A nurse is caring for a client who received radiation therapy to the pelvic area. The client is experiencing chronic diarrhea. Which of the following actions should the nurse take?

The correct answer is choice B: Muscle weakness.

Choice A rationale:

Exaggerated reflexes are not typically associated with water intoxication. They can be a sign of other neurological conditions but not specifically related to the administration of hypotonic IV fluids.

Choice B rationale:

Muscle weakness is a symptom of water intoxication, which can occur due to the dilution of electrolytes, including sodium, in the body when a hypotonic solution is administered.

Choice C rationale:

Hypernatremia, or high levels of sodium in the blood, is the opposite of what occurs in water intoxication. Water intoxication leads to hyponatremia, which is a low sodium concentration in the blood.

Choice D rationale:

Weak pulses are not a direct indicator of water intoxication. While they can be associated with various conditions, they do not specifically point to water intoxication following the administration of a hypotonic IV fluid bolus.

Choice A rationale:
The client's statement, "I can choose an avocado dip instead of salsa," indicates an understanding of the teaching about a low-saturated fat diet. Avocado is a source of healthy monounsaturated fats, which are preferred over saturated fats. This choice aligns with the goal of reducing saturated fat intake, which is important for cardiovascular health. Avocado dip is a better choice than salsa in this context due to its healthier fat content.
Choice B rationale:
The statement "I can eat the skin on poultry if it is broiled" is not indicative of an understanding of a low-saturated fat diet. Poultry skin is high in saturated fat, and even though broiling is a healthier cooking method compared to frying, the saturated fat content in the skin remains a concern.
Choice C rationale:
The statement "I will use margarine on my waffles" is not aligned with the teaching of a low-saturated fat diet. Most margarines contain trans fats or unhealthy saturated fats, which can be detrimental to cardiovascular health. Using margarine on waffles would likely contribute to the intake of unhealthy fats.
Choice D rationale:
The statement "I will include 7 ounces of fish in my diet weekly" does not reflect an understanding of a low-saturated fat diet. While fish is generally a healthy protein source, this statement doesn't specifically address saturated fat reduction. The type of fish and its preparation method can influence the saturated fat content, so simply including a certain amount of fish does not guarantee adherence to a low-saturated fat diet.