A nurse had instructed a mother on the importance of providing a toddler with a balanced diet.
Which observation during a home visit indicates that the instruction has been effective?
The child takes candy from a dish that is placed on the coffee table in the living room.
The mother places a serving of fried finger foods on a plate for the child.
The mother prepares a scrambled egg for the toddler’s breakfast.
The child is eating a piece of cake and ice cream for lunch.
The Correct Answer is C
Choice A rationale
While a child taking candy from a dish may indicate the availability of sugary foods, it does not necessarily reflect the mother's overall efforts to provide a balanced diet. The presence of these foods could be for other family members or guests, and the child's action might not be representative of their regular dietary intake. A balanced diet incorporates multiple food groups, not just the avoidance of sugar.
Choice B rationale
Fried foods are often high in saturated fats and sodium, which can contribute to poor cardiovascular health and obesity. This choice does not demonstrate an understanding of a balanced diet, which emphasizes lean proteins, whole grains, fruits, and vegetables. Providing a plate of fried foods does not align with effective nutritional instruction for a toddler's healthy development.
Choice C rationale
A scrambled egg provides a high-quality source of protein, essential for tissue growth and repair, along with healthy fats and vitamins like B12 and D. This choice indicates an understanding of the need for nutrient-dense foods in a toddler's diet. It is a suitable component of a balanced breakfast, especially when combined with other food groups like fruits or whole-grain toast.
Choice D rationale
Cake and ice cream are high in sugar and saturated fats, offering minimal nutritional value. Consuming these items for lunch is inconsistent with the principles of a balanced diet, which prioritizes nutrient-dense foods from all major food groups. This observation suggests the mother has not effectively implemented the dietary instructions provided by the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Increasing weight loss is an incorrect characteristic. Nephrotic syndrome is marked by massive proteinuria, which leads to a decrease in plasma oncotic pressure. This fluid shift from the intravascular space to the interstitial space results in significant fluid retention, causing weight gain and edema, not weight loss. The body holds onto fluid, masking any potential muscle or fat wasting.
Choice B rationale
Increased urinary output is not a characteristic of nephrotic syndrome. The condition is associated with severe fluid retention and decreased plasma volume, leading to oliguria, or a decreased urinary output. The kidneys are not effectively filtering protein and fluid is being retained in the body, which directly reduces the amount of fluid that can be excreted as urine.
Choice C rationale
Generalized edema is the most common and striking characteristic of nephrotic syndrome. The massive loss of protein, particularly albumin, in the urine leads to a significant decrease in serum albumin levels. Albumin is crucial for maintaining plasma oncotic pressure. The resulting decrease in oncotic pressure causes fluid to shift from the bloodstream into the interstitial spaces, resulting in widespread or anasarca edema.
Choice D rationale
While hypertension can occur, it is not the most common characteristic associated with nephrotic syndrome. The primary physiological change is the massive proteinuria leading to hypoproteinemia and subsequent edema. Hypertension may develop as a result of volume overload, but it is not a hallmark sign. The most prominent and defining symptom is the severe edema.
Correct Answer is D
Explanation
Choice A rationale
Increasing nasal discharge is a common symptom of upper respiratory tract infections and does not specifically indicate a progression to airway occlusion in croup. While it contributes to overall respiratory distress, it is not the most critical sign of a life-threatening compromise of the airway in this condition.
Choice B rationale
A harsher cough, often described as a "barking" cough, is a characteristic symptom of croup caused by inflammation of the larynx, trachea, and bronchi. While concerning, it is not the most reliable indicator of impending airway occlusion. The cough may be present throughout the illness without a complete occlusion.
Choice C rationale
An increasing respiratory rate is an early compensatory mechanism in response to airway obstruction and hypoxia. While it indicates respiratory distress, it is not the most significant sign of impending airway occlusion. It can occur with many respiratory issues and is often a precursor to more severe signs.
Choice D rationale
A toddler stating they are tired and wanting to sleep is a serious and late sign of hypoxia. This indicates that the child is becoming fatigued from the increased work of breathing, leading to decreased respiratory effort. This mental status change signals that the body's compensatory mechanisms are failing, and respiratory failure and airway occlusion are imminent.
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