A nurse is caring for a client who has breast cancer and is postoperative following a bilateral mastectomy. Which of the following statements indicates the client has an altered body image?

Rationale:

A. 0.45% sodium chloride: This is a hypotonic solution that helps lower serum sodium levels by diluting extracellular sodium and promoting cellular rehydration. It is commonly used to treat hypernatremia when there is no significant fluid volume overload.

B. 0.9% sodium chloride: This isotonic solution contains the same concentration of sodium as the blood. It does not correct hypernatremia and may worsen it if sodium levels are already elevated, especially in dehydrated clients.

C. Lactated Ringer's: While this is an isotonic fluid, it contains sodium and electrolytes that do not help reduce high serum sodium levels. It is more appropriate for fluid resuscitation than for treating hypernatremia.

D. 3% sodium chloride: This hypertonic solution is used for severe hyponatremia, not hypernatremia. Administering it to someone with elevated sodium levels would further increase sodium concentration and worsen the condition.

Rationale:

A. Tenting skin turgor: Tenting indicates dehydration or fluid volume deficit, not overload. It reflects reduced skin elasticity due to poor interstitial fluid volume.

B. Respiratory rate 30/min: Tachypnea can result from pulmonary congestion or edema due to excess fluid in the intravascular space. It is a classic sign of fluid overload as the lungs struggle with impaired gas exchange.

C. Skin warm and dry: Warm, dry skin is a normal finding and does not suggest volume overload. Fluid retention typically causes edema or moist skin in severe cases.

D. Heart rate 60/min: A heart rate within normal range does not point to fluid overload. Often, fluid overload is associated with tachycardia due to increased preload and compensatory responses.