A nurse on a pediatric unit is caring for a toddler who has poor dietary intake. Which of the following actions should the nurse take first?

A. Recurring urinary tract infections. Chronic infections act as internal stressors because they arise from within the body, leading to physical discomfort and emotional strain. While they can contribute to stress, they do not originate from an external source, such as environmental or situational factors.
B. Report of feeling depressed. Depression is an internal emotional state rather than an external stressor. Although it can be triggered by external events, depression itself comes from psychological and physiological processes within the individual rather than from outside influences.
C. Lack of nutritional knowledge. Limited knowledge about nutrition is an internal factor affecting decision-making rather than an external stressor. External stressors involve changes in one's environment or circumstances that create pressure, whereas knowledge gaps influence behavior but do not directly impose stress from an outside source.
D. A recent move to a new city. Moving to a new city is an external stressor as it involves environmental change, social adaptation, and logistical challenges. Adjusting to a new home, job, or social network can be overwhelming, increasing stress levels due to uncertainty, unfamiliar surroundings, and the need for adjustment.

Rationale for Correct Options:

• Yellowing of the eyes: Indicates hepatotoxicity, a serious adverse effect of isoniazid, rifampin, and pyrazinamide. These drugs can cause liver damage, leading to jaundice, which presents as yellowing of the eyes and skin. Liver function tests should be monitored closely.
• Blurred vision: Can result from optic neuritis, a known adverse effect of ethambutol. Ethambutol can damage the optic nerve, causing visual disturbances, including decreased visual acuity and color blindness. Patients should undergo routine eye exams.
• Abdominal pain: May indicate hepatotoxicity from TB medications, particularly isoniazid, rifampin, and pyrazinamide. Liver inflammation or damage can manifest as right upper quadrant pain, nausea, and loss of appetite. Monitoring liver enzymes is essential.
• Increased bruising: Can result from thrombocytopenia, a hematologic side effect of rifampin. Rifampin can suppress bone marrow function, leading to reduced platelet production, increasing the risk of spontaneous bruising and prolonged bleeding.
• Increased bleeding tendency: Suggests liver dysfunction, as the liver is responsible for producing clotting factors. Rifampin-induced hepatotoxicity can impair clotting mechanisms, increasing the risk of excessive bleeding from minor injuries.
• Darkening of the urine: A common but harmless side effect of rifampin. Rifampin is excreted in bodily fluids, causing orange or red discoloration of urine, sweat, and tears. Patients should be educated on this expected effect to prevent unnecessary concern.

Rationale for Incorrect Options:

• Dry eyes: Not associated with TB medications and may be due to environmental factors or dehydration.
• Weight gain: Unlikely with TB treatment, as these medications typically cause weight loss rather than weight gain.
• Insomnia: Not a significant adverse effect of first-line TB drugs and may be related to the client’s illness or other factors.
• Urinary frequency: Not a common reaction to TB medications, as these drugs do not significantly affect renal function or bladder activity.