Med-Surg Chapter 39: Nutrition

Which disorder is associated with swollen salivary glands and macerated knuckles?

Bulimia nervosa Rationale: A patient with bulimia nervosa has loss of control related to eating and a persistent concern with body image. The patient exhibits dental problems, broken blood vessels in the eyes, swollen salivary glands, and macerated knuckles. Anorexia nervosa is characterized by self-imposed weight loss. Hair loss, constipation, yellow skin, and sensitivity to cold are the signs of anorexia nervosa. Binge-eating disorder is less severe than bulimia nervosa. A patient with binge-eating disorder is generally overweight or obese. Malabsorption syndrome refers to impaired absorption of nutrients from the gastrointestinal tract. It is associated with frequent episodes of disease in the patient.

A patient receives a prescription for central parenteral nutrition (PN) therapy. Which principle should guide the nurse's administration of the patient's nutrition?

Central PN must be infused in a large central vein so rapid dilution can occur. Rationale: Central PN must be infused in a large central vein so rapid dilution can occur. Central PN is indicated when protein and caloric requirements are high. Central PN solutions are hypertonic, measuring at least 1600 mOsm/L. The glucose content ranges from 20% to 50%.

A patient who is receiving tube feedings develops diarrhea. The nurse recognizes what possible reasons for the diarrhea? Select all that apply.

Certain medications Rate of feeding is too fast Low-fiber formula Contamination of the formula Rationale: During tube feeding, the patient may develop diarrhea, which may be due to sorbitol in liquid medications or to antibiotics. An increased feeding rate may stimulate peristalsis and lead to diarrhea; therefore, the feeding rate should be decreased. A low-fiber formula may increase the risk of diarrhea; therefore, a formula with high fiber should be used. Contamination of the formula may also lead to diarrhea; therefore, any outdated formula should be discarded. Improper placement of the tube leads to vomiting or aspiration.

The nurse is caring for a patient who is receiving enteral feedings of reconstituted formula. After completing the feeding, there is 50 mL of formula still in the bottle. The next feeding is due in five hours. What action should the nurse take?

Discard the formula Rationale: The formula should be discarded because it may become contaminated. Used formula should not be refrigerated for further use. It should not be used for the next feeding because the next feeding is 5 hours later. Reconstituted formula should be discarded after 4 hours. It should not be used for other patients because it may not meet their nutritional demands.

The nurse assesses an older patient in a clinic who reports unintended weight loss over the last 6 months. The nurse reviews documentation from the patient's previous visits and notes a consistent body weight of 160 pounds. For this patient, how much weight loss is a critical indicator for further assessment?

More than 8 pounds Rationale: A loss of more than 5% of the usual body weight over 6 months is a critical indicator for further assessment. The patient's usual body weight is 160 pounds. Five percent of the patient's weight is 8 pounds.

Which statement about the gastrointestinal changes observed in patients who are undernourished is inaccurate?

"Bowel sounds will be increased." Rationale: Bowel sounds are created by the peristaltic movement of the intestines when food passes through the intestine. Undernourished patients have inadequate intake of food, resulting in decreased, not increased, bowel motility and bowel sounds. The tongue of an undernourished patient is swollen, is beefy red (glossitis), and has atrophic papillae. Patients who are undernourished may have loose teeth.

The nurse is teaching a group of nursing students about the pathophysiology changes associated with starvation. The nurse should include that the changes occur in what order?

1. Glycogen metabolism 2. Gluconeogenesis 3. Utilization of fat 4. Depletion of protein Rationale: The body system initially depends on glycogen in liver and muscles for energy during the early stage of starvation. The reserved glycogen is converted to glucose and completely utilized in 18 hours. This is followed by the conversion of skeletal proteins to glucose in liver. This is commonly known as gluconeogenesis. Prolonged starvation results in the utilization of stored fat within 4 to 6 weeks. The utilization of fat is continued by the depletion of proteins from viscera and plasma. The depletion of visceral proteins and plasma proteins results in malfunctioning of the ion exchange pump, leading to death if nutrients are not supplied.

A patient voices a desire to lose weight. The nurse is reviewing the caloric needs of the patient. To lose weight, the patient should consume how many calories per kilogram?

