CHAPTER 60: CARE OF PATIENTS WITH MALNUTRITION AND OBESITY REVIEW QUESTIONS

20. A facility is beginning to perform bariatric surgery on obese clients. Which action by the nursing manager is most important? a. Obtain appropriately sized equipment for these clients. b. Select a dedicated group of staff members for these clients. c. Send personnel to sensitivity training as part of orientation. d. Establish multidisciplinary rounding for clients in this program.

ANS: A All actions might be appropriate and helpful in the care of bariatric clients. However, staff and client safety is a unique priority when working with this group of clients. The manager must ensure appropriately sized equipment, so that neither staff nor clients injure themselves.

10. A client who is malnourished has a total lymphocyte count of 1450/mm3. Which instruction does the nurse provide to the unlicensed assistive personnel helping to care for this client? a. "Wash your hands or use hand foam when you first enter the room." b. "Be sure to offer this client a glass of water each time you are with the client." c. "You may need to open cartons and packages on the client's food tray." d. "Record all of the client's food and drink intake for the shift."

ANS: A Clients who are malnourished often have a low total lymphocyte count, which puts them at higher risk for infection. The nurse should emphasize good hand hygiene. The other interventions may be appropriate depending on client needs, but good hand hygiene would be the priority.

14. The nurse is caring for an overweight client who gained 10 pounds during the previous 2 weeks. The client states that she is hungry all the time and doesn't understand why. Which assessment finding could explain the client's weight gain and hunger? a. The client started taking dexamethasone (Decadron) daily. b. The client started taking naproxen sodium (Naprosyn) daily. c. The client's glycosylated hemoglobin level is 6%. d. The client's thyroxine (T4) level is 8 mcg/dL.

ANS: A Dexamethasone is a corticosteroid. These drugs alter carbohydrate, protein, and lipid metabolism, predisposing the client to obesity when taken on a long-term basis. In addition, corticosteroids increase the client's appetite. Naprosyn is an NSAID, which can lead to gastric upset and ulceration and decreased appetite and weight loss. The client's glycosylated hemoglobin and thyroid levels are within normal limits and would not explain the hunger and weight gain.

5. The nurse is reviewing recent laboratory values for a client who is being treated for malnutrition. Which laboratory finding indicates that the client is not receiving adequate iron supplementation? a. Hematocrit, 31% b. Serum albumin, 3.5 g/dL c. Creatine phosphokinase (CPK), 55 U/mL d. Erythrocyte sedimentation rate (ESR), 15.8 mm/hr

ANS: A Hematocrit is an indicator of iron status. Low hematocrit may indicate that the client has not received enough iron supplementation and remains anemic. Serum albumin indicates protein intake and CPK is a measure of muscle injury. An elevated ESR indicates inflammation.

3. The nurse is caring for a client who is a vegan and has developed B12 deficiency. Which foods does the nurse encourage the client to include in the diet? a. Fortified cereals and tofu b. Pumpkin seeds and blackstrap molasses c. Kale, spinach, and whole grain bread d. Strawberries and sweet red peppers

ANS: A Megaloblastic anemia is caused by lack of folic acid and vitamin B12 in the diet. Vegans are susceptible to this and need to include fortified cereals, soy beverages, or meat substitutes in their diets. The other foods listed are not good sources of folic acid and vitamin B12.

13. The postanesthesia care nurse is caring for a client who had gastric banding surgery and was extubated an hour ago. The client's blood gases are as follows: pH, 7.22; HCO3- 21 mEq/L; PCO2, 65 mm Hg; and PO2, 58 mm Hg. Which is the priority action by the nurse? a. Assess the client's airway. b. Increase the client's oxygen flow rate. c. Check the client's oxygen saturation level. d. Document findings in the client's chart.

