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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The examination light of the ophthalmoscope should be directed toward the client's eye, not the client's face.
B. When examining the left eye, the nurse should stand on the right side of the client to facilitate proper alignment of the ophthalmoscope with the client's eye.
C. Dimming the lights in the room may improve visualization of the client's internal eye
structures, but it is not typically necessary for ophthalmoscopic examination and may hinder the nurse's ability to assess the client effectively.
D. Placing the ophthalmoscope directly against the client's forehead would not facilitate proper examination of the internal eye structures and may cause discomfort to the client.
Correct Answer is A
Explanation
A. Hypotension occurs because hypermagnesemia causes vasodilation, which lowers blood pressure. Magnesium acts as a smooth muscle relaxant, decreasing vascular resistance and contributing to hypotension. This is a common clinical finding when magnesium levels exceed the normal range.
B. Tachycardia is not expected with hypermagnesemia. Elevated magnesium levels depress the heart's electrical activity, leading to bradycardia (slow heart rate) instead of tachycardia.
C. Muscle cramps are typically associated with hypomagnesemia, which increases neuromuscular excitability. In hypermagnesemia, neuromuscular function is suppressed, leading to muscle weakness rather than cramps.
D. Hyperreflexia is a symptom of hypomagnesemia, not hypermagnesemia. In hypermagnesemia, neuromuscular activity is depressed, resulting in diminished or absent deep tendon reflexes
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