20 to 25 cal/kg body weight Rationale: Rule-of-thumb estimations are that an individual should consume 20 to 25 cal/kg body weight to lose weight, 25 to 30 cal/kg to maintain body weight, and 30 to 35 cal/kg to gain weight.

The nurse is assessing a group of patients for risk for malnutrition. Which of these patients has the highest risk of malnutrition?

A 55-year-old woman who has a history of alcohol abuse Rationale: Conditions that increase the risk for malnutrition include dementia, depression, chronic alcoholism, excessive dieting to lose weight, and swallowing disorders. Hernia repair does not place the patient at risk for malnutrition. A woman who wants to lose 20 pounds after giving birth is not at risk for malnutrition; it is normal to want to lose post-baby weight. A patient who is NPO for a colonoscopy is not at risk for malnutrition because this is short-term status.

The nurse provides care for patients on a medical surgical unit. Which patients are likely candidates for parenteral nutrition? Select all that apply.

A patient with a gastrointestinal (GI) obstruction A patient experiencing intractable diarrhea A patient with severe anorexia nervosa A patient that had a complicated surgery Rationale: Parenteral nutrition helps in the administration of nutrients by a route other than the GI tract. It is used when the GI tract cannot be used for the ingestion, digestion, and absorption of essential nutrients. In GI obstruction, there is a problem of digestion, so parenteral nutrition is preferred. Intractable diarrhea is a severe condition and requires parenteral nutrition for instant supply of nutrients. In severe anorexia nervosa, the patient is unable to receive nutrients from oral feeding. In complicated surgery or trauma, the need for calories and protein is increased, and this need is met through parenteral nutrition. Megaloblastic anemia occurs due to the deficiency of cobalamin. Only cobalamin supplements are required, and there is no need of parenteral nutrition.

The nurse identifies that enteral nutrition (EN) is indicated for which types of patients? Select all that apply.

A patient with extensive burns A patient who has a functioning GI tract but is unable to take any oral nourishment A patient with orofacial fractures Rationale: EN is used with the patient who has a functioning GI tract but is unable to take any or enough oral nourishment, or when it is unsafe to do so. Indications for EN include persons with anorexia, orofacial fractures, head and neck cancer, extensive burns, or critical illness, and those receiving chemotherapy or radiation therapy. Common indications for parental nutrition (PN) include GI obstruction and short bowel syndrome. Crushing medications thoroughly and dissolving them in water will help prevent tube obstruction. The use of polyurethane or silicone feeding tubes helps decrease the risk of mucosal damage.

A stable patient is receiving enteral feeding through a gastrostomy tube. Which care could the registered nurse (RN) delegate to a licensed practical/vocational nurse (LPN/LVN)? Select all that apply.

Administer bolus or continuous feedings Administer medications through the gastrostomy tube Rationale: For the stable patient, the LPN/LVN can administer bolus or continuous feedings and administer medications through the gastrostomy. The RN must evaluate the nutritional status of the patient, monitor for complications related to the tube and the enteral feeding, and teach the caregiver about feeding via the gastrostomy tube at home.

Which disorder is characterized by self-imposed weight loss?

Anorexia nervosa Rationale: Anorexia nervosa is characterized by self-imposed weight loss. Hair loss, constipation, yellow skin, and sensitivity to cold are the signs of anorexia nervosa. A patient with bulimia nervosa has loss of control related to eating and has a persistent concern with body image. Binge-eating disorder is less severe than bulimia nervosa. A patient with binge-eating disorder is generally overweight or obese. Malabsorption syndrome refers to impaired absorption of nutrients from the gastrointestinal tract. It is associated with frequent episodes of disease in the patient.

Which disease process contributes to primary protein-calorie malnutrition (PCM)?

Anorexia nervosa Rationale: Primary protein-calorie malnutrition (starvation-related malnutrition) is caused when nutritional needs are not met, such as in the case of anorexia nervosa. Major trauma is an example of injury-related malnutrition, which is associated with a marked inflammatory response. Cancer and obesity are examples of chronic disease-related malnutrition, which is associated with mild-to-moderate inflammation.