ANS: A Obese clients are at higher risk for hypoventilation. The arterial blood gas values indicate acute respiratory acidosis with hypoxia. The client needs oxygen. However, if the airway is not patent, increasing the oxygen flow rate will be of minimal benefit. The first action is to ensure a patent airway and then apply oxygen, notify the physician, and document events. The client may need to be re-intubated and mechanically ventilated. Checking the client's oxygen saturation level will provide no additional information about the client's oxygenation status.

18. A severely malnourished client was started on enteral feedings. The following day, the client is confused, has a heart rate of 112 beats/min, and reports feeling weak. Which laboratory value does the nurse correlate with this condition? a. Serum phosphate, 1.8 mg/dL b. Serum potassium, 3.1 mEq/L c. Serum sodium, 143 mEq/L d. Serum glucose, 110 mg/dL

ANS: A This client has refeeding syndrome, which is caused primarily by hypophosphatemia. The serum phosphate level is low. The potassium is slightly low, but this is not related. The sodium is normal, and the glucose is not related.

3. When reviewing an older client's medical record, which findings lead the nurse to perform a nutrition assessment? (Select all that apply.) a. Widow/widower status b. Chronic constipation c. History of depression d. Random blood sugar level of 198 mg/dL e. Cholecystectomy 4 years ago f. Inability to afford a new pair of glasses

ANS: A, B, C, F Many factors contribute to malnutrition in older clients. Depression and loneliness from the loss of a spouse; constipation; poor eyesight; chronic medical problems, including depression; and taking prescription and/or over-the-counter medications can contribute to malnutrition. Blood glucose levels and a previous cholecystectomy would not necessarily contribute.

1. A client is malnourished and needs encouragement and assistance to eat. Which activities does the nurse delegate to the unlicensed assistive personnel (UAP) when giving this client a food tray? (Select all that apply.) a. Open food packages and cut food if needed. b. Remove the urinal from the bedside table. c. Assess the client's ability to swallow. d. Report to the nurse pain described by the client. e. Sit with the client and do not rush the feeding.

ANS: A, B, D, E When assisting or encouraging a client to eat, appropriate activities include opening food packages and cutting food if needed; removing urinals and bedpans, or other offensive objects, from the immediate area; reporting complaints of pain so it can be treated; and sitting with the client without rushing the client to finish the meal. Only the nurse can assess for swallowing, although the UAP should report choking episodes or coughing.

12. Which statement indicates that the client needs additional discharge teaching after gastric bypass surgery? a. "I hope my type 2 diabetes is cured and I won't need insulin anymore." b. "As soon as I get home, I'm going to enjoy a nice bowl of fruit." c. "If I get nauseated, I know I'm eating too much at one time." d. "I will be sure to report any back, shoulder, or abdominal pain."

ANS: B After gastric bypass surgery, clients are limited to fluids and pureed foods for about 6 weeks. Then the client can progress to a more normal diet. Eating fruit right after discharge would not be recommended. The other statements indicate good understanding.

11. Which client is at highest risk for developing dehydration and hypernatremia as a result of enteral feedings? a. Client receiving an isotonic enteral feeding solution and an IV of D5W (dextrose 5% in water) at 83 mL/hr b. Client receiving a hypertonic enteral feeding solution and an IV of normal saline (0.9 NS) at 125 mL/hr c. Client who can drink liquids and is receiving a supplemental hypertonic enteral feeding solution d. Client receiving a hypertonic enteral feeding solution and an IV of 0.45% NS (0.45 NS) infusing at 125 mL/hr

ANS: B Hypertonic enteral tube feedings can easily lead to dehydration and hypernatremia if not balanced with hypotonic IV solution. D5W and 0.45 NS are hypotonic solutions. A client with hypertonic feedings who can drink liquids should have enough oral fluid intake to prevent dehydration and hypernatremia. The client receiving both a hypertonic enteral feeding and an isotonic IV solution would be at highest risk.

