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?

Hypernatremia

Weak pulses

Exaggerated reflexes

Muscle weakness

Answer and Explanation

The Correct Answer is D

A) Hypernatremia refers to elevated sodium levels in the blood and is not consistent with water intoxication. In water intoxication, hyponatremia (low sodium levels) is more likely due to dilutional effects from excess water intake.

B) Weak pulses are not specific findings associated with water intoxication. While fluid overload can lead to cardiovascular complications, such as hypertension and bounding pulses, weak pulses are not typically indicative of water intoxication.

C) Exaggerated reflexes are not characteristic findings of water intoxication. Instead, neurological symptoms such as confusion, headache, and seizures may occur due to cerebral edema resulting from water intoxication.

D) Muscle weakness is a potential manifestation of water intoxication due to hyponatremia, which can lead to changes in osmolarity and cellular function. Hyponatremia can cause neurological symptoms such as muscle weakness, lethargy, and seizures. As water moves into cells, it can disrupt cellular function and lead to symptoms of cellular swelling. Therefore, muscle weakness is a concerning finding in the context of suspected water intoxication.

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Correct Answer is C

Explanation

C) Cephalhematoma:

A cephalhematoma is a collection of blood between the skull bone and its periosteum. It appears as a raised, bruised area on the scalp and is typically limited by suture lines. Unlike caput succedaneum, which typically resolves within a few days and crosses suture lines, a cephalhematoma does not cross suture lines and may take weeks to months to resolve.

A) Caput succedaneum:

Caput succedaneum is a localized swelling of the soft tissues of the scalp, usually resulting from pressure against the dilating cervix during labor. It typically crosses suture lines and resolves within a few days.

B) Pilonidal dimple:

A pilonidal dimple is a small pit or sinus in the sacrococcygeal area, not related to scalp findings.

D) Molding:

Molding refers to the shaping of the fetal head to adapt to the birth canal during labor and delivery. It is a temporary deformity and does not involve bruising or raised areas on the scalp.

A. Less than 2.5 cm of rubra lochia on perineal pad B. Client report of increased thirst C. Fundus palpable to right of midline D. Client report of frequent uterine contractions

Correct Answer is C

Explanation

A) Less than 2.5 cm of rubra lochia on perineal pad:

The amount of lochia on the perineal pad is an indicator of postpartum bleeding and uterine involution but does not specifically indicate bladder distention.

B) Client report of increased thirst:

Increased thirst may indicate dehydration, which can occur postpartum, but it is not a specific sign of bladder distention.

C) Fundus palpable to right of midline:

This finding suggests bladder distention. A full bladder can displace the uterus to the right side of the midline. Bladder distention can hinder uterine contractions and increase the risk of postpartum hemorrhage. Emptying the bladder can help the uterus contract effectively and prevent complications.

D) Client report of frequent uterine contractions:

Frequent uterine contractions are expected in the immediate postpartum period as the uterus undergoes involution. However, this finding does not specifically indicate bladder distention.

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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?

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