A client with a history of heart and kidney failure is brought to the emergency department. Upon assessment/diagnosis, it is determined the client is in decompensated heart failure

Question

Of the following assessment findings, which are associated with excess intracellular water? Select all that apply.
A) Lethargy
B) Confusion
C) Hyperactive deep tendon reflexes
D) Seizures
E) Firm, rubbery tissue when palpating lower extremities

Answer 1

Ans: A, B, D
Feedback:
Hyponatremia is usually defined as a serum sodium concentration of less than 135 mEq/L. Muscle cramps, weakness, and fatigue reflect the effects of hyponatremia on skeletal muscle function and are often early signs of hyponatremia. The cells of the brain and nervous system are the most seriously affected by increases in intracellular water. Symptoms include apathy, lethargy, and headache, which can progress to disorientation, confusion, gross motor weakness, and depression of deep tendon reflexes. Seizures and coma occur when serum sodium levels reach extremely low levels. Hypovolemia, third spacing (maldistribution of body fluid), and dehydration are associated with hypernatremia and/or hypertonicity.