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?

Exaggerated reflexes.

Muscle weakness.

Hypernatremia.

Weak pulses.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B: Muscle weakness.

Choice A rationale:

Exaggerated reflexes are not typically associated with water intoxication. They can be a sign of other neurological conditions but not specifically related to the administration of hypotonic IV fluids.

Choice B rationale:

Muscle weakness is a symptom of water intoxication, which can occur due to the dilution of electrolytes, including sodium, in the body when a hypotonic solution is administered.

Choice C rationale:

Hypernatremia, or high levels of sodium in the blood, is the opposite of what occurs in water intoxication. Water intoxication leads to hyponatremia, which is a low sodium concentration in the blood.

Choice D rationale:

Weak pulses are not a direct indicator of water intoxication. While they can be associated with various conditions, they do not specifically point to water intoxication following the administration of a hypotonic IV fluid bolus.

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Correct Answer is C

Explanation

Choice A rationale:
Maintaining a low-protein diet is not the appropriate instruction for a client taking a monoamine oxidase inhibitor (MAOI). While dietary restrictions are associated with MAOIs, it's primarily focused on avoiding foods rich in tyramine, which is not limited to just protein-containing foods.
Choice B rationale:
Not eating grapefruit while taking medication is generally applicable advice, but it is not specific to MAOIs. Grapefruit can interfere with the metabolism of certain medications by inhibiting specific enzymes. However, it's not a concern solely related to MAOIs.
Choice C rationale:
Avoiding aged cheeses while taking this medication is the correct instruction. Aged cheeses contain tyramine, which can lead to a hypertensive crisis when consumed with MAOIs. Tyramine interacts with MAOIs to increase blood pressure, potentially causing a serious reaction.
Choice D rationale:
Reducing intake of high-calorie foods is not a primary concern when taking MAOIs. The main dietary focus is on avoiding tyramine-rich foods to prevent dangerous interactions. High-calorie foods are not directly contraindicated with MAOIs.

A. "Albumin in my urine is an indication of normal kidney function." B. "I will keep my blood glucose levels between 200 and 212 milligrams per deciliter." C. "I will keep my HbA1c at five percent." D. "I will have ketones in my urine if my blood glucose is maintained at 190 milligrams per deciliter."

Correct Answer is D

Explanation

Choice Arationale:
Albumin in the urine is not an indication of normal kidney function. The presence of albumin in the urine, known as albuminuria, is a sign of kidney damage, especially in individuals with diabetes. It's essential for individuals with diabetes to monitor and manage their kidney health, as kidney damage is a common complication.

Choice Brationale:
Blood glucose levels between 200 and 212 milligrams per deciliter are higher than the recommended target range for individuals with type 1 diabetes. Maintaining blood glucose levels within a healthy range (typically 80-130 mg/dL fasting) is important to prevent complications.

Choice C rationale:
An HbA1c level of five percent is unrealistically low and not achievable. The HbA1c level reflects the average blood glucose level over the past two to three months. While lower HbA1c levels are associated with better diabetes control, aiming for an HbA1c of five percent would pose a risk of hypoglycemia and potential complications.
Choice D rationale:
The statement "I will have ketones in my urine if my blood glucose is maintained at 190 milligrams per deciliter" demonstrates an understanding of the relationship between high blood glucose levels and ketone production. Elevated blood glucose levels can lead to the breakdown of fats for energy, resulting in the production of ketones, which can be detected in the urine. Ketones in the urine can be a sign of inadequate diabetes management and a risk of diabetic ketoacidosis (DKA).

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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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