# Situation: A 29-year-old office worker has had recurrent crampy lower abdominal pain for 7 months. The pain occurs about twice a week, eases after she passes stool, and comes with looser, more frequent stools; she has had no hard or lumpy stools. She has no fever and no night-time symptoms. She keeps a 5-day food and symptom diary. Day 1: glass of fresh milk at breakfast — bloating and loose stool within 2 hours Day 2: plain yogurt with fruit — no symptoms Day 3: aged hard cheese with rice crackers — no symptoms Day 4: ice cream — bloating, gas, and loose stool within 2 hours Day 5: tea with fresh milk — cramps and loose stool within 2 hours Which conclusion do the entries BEST support?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630486  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 29-year-old office worker has had recurrent crampy lower abdominal pain for 7 months. The pain occurs about twice a week, eases after she passes stool, and comes with looser, more frequent stools; she has had no hard or lumpy stools. She has no fever and no night-time symptoms.

She keeps a 5-day food and symptom diary.
Day 1: glass of fresh milk at breakfast — bloating and loose stool within 2 hours
Day 2: plain yogurt with fruit — no symptoms
Day 3: aged hard cheese with rice crackers — no symptoms
Day 4: ice cream — bloating, gas, and loose stool within 2 hours
Day 5: tea with fresh milk — cramps and loose stool within 2 hours
Which conclusion do the entries BEST support?

## 보기

1. All dairy foods trigger her symptoms, so dairy should be stopped
2. The pattern points to an allergy to the protein in cow's milk
3. Dairy fat is poorly digested and triggers her symptoms
4. High-lactose foods trigger symptoms; yogurt and cheese do not **✔ 정답**

**정답: 4**

## 해설

Symptoms followed fresh milk, ice cream, and milk tea, all high in lactose, but not yogurt or aged hard cheese, which are low in lactose and usually tolerated. This fits lactose intolerance: she can reduce lactose to the amount tolerated and keep calcium intake from tolerated sources.

## 심화 해설

Reading the diary
The diary links symptoms to specific foods. Bloating, gas, cramps, and loose stool appeared within 2 hours after fresh milk, ice cream, and tea with fresh milk. No symptoms followed plain yogurt or aged hard cheese. The foods that caused symptoms are all high in lactose; the tolerated foods are dairy products that are low in lactose. The pattern points to lactose as the trigger, not dairy as a whole.

The mechanism of lactose intolerance
Lactose, the sugar in milk, is digested by the brush-border enzyme lactase in the small intestine. When lactase activity is low, undigested lactose reaches the colon, where it draws water into the bowel by osmosis and is fermented by bacteria, producing gas and short-chain fatty acids. The result is bloating, flatulence, cramps, and loose stools within a few hours of a high-lactose food. Yogurt is tolerated because its live bacteria partly digest the lactose, and aged hard cheese loses most of its lactose during fermentation and ripening.

| Food | Lactose content | Her response |
| --- | --- | --- |
| Fresh milk | High | Bloating, loose stool |
| Ice cream | High | Bloating, gas, loose stool |
| Tea with fresh milk | High | Cramps, loose stool |
| Plain yogurt | Low | No symptoms |
| Aged hard cheese | Very low | No symptoms |

Why the other conclusions are not supported
Stopping all dairy is not supported because she tolerated yogurt and cheese, and removing dairy completely would put her calcium intake at risk. A cow's milk protein allergy is unlikely because yogurt and cheese contain the same milk proteins yet caused no reaction. Dairy fat cannot explain the pattern either: aged hard cheese is high in fat and was tolerated. Watch out! Diary questions are solved by finding what the symptom-producing foods share that the tolerated foods lack.

Exam takeaway
In lactose intolerance, clients reduce lactose to the amount they tolerate rather than eliminating dairy. Options include lactose-free milk, yogurt, aged cheese, taking small portions of milk with meals, and lactase supplements, while keeping calcium and vitamin D intake from tolerated sources. Key point! Symptoms after milk and ice cream but not after yogurt or aged cheese indicate lactose intolerance.

## 임상 시나리오

Lactose Intolerance PatternInterpreting a food and symptom diary
Symptoms within 2 hours of fresh milk, ice cream, and milk tea, all high in lactose, point to lactose intolerance.

Yogurt and aged hard cheese are low in lactose and were tolerated, so milk protein allergy and fat intolerance are not supported.

Reduce lactose to the tolerated amount and keep calcium intake from tolerated foods such as yogurt, cheese, and lactose-free milk.

CautionEliminating all dairy is unnecessary and can lower calcium intake.

## 핵심 개념

- **Lactose intolerance** — Digestive symptoms after lactose intake caused by reduced lactase activity in the small intestine.
- **Lactase** — The small-intestinal brush-border enzyme that splits lactose into glucose and galactose.
- **Cow's milk protein allergy** — An immune reaction to milk proteins that occurs with any food containing those proteins.
- **Osmotic diarrhea** — Diarrhea caused by unabsorbed substances drawing water into the bowel.

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