Which component of nutritional assessment includes determining a patient's body mass index, height, weight, and amount of weight loss?

Anthropometric measurements Rationale: Anthropometry refers to the measurement of the human individual. It helps in understanding human physical variation. Usually height, weight, and organ size are measured in anthropometric studies. Because body mass index calculation involves both height and weight, it is also included under anthropometric measurement. Assessing the patient's acute or chronic illness and personal and family history is part of the health history component of nutritional assessment. Measuring the patient's ability to perform basic daily activities is part of the functional status component of nutritional assessment. Assessing the patient's physical appearance, muscle mass, and strength is part of the physical examination component of nutritional assessment.

A patient presents with a fever, nausea, vomiting, loss of appetite, and increased basic metabolic rate (BMR). The nurse suspects that which medication in the patient's medication history is the cause of the patient's clinical manifestations?

Antibiotics Rationale: Nausea, vomiting, and loss of appetite with an increase in the BMR indicate malabsorption syndrome. Several drugs have undesirable gastrointestinal side effects and alter normal digestive and absorptive processes. Antibiotics disturb the flora of the intestine, which decreases the ability of the body to synthesize biotin. Diuretics and laxatives are used in bulimia nervosa. Antidepressants do not cause malabsorption syndrome but may be used to treat eating disorders.

Which conditions can cause bulimia nervosa? Select all that apply.

Anxiety Substance abuse Affective disorder Rationale: Anxiety, substance abuse, and affective disorder can cause bulimia nervosa. Chronic alcoholism may cause malnutrition and also increases the risk of refeeding syndrome. Anorexia nervosa is characterized by endocrine dysfunction.

Which is a positive acute phase protein?

C-reactive protein Rationale: C-reactive protein is a positive acute phase protein whose levels are elevated during inflammation. Albumin is a negative acute phase protein with a half-life of 20 to 22 days. Prealbumin is a negative acute phase protein and is the best indicator of the patient's recent nutritional status. Transferrin is a negative acute phase protein synthesized by the liver; it is used to transport iron.

Which acute phase protein is elevated during inflammation?

C-reactive protein (CRP) Rationale: C-reactive protein (CRP) is a positive acute phase protein that is elevated during inflammation and helps in predicting morbidity and mortality. Negative acute phase proteins such as albumin, transferrin, and prealbumin are decreased during an inflammatory response.

The nurse is providing care for a patient who is diagnosed with anorexia. The patient is receiving enteral nutrition through a nasogastric tube and has developed constipation. Which factors may be responsible for the constipation? Select all that apply.

Certain drugs Poor fluid intake Excessive vomiting Formula components Rationale: Enteral nutrition is provided through the gastrointestinal (GI) tract via a tube, catheter, or stoma that delivers nutrients distal to the oral cavity. Certain drugs tend to slow peristalsis, leading to constipation. Poor fluid intake also leads to constipation by making the feces hard and difficult to pass. Therefore, fluid intake should be increased. Formula components may produce the problem of constipation. A primary healthcare provider may be consulted to change the formula. Feeding too fast leads to diarrhea due to increased peristalsis. Excessive vomiting causes dehydration.

The nurse completes a nutritional screening and identifies that a patient is at risk for malnutrition. What is the next step for the nurse to take?

Complete a full nutritional assessment Rationale: A full nutritional assessment includes history and physical examination and laboratory data. The nutritional assessment will need to be done to provide the basis for nutrition intervention. Supplements may be given if prescribed; the family bringing food from home and socializing with meals may be an option after a full nutritional assessment is done.

The nurse recognizes that parenteral nutrition is often prescribed for which patient conditions? Select all that apply.

Complicated surgery Severe malabsorption Gastrointestinal obstruction Rationale: Parenteral nutrition refers to the administration of nutrients from routes other than the gastrointestinal tract. The most common route of parenteral nutrition is the intravenous route of administration. It is practiced in patients under attentive medical care for the daily nutritional requirement. Patients who have undergone complicated surgeries have decreased absorption of nutrients and need parenteral nutrition to meet their nutritional needs. Malabsorption in patients can be due to several intestinal pathogens and several physiologic conditions. Gastrointestinal obstructions occur due to the alterations in the normal physiologic conditions. A cancer patient does not have reduced absorption level and can have an oral intake of food. Patients with nutritional disorders are recommended a balanced diet and they can have reduced absorption, but they do not need parenteral nutrition.

