A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect?

Generalized edema

Elevated urine specific gravity

Thready pulse

Increased hematocrit

Answer and Explanation

The Correct Answer is C

A. Water intoxication can lead to dilutional hyponatremia, which may result in fluid shifting into cells, causing cellular swelling and potentially cerebral edema, but generalized edema is not typically associated with water intoxication.

B. Water intoxication leads to dilution of electrolytes, including sodium, which results in decreased urine specific gravity rather than elevated.

C. Thready pulse is a common finding in water intoxication due to electrolyte imbalances and hemodilution.

D. Increased hematocrit is not typically associated with water intoxication; rather, it may indicate dehydration or hemoconcentration.

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Correct Answer is C

Explanation

A. Providing guidance on incentive spirometry requires specialized knowledge and skill that should be provided by a licensed healthcare provider, such as a nurse.

B. A client who had a myocardial infarction 3 days ago and reports chest discomfort requires ongoing assessment and monitoring by a licensed healthcare provider, such as a nurse, due to the potential for cardiac complications.

C. Assisting a client who had a stroke 2 days ago and needs help toileting is a task that can be safely delegated to an assistive personnel, as long as the client's condition is stable and the assistive personnel has been trained in providing basic care.

D. Providing a drink to a client who has awoken following a bronchoscopy may require assessment and monitoring for potential complications, such as aspiration or respiratory distress, which should be provided by a licensed healthcare provider, such as a nurse.

A. Encourage the client to ambulate in the hallway 1 hr before bedtime. B. Tell the client to avoid drinking fluids 1 hr before bedtime. C. Schedule routine care tasks during hours when the client is awake. D. Advise the client to leave the television in the room on when trying to fall asleep.

Correct Answer is C

Explanation

A. Encourage the client to ambulate in the hallway 1 hr before bedtime - While light exercise during the day can promote better sleep, exercising close to bedtime can actually disrupt sleep.

B. Tell the client to avoid drinking fluids 1 hr before bedtime - While limiting fluids close to bedtime can reduce nighttime awakenings to urinate, it may not directly address difficulty falling asleep.

C. Schedule routine care tasks during hours when the client is awake - This action ensures that the client can maximize restful sleep during the night by minimizing disruptions from care

activities.

D. Advise the client to leave the television in the room on when trying to fall asleep - Screen

time before bed can interfere with falling asleep due to the stimulating effect of light and content.

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A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect?

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