A nurse is providing anticipatory guidance to a client who has phenylketonuria (PKU) and is planning a pregnancy. Which of the following information should the nurse include in the discussion?
A low-protein diet should be followed for 3 months prior to conception.
Serum bilirubin should be monitored one to two times per month during pregnancy.
Diet sodas should not be consumed more than two or three times per week.
Breastfeeding will prevent your baby from developing PKU.
The Correct Answer is A
Choice A reason: A low-protein diet is essential for clients who have PKU, as they cannot metabolize the amino acid phenylalanine. High levels of phenylalanine can cause intellectual disability and other neurological problems. A low-protein diet should be started before pregnancy and maintained throughout pregnancy to prevent fetal harm.
Choice B reason: Serum bilirubin is not related to PKU. It is a product of red blood cell breakdown and is elevated in conditions such as jaundice, liver disease, or hemolytic anemia. It does not need to be monitored routinely in clients who have PKU.
Choice C reason: Diet sodas are not recommended for clients who have PKU, as they often contain artificial sweeteners such as aspartame, which is a source of phenylalanine. Diet sodas should be avoided completely or consumed very sparingly by clients who have PKU.
Choice D reason: Breastfeeding will not prevent the baby from developing PKU, as PKU is a genetic disorder that is inherited from both parents. If both parents have PKU, the baby will have a 100% chance of having PKU. If one parent has PKU and the other is a carrier, the baby will have a 50% chance of having PKU. If one parent has PKU and the other is not a carrier, the baby will not have PKU but will be a carrier. Breastfeeding may provide some benefits for the baby, such as immunity and bonding, but it will not affect the baby's PKU status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Confusion and weakness are signs of dehydration and electrolyte imbalance, which can result from vomiting and diarrhea. These are serious complications that can affect the client's mental status, blood pressure, heart rate, and kidney function. The nurse should report these findings to the provider and monitor the client's vital signs and fluid status.
Choice B reason: Dry oral mucosa and furrowed tongue are also signs of dehydration, but they are less severe than confusion and weakness. The nurse should report these findings to the provider as well, but they are not the most urgent ones.
Choice C reason: A temperature of 37.4° C (99.3° F) is slightly elevated, but not indicative of a fever or infection. The nurse should document this finding, but it does not require immediate follow-up.
Choice D reason: A blood pressure of 90/58 mm Hg is low, but not hypotensive. The nurse should document this finding, but it does not require immediate follow-up.
Correct Answer is C
Explanation
Choice A reason: Hypernatremia is not a sign of water intoxication, but rather the opposite condition. Hypernatremia means high sodium levels in the blood, which can occur when the body loses more water than sodium, such as in dehydration, diabetes insipidus, or excessive salt intake. Water intoxication causes hyponatremia, which means low sodium levels in the blood, due to excessive water intake or retention.
Choice B reason: Weak pulses are not a specific sign of water intoxication, but rather a general sign of poor perfusion or circulation. Weak pulses can have many causes, such as hypotension, shock, heart failure, or peripheral vascular disease. Water intoxication can cause hypotension, but it can also cause hypertension, depending on the volume status of the client.
Choice C reason: Muscle weakness is a sign of water intoxication, as it reflects the effect of low sodium levels on the neuromuscular system. Sodium is essential for nerve and muscle function, as it helps generate electrical impulses and contractions. When sodium levels drop too low, the nerves and muscles become less responsive and weaker. Other signs of water intoxication affecting the nervous system include confusion, headache, seizures, and coma.
Choice D reason: Exaggerated reflexes are not a sign of water intoxication, but rather a sign of hyperreflexia, which is a condition of overactive reflexes. Hyperreflexia can have many causes, such as spinal cord injury, stroke, multiple sclerosis, or electrolyte imbalance. Water intoxication can cause electrolyte imbalance, but it usually leads to hyporeflexia, which is a condition of reduced or absent reflexes.
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