The nurse reviews the medication history of a patient experiencing dry and scaly lips, brittle nails, and mouth crusting. The nurse suspects that the patient is malnourished. Which type of medication in the patient's history supports the nurse's conclusion?

Corticosteroids Rationale: Corticosteroids have catabolic properties, which supports the nurse's suspicion of malnutrition. Diuretics and laxatives contribute to bulimia nervosa. Antidepressants are used in the treatment of bulimia nervosa.

Which lab result is associated with steatorrhea in a patient with malnutrition?

Decreased serum levels of fat-soluble vitamins Rationale: A deficiency of fat-soluble vitamins leads to decreased absorption of fats in the body; they are excreted into the feces, resulting in steatorrhea (fatty stools). Decreased serum albumin, altered serum electrolytes, and elevated liver enzymes are associated with malnutrition but they do not cause steatorrhea.

The nurse finds that a patient receiving tube feedings has developed diarrhea. What is an appropriate treatment plan?

Discontinue excess water boluses. Rationale: If a patient who is on tube feedings develops diarrhea, treatments include discontinuing excessive water boluses, diluting or decreasing the rate of feedings, and/or changing to continuous drip feedings. Increased rate of feedings, low-fiber formula, and contaminated formula (caused by not refrigerating unused formula) are causes of diarrhea.

A patient who is malnourished is being administered an intravenous fat emulsion. The nurse's assessment findings include an elevated body temperature, increased triglyceride levels, and a decreased respiratory rate. Which action should the nurse take?

Discontinue the emulsion. Rationale: Intravenous fat emulsions are not recommended for patients suffering from fever, hyperlipidemia, clotting problems, and respiratory disease; the nurse should discontinue IVFE to prevent complications. Slowing the rate of an emulsion administration will put the patient's safety at risk. The nurse cannot change the route of administration without consulting the patient's primary health care provider. Documenting the findings and continuing the infusion will put the patient's safety at risk.

While monitoring a patient who has a nasointestinal tube in place, the nurse observes an increase in gastric residual volume. What does the nurse suspect is the cause of the increased volume?

Displacement of the tube Rationale: An increase in gastric residual volume indicates displacement of the nasointestinal tube. Tube kinking occurs because of vomiting or coughing. Tube clogging is observed when tubes are not flushed before and after administrating medication. The size of the tube does not cause a change in residual amounts.

The nurse recalls that which socioeconomic factors contribute to the development of malnutrition? Select all that apply.

Elderly on a fixed income Food insecurity Rationale: Elderly people tend to eat less nutritious food due to functional disability and limited access to resources. Assistance of a registered dietician can guide older adults to meet their nutritional requirements with available resources. Food insecurity arises in families with low income levels. They opt for filling foods with high calorific value and less nutritional value. Alcoholism is not a direct cause of malnutrition. Hospitalization due to surgery, illness, or trauma can result in a reduced metabolic rate and diet restrictions but is not a direct cause of malnutrition. Food-drug interactions can result in decreased appetite and loss in effectiveness of the drug but are not direct causes of malnutrition.

A patient is receiving an initial infusion of parenteral nutrition (PN). What is a priority nursing assessment?

Electrolyte levels and daily weights Rationale: The use of PN necessitates frequent and thorough assessments. Key focuses of these assessments include daily weights and close monitoring of electrolyte levels. Refeeding syndrome is a complication associated with PN and is characterized by fluid retention and electrolyte imbalance. Assessments of bowel sounds, integument, peripheral vascular system, LOC, chest sounds, and blood coagulation may be performed, but close monitoring of fluid and electrolyte balance supersedes these in importance.

What dietary changes are appropriate for the nurse to implement for older adults with malnutrition? Select all that apply.

