A nurse is caring for a toddler who drinks 946 mL (32 oz) of whole milk per day and has a poor appetite. The nurse should identify the toddler as being at risk for which of the following conditions?
Iron deficiency anemia
Vitamin A toxicity
Impaired carbohydrate metabolism
Lactose intolerance
The Correct Answer is A
A. Iron deficiency anemia: Whole milk is a poor source of iron, and excessive consumption of whole milk can displace iron-rich foods from the diet. Therefore, a toddler who consumes a large amount of whole milk and has a poor appetite is at risk for iron deficiency anemia due to inadequate iron intake. Iron deficiency anemia is characterized by low levels of iron in the body, leading to decreased production of red blood cells and impaired oxygen transport.
B. Vitamin A toxicity: While excessive intake of vitamin A can lead to toxicity, it is unlikely to occur from consuming whole milk alone. Vitamin A toxicity is more commonly associated with excessive intake of vitamin A supplements or foods that are rich in preformed vitamin A, such as liver. Therefore, vitamin A toxicity is not a significant risk for a toddler who drinks whole milk.
C. Impaired carbohydrate metabolism: There is no direct relationship between whole milk consumption and impaired carbohydrate metabolism. Impaired carbohydrate metabolism is typically associated with conditions such as diabetes mellitus or metabolic syndrome, rather than dietary factors like milk consumption.
D. Lactose intolerance: Lactose intolerance is the inability to digest lactose, the sugar found in milk and dairy products, due to a deficiency of the enzyme lactase. While excessive consumption of whole milk may exacerbate symptoms in a child with lactose intolerance, it is not a risk factor for developing lactose intolerance itself. Lactose intolerance is more commonly observed in individuals of certain ethnic backgrounds or those with a genetic predisposition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Apply a dry gauze dressing twice per day."
This instruction may not be necessary for a hypospadias repair procedure. Typically, the surgical site will have a dressing applied immediately after the surgery, but ongoing dressing changes may not be required once the infant is discharged. It's essential to follow the specific postoperative care plan provided by the healthcare provider.
B. "Perform hourly measurements of the infant's urinary output."
Hourly measurements of urinary output may not be necessary unless specifically instructed by the healthcare provider due to concerns such as urinary retention or dehydration. However, regular monitoring of urinary output as part of routine care may be appropriate.
C. "Offer the infant 12 to 18 ounces of fruit juice daily."
Offering 12 to 18 ounces of fruit juice daily to a 6-month-old infant is not recommended. Introduction of fruit juice should be gradual and in small amounts, following guidance from healthcare providers and infant nutrition guidelines. Excessive fruit juice consumption can lead to gastrointestinal issues and may not be suitable for all infants.
D. "Avoid giving the infant a tub bath until the stent is removed."
This instruction is appropriate. After hypospadias repair surgery, a stent or catheter may be placed to aid in healing and ensure proper urine drainage. It's essential to follow healthcare provider instructions regarding bathing and hygiene to minimize the risk of infection and to ensure the stent remains in place until it is ready to be removed.
Correct Answer is A
Explanation
A. Report of diplopia
Diplopia, or double vision, can be a symptom of increased intracranial pressure (ICP) due to its effects on cranial nerve function. Therefore, it is a manifestation that the nurse should recognize as indicating the presence of increased ICP.
B. Hyperactivity
Hyperactivity is not typically associated with increased ICP. Instead, manifestations of increased ICP often include altered level of consciousness, lethargy, or even coma.
C. Nuchal rigidity
Nuchal rigidity, or stiffness in the neck, is not a direct manifestation of increased ICP. It is more commonly associated with meningitis or other conditions affecting the meninges.
D. Report of sore throat
A sore throat is not typically associated with increased ICP unless it is related to complications such as pharyngeal injury or infection.
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