A nurse is collecting data from the guardian of a toddler during a well-child visit. The guardian expresses concern to the nurse because his child has a poor appetite, but drinks a quart of milk each day. The nurse should identify that this practice places the toddler at risk for which of the following conditions?
Celiac disease
Lactose intolerance
Acute renal failure
Iron-deficiency anemia
The Correct Answer is D
A. Celiac disease: Celiac disease is an autoimmune disorder triggered by gluten ingestion that damages the small intestine and impairs nutrient absorption. While it can cause poor appetite and growth issues, high milk intake alone does not cause or increase the risk for celiac disease. Diagnosis is based on genetic susceptibility and gluten exposure, not dietary patterns.
B. Lactose intolerance: Lactose intolerance results from deficiency of lactase, leading to diarrhea, bloating, and abdominal discomfort after dairy consumption. Drinking large amounts of milk may exacerbate symptoms if the child is lactose intolerant, but intolerance is not caused solely by high milk intake.
C. Acute renal failure: Acute renal failure is typically caused by severe dehydration, infection, toxins, or obstruction and is not related to high milk intake in a toddler. Daily consumption of milk, even in large quantities, does not precipitate acute renal failure in a healthy child.
D. Iron-deficiency anemia: Excessive milk intake can displace iron-rich foods from the toddler’s diet and interfere with iron absorption, increasing the risk for iron-deficiency anemia. Milk is low in iron, and consuming more than 24 ounces per day can contribute to inadequate dietary iron intake and subsequent anemia in toddlers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "You should verify the identity of anyone who wants to remove your baby from the room.": Parents should confirm the identity and role of anyone attempting to take the newborn to prevent abduction or misidentification. Verifying identification badges and following hospital protocols for infant security is a critical safety measure in the maternal-newborn unit.
B. "You can leave your baby in your room while you walk in the hallway.": Newborns should never be left unattended, even briefly, due to the risk of falls, accidental injury, or abduction. Continuous supervision by a parent or staff member is required at all times.
C. "Your baby should have one identification band on either their right arm or right leg.": Standard newborn safety procedures require two identification bands—one on the wrist and one on the ankle—to ensure correct identification. A single band is insufficient for reliable infant security.
D. "You can leave the unit with your baby as long as you notify the nurse.": Leaving the unit with a newborn without following strict security protocols, including escort and verification, is prohibited. Unauthorized movement of the infant could compromise safety and breach hospital security policies.
Correct Answer is B
Explanation
A. Discontinue the enema: Mild cramping is a common response during enema administration and does not require stopping the procedure. Discontinuing unnecessarily would prevent the client from receiving the intended therapeutic effect.
B. Slow the rate of instillation: Cramping often occurs when the solution enters the rectum too quickly. Slowing the rate allows the colon to accommodate the fluid more comfortably, reducing discomfort while continuing the enema safely and effectively.
C. Ask the client to hold his breath until the cramping passes: Holding the breath does not relieve rectal cramping and may increase client discomfort or anxiety. Comfort measures should focus on adjusting the procedure rather than altering breathing inappropriately.
D. Pause the enema to administer pain medication to the client: Administering systemic pain medication is unnecessary for mild, transient cramping. Slowing the enema is sufficient to manage discomfort, and pausing for medication would unnecessarily delay treatment.
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