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?

Choice A rationale:
Diluting juice with 50 percent water to supplement between feedings is not recommended for newborns. Newborns should primarily be receiving breast milk or formula to ensure proper nutrition. Offering diluted juice can lead to inadequate intake of essential nutrients and unnecessary exposure to sugar. It's important for the newborn's diet to be appropriate for their stage of development.
Choice B rationale:
Beginning and ending with the same breast during feeding sessions promotes effective breastfeeding and adequate milk supply. This approach ensures that the baby receives both the foremilk (low-fat milk that comes at the beginning of a feeding) and hindmilk (higher-fat milk that comes later in a feeding), which is important for proper nutrition and growth. This choice demonstrates an understanding of the principles of breastfeeding.
Choice C rationale:
Feeding the baby on demand at least eight times each day is a suitable recommendation. Newborns have small stomachs and need frequent feedings to meet their nutritional needs and support healthy growth. Feeding on demand helps establish a good milk supply and ensures that the baby gets enough milk to thrive.
Choice D rationale:
Using pumped breast milk within 72 hours of refrigeration is a correct statement. Breast milk can be refrigerated for a limited time while maintaining its nutritional quality. Using pumped milk within 72 hours helps minimize the risk of bacterial growth and ensures that the baby receives milk that's still rich in nutrients and antibodies.

Choice A rationale:
Serving foods hot might seem like a way to enhance the aroma and taste, which could be appealing to the client. However, hot foods might worsen nausea and discomfort for someone undergoing radiation therapy due to their heightened sensitivity to smells. This choice doesn't directly address the client's symptoms.
Choice B rationale:
Increasing the intake of liquids at mealtime could be helpful to prevent dehydration, but it doesn't directly address the reported symptoms of nausea, stomatitis (inflammation of the mouth), and weight loss. Moreover, certain liquids might irritate the client's throat, making this choice less suitable.
Choice C rationale:
Consuming foods high in fat content is not the ideal choice for this client. Fat-rich foods can be heavy and difficult to digest, potentially exacerbating nausea and not being well-tolerated by someone experiencing stomatitis.
Choice D rationale:
The best choice is to recommend foods high in protein. Protein is essential for tissue repair, immune function, and maintaining lean body mass. Given the client's reported weight loss and stomatitis, protein-rich foods can aid in promoting tissue healing and preventing further muscle loss. Additionally, focusing on protein sources that are easy to swallow and tolerate can address the client's discomfort while supporting their nutritional needs.