Give a vitamin D supplement daily. Provide parenteral nutrition when required. Use oral liquid supplements instead of water with oral medications. Rationale: Daily D requirements are higher in older adults; therefore, a supplement should be provided. Some older persons may require parenteral nutritional support therapies until their strength and general health improve. In long-term care, oral liquid supplements may be used instead of water with oral medications to increase calorie intake. Nutritional supplements should not be used as meal substitutes but, rather, should be used between meals as snacks. Nutritional supplements do not provide all of the benefits of a complete meal. A moderate amount of high-quality protein at each meal is necessary to prevent loss of muscle mass and to maintain function.

A patient is diagnosed with anorexia nervosa. The nurse expects what clinical manifestations?

Hair loss, dry, yellowish skin, and constipation Rationale: The patient with anorexia nervosa, along with abnormal weight loss, is likely to have hair loss, dry, yellow skin, constipation, sensitivity to cold, and absent or irregular menstruation. Other signs of malnutrition also are noted during physical examination. The anorexic patient will not have tan skin, may have hair color other than blonde, and will not have diarrhea.

Which changes in laboratory parameters occur in a patient with bulimia nervosa? Select all that apply.

Hypokalemia Metabolic alkalosis Elevated serum amylase Rationale: Abnormal laboratory parameters, including hypokalemia, metabolic alkalosis, and elevated serum amylase may occur with frequent vomiting. Leukopenia and hypoglycemia are manifestations of potassium deficiency in patients with anorexia nervosa.

A patient is hospitalized with malnutrition. The nurse recalls that what laboratory result is associated with disease-related malnutrition with inflammation?

Increased C-reactive protein (CRP) Rationale: Inflammation is an important aspect of the nutritional status and it affects nutrient metabolism. In inflammation, there is an increase in CRP protein due to alterations in the expression of proinflammatory and inflammatory cytokines. In disease-related malnutrition, there is an increased glucose turnover. Decreased nitrogen excretion and basal metabolic rate indicate starvation-related malnutrition.

A patient is hospitalized with malnutrition. The nurse recalls that, during the starvation process, which changes are the results of alterations in cytokines? Select all that apply.

Increased protein breakdown Increased positive phase protein Increased skeletal muscle breakdown Rationale: In inflammatory states, there are alterations in the expression of proinflammatory and antiinflammatory cytokines. These cytokine changes result in increased protein breakdown, increased positive acute phase protein production, and increased skeletal muscle breakdown. There is increased glucose turnover and increased BMR.

The nurse is educating a student nurse about enteral feedings that are administered through a nasogastric (NG) tube. What is appropriate for the nurse to include in the teaching about the NG tube?

It is inserted through the nose into the stomach. Rationale: A nasogastric tube is inserted through the nose and goes to the stomach via the throat. The tube does not go all the way to the jejunum. The insertion of a nasogastric tube is not a surgical intervention.

Which fluid and electrolyte change occurs with malnutrition?

Movement of sodium within the cell Rationale: Sodium is an extracellular ion. In malnutrition, as the fluid shifts to interstitial space, sodium also moves with the fluid, resulting in increased amounts of sodium within the cells. There is a fluid shift, rather than a potassium shift, to interstitial spaces. Potassium, which is a predominant intracellular ion, is shifted to the extracellular space. Fluids move to the interstitial space rather than to the extracellular space.

What signs of malnutrition can a nurse assess in a patient's eyes? Select all that apply.

Pale conjunctivae Fissuring of eyelid corners Blood vessel growth in cornea Gray keratinized epithelium on conjunctiva Rationale: In patients with malnutrition, the conjunctiva becomes pale or red. The eyelid corners fissure and blood vessel growth occurs in the cornea. Keratinized epithelium on conjunctiva turns gray. Soft corneas, not hard corneas, are associated with malnutrition.

A patient with a history of parenteral nutrition (PN) therapy develops a complication associated with the therapy, including hypophosphatemia. The nurse should monitor the patient closely for which outcomes? Select all that apply.

Paresthesias Respiratory arrest Cardiac dysrhythmias Rationale: Hypophosphatemia is the hallmark of refeeding syndrome and is associated with serious outcomes, including cardiac dysrhythmias, respiratory arrest, and neurologic disturbances (e.g., paresthesias). Diarrhea, nausea, and vomiting are not commonly found in refeeding syndrome.

