less effective for deep pelvic discomfort.
D. "My nurse can teach me biofeedback at the beginning of labor.": Biofeedback requires prior training and practice before labor begins to be effective. Learning it for the first time during active labor is impractical and unlikely to yield good results.
Correct Answer is D
Explanation
Rationale:
A. Being honest with the parents of a child about the need to report suspected abuse: This reflects the ethical principle of veracity, which involves truth-telling and providing accurate information, rather than distributive justice.
B. Accepting the decision of an older adult client to live alone in her home: This action demonstrates respect for autonomy, which is honoring a client’s right to make decisions about their own life and care, not distributive justice.
C. Keeping a promise to visit with a client who is housebound after the delivery of care: This is an example of fidelity, the ethical obligation to keep commitments and follow through on promises made to clients.
D. Ensuring that a homeless client receives preventive medical care: Distributive justice focuses on fair and equitable allocation of resources and services, particularly for vulnerable or underserved populations. Providing preventive care to a homeless client exemplifies this principle.
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