A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, 'I don't understand why my child is so upset. I've never seen my child act this way around others before.' Which of the following statements should the nurse make?

Correct Answer: A

Rationale: The correct answer is 'This is a normal, expected reaction for a child of this age.' Separation anxiety typically peaks around 8-10 months of age, leading to distress when separated from caregivers. Choice B is incorrect because the infant's behavior is more likely due to separation anxiety rather than overstimulation. Choice C is incorrect as the infant's behavior is not related to overexposure to caregivers but rather a natural developmental stage. Choice D is incorrect as the infant's behavior is not indicative of illness but rather a normal emotional response.

Correct Answer: C

Rationale: The correct answer is Lettuce. Lettuce has the highest percentage of water by weight among the options provided, making it an excellent choice to increase fluid intake. Yogurt and milk have some water content but are not as high in water percentage as lettuce. Honey, on the other hand, contains very little water and is not a good choice for increasing fluid intake.

Correct Answer: B

Rationale: Among the indicators of nutritional risk among adolescents, skipping meals, eating without family supervision, and frequently skipping breakfast are commonly associated with poor nutrition. However, eating fast food once weekly may not necessarily indicate a significant nutritional risk, as occasional consumption of fast food in moderation is not uncommon among adolescents. This choice is the correct answer because it does not strongly correlate with nutritional risk compared to the other options provided.

Correct Answer: B

Rationale: In caring for a client receiving parenteral nutrition, it is important to follow proper guidelines to ensure safety and effectiveness. Unused parenteral nutrition should be removed after 24 hours, not 12 hours, to prevent contamination and reduce the risk of infection. Option A is correct as it ensures the solution is at room temperature before infusion. Option C is essential for monitoring the client's response to parenteral nutrition. Option D is important to maintain the correct flow rate and adjust it as needed. Therefore, option B is the incorrect choice among the options provided.

Correct Answer: B

Rationale: The nurse should recommend brewed iced tea as it generally contains less caffeine compared to other choices. Lemon-lime soda, diet cola, and chocolate milk all contain caffeine, which can contribute to sleep disturbances. Lemon-lime soda and diet cola are carbonated beverages that typically contain caffeine unless specified as caffeine-free. Chocolate milk also contains caffeine due to the cocoa content. Therefore, brewed iced tea is the most suitable choice to reduce caffeine intake and improve sleep quality.

Correct Answer: C

Rationale: During the second trimester of pregnancy, it is recommended that a client increases their caloric intake by around 340 calories per day to support the growing needs of both the mother and the developing fetus. This additional intake helps ensure the proper nutrition and energy levels required during this crucial stage of pregnancy. Option A (110 cal/day) is too low to meet the increased demands. Option B (225 cal/day) is also below the recommended amount. Option D (450 cal/day) is higher than necessary and could lead to excessive weight gain, which is not ideal during pregnancy.

Correct Answer: C

Rationale: Exposure to sunlight is the trigger for the formation of vitamin D in the body. When the skin is exposed to sunlight, it produces vitamin D. This process is essential for maintaining healthy levels of vitamin D in the body. Calcium (Choice A) is important for bone health but is not the trigger for vitamin D formation. Vitamin A depletion (Choice B) does not directly trigger the formation of vitamin D. Weight-bearing exercise (Choice D) is crucial for bone health but is not directly related to the formation of vitamin D.

Correct Answer: D

Rationale: In a client with cirrhosis and ascites, decreasing carbohydrate intake is essential as it helps reduce the production of ascitic fluid. Excess carbohydrates can lead to fluid retention. Choices A, B, and C are incorrect. Decreasing fluid intake can worsen dehydration, increasing saturated fat intake is not recommended due to its impact on liver health, and increasing sodium intake can worsen fluid retention and exacerbate ascites in these clients.

Correct Answer: D

Rationale: Orange juice is high in potassium and should be avoided in a low-potassium diet. Butter, poultry, and yogurt are low-potassium food choices and can be included in a low-potassium diet. Poultry is a good source of lean protein, yogurt is a good source of calcium and protein, and butter is low in potassium. Therefore, the nurse should instruct the client to avoid orange juice as it is high in potassium, which is not suitable for a low-potassium diet.