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 A

Explanation

A) "This is a cephalhematoma, which can occur spontaneously":

This is the correct response. A cephalhematoma is a collection of blood between the skull bone and its periosteum and does not cross suture lines. It often develops after vacuum extraction during delivery due to rupture of blood vessels. It is typically benign and resolves on its own over several weeks to months as the blood is reabsorbed by the body. It is important to reassure the mother that this is a common occurrence and usually resolves without intervention.

B) "Mongolian spots can be found on the skin of many newborns":

Mongolian spots are blue-gray birthmarks that commonly appear on the skin of newborns, typically over the buttocks and lower back. They are not related to the swelling on the baby's head and do not cross suture lines.

C) "This is erythema toxicum, which is a transient condition":

Erythema toxicum is a benign rash that appears in many newborns within the first few days of life. It presents as small, yellow or white papules surrounded by erythema and often resolves without treatment within a week. It is not related to the swelling on the baby's head and does not cross suture lines.

D) "A caput succedaneum occurs due to compression of blood vessels and will cross the sutures lines on the baby's head":

While a caput succedaneum is a collection of serosanguinous fluid that crosses suture lines and typically resolves within a few days after birth, it is usually associated with swelling over the presenting part of the fetus during labor, not vacuum extraction. Additionally, caput succedaneum is not typically located on the top of the head, where the swelling from a cephalhematoma would be observed.

A. Salami B. Barley C. Corn D. Wheat germ

Correct Answer is C

Explanation

A) Salami is typically not recommended for individuals with celiac disease because it often contains gluten as a filler or binder. Processed meats like salami may have additives or seasonings that contain gluten, so individuals with celiac disease should carefully read labels and choose gluten-free options.

B) Barley is a grain that contains gluten and is not suitable for individuals with celiac disease. It is commonly found in bread, cereals, soups, and other processed foods. Consuming barley can trigger adverse reactions in individuals with celiac disease due to the gluten content.

C) Corn is a suitable option for individuals with celiac disease who need to follow a gluten-free diet. Corn is naturally gluten-free and can be included in various forms, such as whole corn, cornmeal, or corn flour, in gluten-free recipes. It provides carbohydrates, fiber, vitamins, and minerals without containing gluten, making it a safe choice for those with celiac disease.

D) Wheat germ is derived from wheat, which contains gluten. Therefore, wheat germ is not appropriate for individuals with celiac disease as it can cause gluten-related symptoms. It's important for individuals with celiac disease to avoid all sources of gluten, including wheat and wheat-derived products like wheat germ.

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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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