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.

Rationale:

A. Limit visitors to 30 min per day: Time restrictions help reduce others’ exposure to radiation from the sealed implant. Limiting duration minimizes cumulative exposure for visitors while still allowing social interaction for the client.

B. Place the client in a semi-private room: Clients with internal radiation implants require a private room to protect others from unnecessary radiation exposure. A semi-private room increases the risk of radiation exposure to other patients and is inappropriate.

C. Instruct visitors who are pregnant to remain 3 feet from the client: Pregnant visitors should avoid contact with clients receiving internal radiation entirely, as even minimal exposure could harm the fetus. The safest recommendation is to avoid visiting during treatment.

D. Wear a lead apron when providing care: A lead apron shields the nurse from radiation exposure, especially when working close to the client. This is part of the time, distance, and shielding principles for radiation safety.

E. Close the door to the client's room: Keeping the door closed helps contain radiation within the client’s room, reducing exposure to staff and visitors in nearby areas. This is a standard precaution in caring for clients with sealed implants.

Rationale for Correct Answers:

• Uterus firm at 1 cm above the umbilicus and tender to palpation: Normally, by postpartum day 3, the uterus should be well below the umbilicus. A uterus that is still above and tender suggests endometritis or subinvolution, especially when combined with foul-smelling lochia.
• Moderate amount of dark brown, foul-smelling lochia noted: Lochia should progress from rubra (day 1–3, red) → serosa (day 4–10, pink/brown) → alba (day 10 onward, white/yellow). Foul-smelling lochia is a hallmark of uterine infection (endometritis).
• Temperature 38.2° C (100.8° F): A postpartum fever ≥38°C on two occasions, or even once when associated with uterine tenderness and foul lochia, is significant and indicates infection.
• WBC count 33,000/mm³: Although WBCs can be physiologically elevated postpartum (up to 20,000–25,000), a count this high is abnormal and strongly suggests severe infection.

Rationale for Incorrect Answers:

• Surgical incision well approximated with slight edema present: Mild edema is expected in the early healing process; no erythema, drainage, or dehiscence is noted, so no immediate concern.
• Respiratory rate 18/min: This is within normal range (12–20/min), no evidence of respiratory compromise.

SaO₂ 97% on room air: This is normal oxygen saturation, not concerning