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?

Weak pulses

Hypernatremia

Muscle weakness

Exaggerated reflexes

Answer and Explanation

The Correct Answer is C

Muscle weakness is a finding that indicates the client is experiencing water intoxication. Muscle weakness is a symptom of water intoxication because the excessive intake of water dilutes the sodium levels in the blood, causing hyponatremia. Sodium is an electrolyte that helps maintain the balance of fluids in and around cells and also regulates muscle contraction. When sodium levels are too low, the cells swell and the muscles lose their ability to function properly.

Weak pulses are not a specific finding for water intoxication, as they can be caused by other factors such as decreased blood volume or inadequate cardiac output.

Hypernatremia is the opposite of hyponatremia, meaning high sodium levels in the blood. This can occur due to dehydration, excessive salt intake, or certain medical conditions, but not water intoxication.

Exaggerated reflexes are not typically associated with water intoxication. They may be seen in conditions such as hyperreflexia or certain neurological disorders.

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Correct Answer is B

Explanation

Phenylketonuria (PKU) is an inherited metabolic disorder in which the body cannot properly process an amino acid called phenylalanine. If left untreated, phenylalanine can build up to harmful levels in the body, leading to intellectual disability and other health problems. Managing PKU involves following a strict low-phenylalanine diet.

When discussing anticipatory guidance for a client with PKU who is planning a pregnancy, it is important to focus on monitoring the maternal phenylalanine levels during pregnancy. Serum bilirubin is not directly related to PKU management and would not require specific monitoring in this context.

Regarding the other options:

"Diet sodas should not be consumed more than two or three times per week": While it is generally advisable to limit the consumption of diet sodas due to their artificial sweeteners, this statement does not directly relate to PKU management or pregnancy planning.

"A low-protein diet should be followed for 3 months prior to conception": A low-protein diet is a fundamental aspect of managing PKU. However, the timeline mentioned (3 months prior to conception) is not supported by current guidelines. PKU management should be ongoing and tailored to the individual's needs, with dietary adjustments made as necessary throughout pregnancy.

"Breastfeeding will prevent your baby from developing PKU": This statement is incorrect. Breast milk naturally contains phenylalanine, which could be harmful to an infant with PKU. Infants with PKU must receive a specialized formula that is low in phenylalanine from birth. Breastfeeding is not recommended for infants with PKU unless specifically guided by a healthcare professional.

A. HbA1c 5% B. Fasting glucose 140 mg/dL C. LDL 64 mg/dL D. Total cholesterol 173 mg/dL

Correct Answer is B

Explanation

Coronary heart disease (CHD) is a condition characterized by the buildup of plaque in the coronary arteries, leading to reduced blood flow to the heart. Several risk factors contribute to the development of CHD, including high blood glucose levels, high levels of low-density lipoprotein (LDL) cholesterol, and high total cholesterol levels.

HbA1c 5%: HbA1c is a measure of average blood glucose levels over the past 2-3 months. A level of 5% is within the target range for individuals without diabetes and indicates good glycemic control. It does not place the client at risk for CHD.

Fasting glucose 140 mg/dL: Fasting glucose levels above 126 mg/dL are considered diagnostic criteria for diabetes mellitus. A level of 140 mg/dL indicates hyperglycemia and suggests impaired glucose metabolism, which is a risk factor for CHD.

LDL 64 mg/dL: LDL cholesterol is often referred to as "bad" cholesterol, as elevated levels are associated with an increased risk of CHD. A level of 64 mg/dL is within the desirable range and does not place the client at risk for CHD.

Total cholesterol 173 mg/dL: Total cholesterol levels below 200 mg/dL are generally considered desirable. A level of 173 mg/dL is within the desirable range and does not place the client at risk for CHD.

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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?

Nursing Test Bank

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