The nurse continues to care for the client.
For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis

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.

Rationale:

A. "I allow myself 10 minutes to finish each client's dressing change.": Assigning a fixed time to every procedure may not be realistic, as dressing change complexity and patient needs can vary. Overly rigid timing can compromise quality of care and flexibility in prioritizing tasks.

B. "I try to be working on at least three tasks at once so I can finish on time.": Multitasking in nursing can lead to errors, incomplete documentation, and compromised patient safety. Prioritizing and completing tasks sequentially is more effective for accuracy and quality care.

C. "I do not document my interventions in the electronic medical records until the end of each shift.": Delayed documentation increases the risk of errors, omissions, and inaccurate reporting. Timely documentation is essential for continuity of care and legal accuracy.

D. "I perform stat and time-critical care as soon as I receive the provider's prescriptions.": Addressing urgent and time-sensitive tasks immediately ensures that critical needs are met without delay. This reflects appropriate prioritization and effective time management.