Explanation
(A) The infant has not ingested any protein immediately after birth, which is necessary to detect excessive serum phenylalanine. (B) It is important that the infant take in 2-3 full days of milk or formula feedings to preclude a false-negative reading. (C) At 2-3 days of age, inadequate milk could have been ingested owing to a delay in the initial feeding. (D) The biochemical buildup of serum phenylalanine is detectable after 2-3 days of milk or formula ingestion.

Section: Questions Set D
Explanation:
(A) Children experience impatience with soiled diapers when readiness for training is apparent. They often desire to be changed immediately. (B) A child must be able to use verbal or nonverbal skills to communicate needs. (C) A readiness indicator would be awaking dry from naps. (D) The age at which a sibling was toilet trained has no implications for training this child.

Explanation
(A) Tachypnea is not a symptom. (B) Circumoral pallor is not a symptom. (C) Autonomic dysreflexia is an uninhibited and exaggerated reflex of the autonomic nervous system to stimulation, which results in vasoconstriction and elevated blood pressure. (D) Pallor and itching are not symptoms.

Explanation/Reference:
Explanation:
(A) A tension pneumothorax is an accumulation of air in the pleural space. Important physical assessment findings to confirm this condition include cyanosis, jugular vein distention, absent breath sounds on the affected side, distant heart sounds, and lowered blood pressure. (B) Asthma is a disorder in which there is an airflow obstruction in the bronchioles and smaller bronchi secondary to bronchospasm, swelling of mucous membranes, and increased mucus production.Physical assessment reveals some important findings: agitation, nasal flaring, tachypnea, and expiratory wheezing. (C) Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung in the alveolar and interstitial tissue and results in consolidation. Specific assessment findings to confirm this condition include decreased chest expansion caused by pleuritic pain, dullness on percussion over consolidated areas, decreased breath sounds, and increased vocal fremitus. (D) A pulmonary embolus is the passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into the pulmonary artery or its branches, with subsequent obstruction of blood supply to lung tissue. Specific assessment findings that confirm this condition include tachypnea, tachycardia, crackles (rales), transient friction rub, diaphoresis, edema, and cyanosis.

(A) Allowing him to eat late is not a solution to the problem because the ritual affects more than just this meal. (B) He is helpless to change this behavior because the rituals occur as a result of an irrational effort to control his anxiety. (C) To interfere with the ritual will increase anxiety. Until the basic problem is resolved, and in turn his need for the ritual relieved, arrange the schedule so that essential activities may be included (such as meals with the group). (D) This approach would be very disruptive to the other clients and would not serve to relieve the anxiety of the client.