A nurse is assessing a 3-month-old infant whose parents report starting cow's milk feedings 1 week ago. Which of the following actions should the nurse take?

Instruct the parent to give 5 mcg of vitamin D daily.

Instruct the parent to give the infant water every 3 hr between feedings.

Advise the parent to avoid giving cow's milk to the infant prior to 1 year of age.

Recommend the parent mix the milk with rice cereal for feedings.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Instruct the parent to give 5 mcg of vitamin D daily: While vitamin D supplementation is recommended for breastfed infants, this advice does not address the inappropriate introduction of cow’s milk, which can cause complications such as intestinal bleeding and iron deficiency in infants under 12 months.

B. Instruct the parent to give the infant water every 3 hr between feedings: Offering water to infants under 6 months is discouraged, as it can displace essential nutrients from breast milk or formula and increase the risk of water intoxication due to immature kidneys.

C. Advise the parent to avoid giving cow's milk to the infant prior to 1 year of age: Cow's milk is not suitable for infants under 12 months because it lacks adequate iron and nutrients, and its high protein content can irritate the immature kidneys and intestinal lining.

D. Recommend the parent mix the milk with rice cereal for feedings: Mixing cow’s milk with cereal does not resolve its nutritional inadequacy or potential risks. Introducing solids and allergenic foods should follow developmental readiness and established pediatric guidelines.

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Correct Answer is D

Explanation

Rationale:

A. "Every so often, I think about whether or not to have this surgery.": This statement suggests the client is still ambivalent or uncertain, which means informed consent has not yet been fully achieved. Clients must be sure and fully informed before agreeing to proceed.

B. "I will talk with the doctor about my surgery when I get into the operating room.": Informed consent must be obtained well before the procedure begins. Waiting until the operating room is inappropriate, as the client may be under stress or sedation.

C. "Can you tell me more about the surgery I am having?": This indicates the client lacks essential information about the procedure. Informed consent requires that the client already understand the nature, risks, benefits, and alternatives before signing.

D. "Signing this form indicates that I give my permission for the surgery, right?": This reflects an understanding that the consent form gives legal authorization for the procedure. It shows the client knows their signature confirms informed agreement to the surgery.

A. "You should expect your blisters to last up to three weeks." B. "Antiviral medications are most effective if taken within the first 72 hours of symptoms." C. "People who have had chicken pox are at a decreased risk for herpes zoster” D. "Severe pain after the blisters are gone is less common in older adults."

Correct Answer is B

Explanation

Rationale:

A. "You should expect your blisters to last up to three weeks.": Herpes zoster lesions typically last 7 to 10 days, with crusting and healing often occurring within 2 weeks. While some cases may extend slightly longer, stating "up to three weeks" may overgeneralize and mislead.

B. "Antiviral medications are most effective if taken within the first 72 hours of symptoms.": Antiviral drugs like acyclovir or valacyclovir are most effective when initiated within 72 hours of symptom onset. Early treatment reduces severity, duration, and the risk of complications such as postherpetic neuralgia.

C. "People who have had chicken pox are at a decreased risk for herpes zoster.": Herpes zoster occurs due to reactivation of the varicella-zoster virus, which remains dormant after chickenpox. Therefore, individuals who have had chickenpox are actually at increased risk.

D. "Severe pain after the blisters are gone is less common in older adults.": Older adults are more likely to experience postherpetic neuralgia, a complication involving persistent nerve pain after lesions resolve. The risk and severity of this pain increase with age, not decrease.

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A nurse is assessing a 3-month-old infant whose parents report starting cow's milk feedings 1 week ago. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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