15. The nurse is caring for an obese client who will be taking orlistat (Xenical) to help her lose weight. Which statement indicates that the client understands teaching about orlistat? a. "This medication will help speed up my metabolism." b. "I may have loose stools after meals if I eat too much fat." c. "This medication will suppress my appetite so I won't be hungry." d. "This medication will make me feel full after I eat small amounts."

ANS: B Orlistat (Xenical) inhibits lipase, leading to partial hydrolysis of triglycerides. Fats are only partially digested and absorbed and are excreted in the feces. The client may experience nausea, cramps, and loose stools when fats are increased in the diet. Orlistat does not increase metabolism, suppress appetite, or make the client feel full after small meals.

19. A client has a small-bore nasoenteric feeding tube. The nurse assesses the following vital signs: temperature, 100.2° F (37.8° C); pulse, 112 beats/min; respiratory rate, 22 breaths/min; and blood pressure, 106/62 mm Hg. Which action by the nurse takes priority? a. Remove the tube immediately and notify the heath care provider. b. Auscultate lung sounds and obtain oxygen saturation. c. Add blue dye to the feeding tube formula. d. Auscultate bowel sounds and slow the feeding down.

ANS: B The client may have aspirated. The nurse should further assess the client's respiratory and oxygenation status. The client may have another reason for the abnormal vital signs, so the nurse should not pull out the tube before performing other assessments. Adding blue dye to the tube feeding formula is not recommended to check for aspiration. Slowing the feeding down will not be helpful.

2. The nurse is teaching a health promotion class about weight loss and asks students to list health risks that can occur as a result of obesity. Which student responses indicate that additional teaching is required? (Select all that apply.) a. Sleep apnea b. Infertility c. Rheumatoid arthritis d. Cervical cancer e. Cholecystitis f. Hypothyroidism

ANS: B, C, D, F Sleep apnea and cholecystitis are potential health risks that can occur as a result of obesity. The other conditions are not caused by obesity.

17. The new nursing supervisor at a long-term care facility is concerned about the number of residents who appear malnourished. Which action by the nurse is best? a. Institute daily weighing for at-risk or underweight residents. b. Provide a supply of easy to access high-calorie snacks. c. Ask dining room personnel about residents coughing at meals. d. Assess the residents' opinions on the quality of food served.

ANS: C All actions would be helpful. However, because unrecognized dysphagia is common among older clients, the nurse should first assess for this. Weighing residents, providing snacks, and assessing their opinions on the quality of food will not be helpful if at-risk residents cannot swallow.

4. The nurse is caring for a client who has a new small-bore nasoduodenal tube for feedings. Which intervention most effectively prevents clogging of the tube? a. Administering medications that have been thoroughly crushed and dissolved in cold water b. Flushing the feeding tube with 60 mL of cranberry juice or carbonated beverage four times daily c. Irrigating the tube with water before and after administration of medications using 20 to 30 mL d. Diluting the tube feeding to half-strength with cold water before infusion into the feeding tube

ANS: C Irrigating the feeding tube with 20 to 30 mL of warm water before and after medication administration will help maintain patency of the tube. Irrigation with cranberry juice or carbonated beverages is not recommended. Administration of only liquid medications (not crushed and dissolved in liquid) through the tube will help prevent clogging. Dilution of tube feeding should not be done without an order from the provider.

6. The nurse is caring for a client on a limited income who has been diagnosed with kwashiorkor. Which foods does the nurse suggest to improve the client's nutritional status with minimal increase in food costs? a. Oatmeal and bananas b. Tomato soup with oyster crackers c. Omelet made with cheddar cheese d. Whole wheat pasta with tomato sauce

ANS: C Kwashiorkor develops as a result of lack of protein intake despite adequate calories. The client needs to increase protein-containing foods. Eggs and cheese are high-protein foods that are less expensive than meats. Pasta, vegetables, fruit, and oatmeal have less protein than eggs and cheese.