The nurse is reviewing diagnostic study results for a patient with suspected malnutrition. When compared to other lab studies, which diagnostic test is considered to be the best indicator of current nutritional status?

Prealbumin Rationale: Prealbumin, a protein synthesized by the liver, has a half-life of 2 days. When compared to albumin, it is a better indicator of recent or current nutritional status. Serum transferrin level is another indicator of protein status. Transferrin, a protein synthesized by the liver and used to transport iron, decreases when protein is deficient. Serum albumin has a half-life of approximately 20 to 22 days. In the absence of marked fluid loss, such as from hemorrhage or burns, the serum albumin value lags behind actual protein changes by more than 2 weeks. Therefore, albumin is not a good indicator of acute changes in nutritional status. Hemoglobin and hematocrit are not the best indicators of current nutritional status.

A patient who is receiving parenteral nutrition reports burning and prickling sensations. The nurse suspects that the paresthesias are related to what?

Presence of refeeding syndrome Rationale: Refeeding syndrome is characterized by respiratory distress, cardiac dysrhythmias, and neurologic disturbances such as paresthesias, which include burning and prickling sensations. Abdominal distention does not cause a burning or prickling sensation. The displacement of a catheter results in increased body temperature, pulse rate, and shortness of breath. Decreased serum levels of fat-soluble vitamins can lead to fatty stools, termed as steatorrhea.

A patient with severe trauma is scheduled for surgery. The nurse identifies that the patient will require which nutritional components to promote wound healing?

Proteins and calories Rationale: With increased stress, such as surgery, severe trauma, or sepsis, the patient requires increased protein and calories. Wound healing requires increased protein synthesis. Carbohydrates, vitamins, and minerals are important as well, but increased protein and calories are most effective for promoting wound healing.

The nurse reviews the pathophysiology of starvation. When carbohydrate (glycogen) stores are depleted, what does the body convert to glucose for energy?

Skeletal protein Rationale: Once carbohydrate stores are depleted in starvation, the body converts skeletal protein into glucose for energy. Visceral and body proteins are used when the fat stores are gone. Within five to nine days after starvation, the body mobilizes fat to supply much of the needed energy. Carbohydrate stores found in muscle tissue are minimal and can be totally depleted within 18 hours.

The body mass index (BMI) of a patient is 26 kg/m2. How should the nurse interpret the assessment finding?

The patient is overweight. Rationale: A BMI of 25 to 29.9 kg/m2 indicates that the patient is overweight. A BMI of 30 kg/m2 or greater indicates that the patient is obese. A BMI of 18.5 to 24.9 kg/m2 indicates that the patient is normal. A BMI of less than 18.5 kg/m2 indicates that the patient is underweight.

The health care team creates a collaborative plan of care for patients with nasogastric (NG) and gastric tubes and enteral feedings. What is a primary role of the registered nurse (RN)?

To insert the nasogastric tube for an unstable patient Rationale: The registered nurse inserts nasogastric tubes for an unstable patient. The licensed practical nurse/licensed vocational nurse (LPN/LVN) inserts NG tubes for stable patients. Providing oral care to the patient, positioning the patient, and weighing the patient are the roles of unlicensed assistive personnel (UAP). Insertion and management of nasogastric and gastric tubes for enteral feeding may be subject to the policy and protocols of a health care facility. Many organizations establish that only an RN may insert a nasogastric tube. Additionally, most facilities have disposable collection devices for gastric tubes and prohibit emptying and reusing containers, instead requiring disposal of the waste and the vessel in appropriate biohazard receptacles.

The nurse is caring for a patient who is suspected to be malnourished. What anthropometric measurements should the nurse assess? Select all that apply.

Waist circumference Skin fold thickness Midarm muscle circumference Hip-to-waist ratio Rationale: Anthropometric measurements are gross measures of fat and muscle contents. They consist of measures of skin fold thickness at various sites, which are indicators of subcutaneous fat stores, and midarm muscle circumference, which is an indicator of protein stores. Hip-to-waist ratio and waist circumference are also anthropometric measurements. Such measurements are compared with the standards for healthy persons of the same age and gender. A person's height alone cannot indicate the malnutrition status. Chest circumference does not directly indicate malnutrition.