A nurse in the emergency department is assessing a young adult client who was administered a hypotonic IV fluid bolus for rehydration after collapsing at an athletic event. Which of the following findings indicates the client is experiencing water intoxication?
A. Exaggerated reflexes. B. Muscle weakness. C. Hypernatremia. D. Weak pulses.
Answer and Explanation
The Correct Answer is A
Choice A rationale:
Exaggerated reflexes - Water intoxication, also known as water poisoning or hyponatremia, occurs when there's an excessive intake of water that dilutes the body's sodium levels. This can lead to low sodium concentrations in the blood, which disrupts the balance of electrolytes and can result in neurological symptoms, including exaggerated or hyperactive reflexes.
Choice B rationale:
Muscle weakness - Muscle weakness can be a symptom of various conditions, but it is not a typical finding in water intoxication. Hyponatremia, which is associated with water intoxication, tends to affect the nervous system and can lead to neurological symptoms rather than muscle weakness.
Choice C rationale:
Hypernatremia - Hypernatremia refers to elevated levels of sodium in the blood. However, water intoxication is characterized by hyponatremia, which is low sodium levels due to excessive water intake. Therefore, hypernatremia is not a finding associated with water intoxication.
Choice D rationale:
Weak pulses - Water intoxication affects the balance of electrolytes, primarily sodium, in the body. Weak pulses are not a typical manifestation of water intoxication. Symptoms related to the nervous system, such as confusion, seizures, and altered consciousness, are more common due to the impact of electrolyte imbalances on brain function.
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Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Allowing the toddler to feed himself is an important aspect of promoting autonomy and developing fine motor skills. It encourages self-sufficiency and exploration of different food textures. However, close supervision is necessary to ensure the toddler's safety during feeding.
Choice B rationale:
Avoiding snacks between meals is not the most appropriate instruction for a toddler's nutritional needs. Toddlers have smaller stomach capacities and higher energy requirements due to their rapid growth. Healthy snacks can help meet their nutritional needs and prevent excessive hunger between meals.
Choice C rationale:
Providing different food for the toddler than the parents is not recommended. Ideally, toddlers should be exposed to the same nutritious foods that the family consumes. This practice helps establish healthy eating habits and exposes the toddler to a variety of foods.
Choice D rationale:
Setting meal times immediately after physical activity is not necessarily beneficial. While regular physical activity is important for toddlers, scheduling meals immediately after activity might lead to poor appetite or discomfort. It's generally better to ensure the toddler is well-rested and hungry before meals.
Correct Answer is D
Explanation
Choice A rationale:
The instruction "Eat protein at each meal" is appropriate for a client with dumping syndrome. Dumping syndrome is a condition in which food, especially high-carbohydrate meals, moves too quickly from the stomach to the small intestine. This can lead to symptoms like nausea, vomiting, and diarrhea. Including protein at each meal can help slow down the emptying of the stomach, reducing the severity of dumping syndrome symptoms.
Choice B rationale:
The instruction "Drink beverages with meals" is not advisable for a client with dumping syndrome. Consuming beverages with meals can exacerbate dumping syndrome symptoms by contributing to the rapid movement of food from the stomach to the small intestine. It's generally recommended for individuals with dumping syndrome to avoid drinking liquids with meals.
Choice C rationale:
The instruction "Consume three large meals daily" is not suitable for a client with dumping syndrome. Large meals can trigger more severe dumping syndrome symptoms due to the rapid emptying of the stomach contents. Smaller, more frequent meals are often recommended to minimize symptoms.
Choice D rationale:
The instruction "Sit up in bed after meals" is appropriate for a client with dumping syndrome. Maintaining an upright position after meals can help slow down the movement of food from the stomach to the small intestine, reducing the risk of dumping syndrome symptoms. Lying down immediately after eating can contribute to faster gastric emptying and worsen symptoms.
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