16. Which dietary adjustments does the nurse recommend to an older adult client asking what changes she should institute to prevent or manage constipation? a. "Increase your calcium intake." b. "Limit your fluid intake." c. "Include plenty of fiber." d. "Take a laxative with every meal."

ANS: C Older adults are prone to constipation. To manage or prevent constipation, teach the older client to drink eight glasses of water daily and to take in plenty of fiber. These guidelines are good for other clients as well. The other suggestions will not prevent or help manage constipation.

2. The nurse is caring for a male client who is 6 feet, 1 inch tall and weighs 215 pounds. The client asks the nurse if his weight is appropriate for his height. Which is the nurse's best response? a. "Your weight is just about right for someone your height." b. "Your weight is a few pounds under the ideal for your height." c. "Your weight is a few pounds over the ideal for your height." d. "Your weight is quite a few pounds over the ideal for your height."

ANS: C The client's BMI is 28.4, indicating that the client is overweight. However, he is not obese. The nurse should not state that the client's weight is just about right, a few pounds under, or quite a bit over the ideal weight for his height.

9. The nurse is caring for an anorexic client who is severely malnourished. A nasogastric feeding tube is inserted, and tube feedings are started. Which laboratory finding is the best indication that the client's nutritional status is improving? a. Sodium has risen from 130 to 144 mg/dL. b. Creatinine has dropped from 1.9 to 0.5 mg/dL. c. Prealbumin level has risen from 9 to 13 mg/dL. d. Blood urea nitrogen (BUN) level has dropped from 15 to 11 mg/dL.

ANS: C The prealbumin level is a good measure of nutritional status because its half-life is only 2 days, so it reflects current nutritional status. The client's prealbumin level is rising and almost normal, indicating that the client's nutritional status is improving. The other laboratory values are more reflective of fluid balance and kidney function.

8. The nurse is caring for a client who was started on total parenteral nutrition (TPN) 2 days previously. The client reports blurred vision, dry mouth, and frequent urination. Which is the nurse's priority action? a. Weigh the client. b. Assess the client's vital signs. c. Slow down the TPN infusion. d. Assess the client's blood sugar.

ANS: D Dry mouth, frequent urination, and blurred vision all are symptoms of hyperglycemia, a potential complication of TPN infusion. The nurse should assess the client's blood sugar level. Weighing the client and checking vital signs will not help with assessment of hyperglycemia. The nurse should obtain an order from the provider to slow the TPN solution.

1. The nurse is caring for a female client who is 5 feet, 7 inches tall and weighs 115 pounds. The client asks the nurse if she needs to lose weight. Which response by the nurse is best? a. "Yes. Your body mass index suggests you are slightly overweight." b. "Maybe. Let's look at your risks for cardiovascular disease." c. "Your weight is just fine. Don't worry about it." d. "No. In fact, your body mass index suggests that you are already underweight."

ANS: D The client's body mass index (BMI) is 18.0, so she is already underweight. It is inaccurate to tell the client she is overweight, and it is unnecessary to consider her weight in light of any cardiovascular risk factors. The nurse should not reassure the client that her weight is just fine because she is underweight.

7. The nurse is preparing to administer tube feedings through a client's new Salem sump nasogastric tube. The nurse is unable to withdraw any fluid from the tube before starting the feeding. Which is the priority action of the nurse? a. Start the tube feeding as ordered and check the residual in 30 minutes. b. Inject air into the nasogastric tube while auscultating the client's epigastric area. c. Lower the head of the client's bed and attempt to aspirate fluid again. d. Obtain orders for a chest x-ray to confirm placement before starting the feeding.

ANS: D The nurse must verify tube placement before beginning any tube feeding or administering any medications through a tube. The most accurate way to determine placement is via chest x-ray. The nurse could cause the client to aspirate if she or he started the feeding then checked later for placement. Insufflation does not provide accurate results and should not be used to verify tube placement. The nurse must keep the client's head elevated at least 30 degrees.