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 D

Explanation

D. Fish and poultry are primary sources of heme iron: This is correct. Fish and poultry are rich sources of heme iron, which is the type of iron found in animal-based foods. Heme iron is more easily absorbed by the body than non-heme iron, which is found in plant-based foods.

A. "Protein requirements decrease in times of stress." B. "Glucose is broken down more slowly during times of stress." C. "Acute stress causes an increase in metabolism." D. "Stress causes a positive nitrogen balance in the body."

Correct Answer is C

Explanation

A) "Protein requirements decrease in times of stress": This statement is incorrect. During times of stress, such as illness or injury, the body's protein requirements often increase to support tissue repair, immune function, and other metabolic processes. Therefore, protein requirements typically increase rather than decrease during periods of stress.

B) "Glucose is broken down more slowly during times of stress": This statement is also incorrect. During stress, the body releases hormones such as cortisol and adrenaline, which promote the breakdown of glycogen into glucose, providing a quick energy source for the body's response to stress. Therefore, glucose is broken down more rapidly during times of stress to meet the increased energy demands.

C) "Acute stress causes an increase in metabolism": This statement is accurate. Acute stress triggers the release of stress hormones, such as cortisol and adrenaline, which can increase metabolism. These hormones stimulate processes such as gluconeogenesis (the production of glucose from non-carbohydrate sources), lipolysis (the breakdown of fats), and increased heart rate and blood pressure, all of which contribute to an increase in metabolic rate during acute stress.

D) "Stress causes a positive nitrogen balance in the body": This statement is incorrect. Stress, particularly severe or prolonged stress, can lead to a negative nitrogen balance in the body. During stress, there may be increased protein breakdown to provide amino acids for energy production and other metabolic needs. Additionally, stress can impair protein synthesis and utilization, leading to muscle wasting and a negative nitrogen balance.

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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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