The nurse prepares dietary teaching for the family of a child with phenylketonuria (PKU) disease. What needs of the child should the nurse emphasize with the parents?
a. Daily vitamin supplements
b. Foods that have very little phenylalanine
c. Foods with high biologic protein every day
d. A combination of complete and incomplete proteins every day
b. Foods that have very little phenylalanine
PKU disease occurs when there is a deficiency of the phenylalanine hydroxylase enzyme. Untreated, it leads to cognitive delays and other health problems. These children must avoid foods with phenylalanine. Phenylalanine is part of protein; therefore, protein intake from any source must be limited. Vitamins are not protein.
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The nurse caring for a patient with an endotracheal tube recognizes which of the following as one of their greatest disadvantages?
A) Mobility is limited. B) The patient is unable to speak. C) They require oxygen support. D) The cough reflex is depressed.
Which finding would the nurse expect when assessing a full thickness wound?
A) Dermis remains intact. B) Epidermis remains intact. C) Epidermis and full thickness of dermis is destroyed. D) Only epidermis is destroyed.
A pregnant woman at 25 weeks of gestation told the nurse that she dropped a pan last week and her baby jumped at the noise. Which of the following responses by the nurse is most ac-curate?
1. "That must have been a coincidence; babies cannot respond like that.". 2. "The fetus is demonstrating the aural reflex.". 3. "Babies respond to sound starting at about 24 weeks of gestation.". 4. "Let me know if it happens again; we need to report that to your midwife.".
The nurse is caring for a patient recovering in the PACU. The patient awakens confused and disoriented. What action should the nurse take first?
a. Take the patient's vital signs. b. Encourage the patient to return to sleep. c. Reorient and reassure the patient. d. Document that the patient is awake and disoriented.