17: Altered Nutrition

Frustrated with his inability to lose weight despite attempting numerous fad diets, a 42 year-old male who is 5'11" (1.8 m) and 270 lbs (122.7 kg) has visited a clinic to gain tools to achieve long term weight loss. Which statement by the clinician is most accurate?

"A combined approach of behavior therapy, changing your lifestyle habits, and increased physical activity gives the highest chance of long term success." Explanation: A combined approach to weight loss including diet modification, exercise, and drug therapy has been shown to be successful in the treatment of obesity. In spite of a genetic component, obesity is still considered to be preventable. A reasonable rate of weight loss should be 5% to 10% of total body weight over a 6-month period. A reduction in food intake of between 500 and 1000 kcal, not a total food intake of 500 to 1000 kcal, is often necessary in the treatment of individuals with high BMIs. Pharmacotherapy and surgery are available as adjuncts.

A client is having difficulty with a weight loss plan and asks the nurse, "What is wrong with me? Why can't I lose this weight?" Which rationale might the nurse offer to this client?

"Obesity ultimately results from an energy imbalance of eating too many calories and not getting enough exercise." Explanation: The epidemic of obesity results from many causative factors, and research is adding to the body of knowledge almost daily. Although excessive weight and obesity ultimately result from an energy imbalance of eating too many calories and not getting enough physical activity, many factors contribute to both the development of obesity and the body's response to attempts to control it.

A homeless client asks, "Why can't I get this wound on my foot to heal?" Knowing that the client is not receiving good nutrition on a regular basis, the nurse will reply:

"Right now your immune system is decreased because you are not eating a balanced diet." Explanation: As protein is lost from the liver, hepatic synthesis of proteins declines, and plasma protein levels decrease. There also is a decrease in immune cells. Wound healing is poor, and the body is unable to fight off infection because of multiple immunologic malfunctions throughout the body.

A dietitian is working with a morbidly obese client in an effort to facilitate weight loss. Which of the dietitian's teaching points about the nature of adipose tissue should be included in the client education?

"Your fat cells can be considered to be one large energy-storage organ that also has a role in hormone production." Explanation: Fat cells are collectively considered a large energy-collection organ; the role of adipose tissue as an endocrine organ has also been recently elucidated. It is neither a desirable or reasonable goal to entirely rid the body of fat, given the key roles it plays in homeostasis, and brown fat is not common in postnatal life. Preadipocytes have been shown to play a role in obesity, but the condition is still primarily a consequence of energy intake exceeding output.

water-soluble vitamins

(vitamin C and the B vitamins) thiamine, riboflavin, niacin, vitamin B6, pantothenic acid, vitamin B12, folate, and biotin. -Because excess amounts of the water-soluble vitamins are excreted in the urine, it is less likely that they may become toxic to the body, but the fat-soluble vitamins are stored in adipose tissue and may reach toxic levels

Which of the following clients coming to a small free clinic are at high risk for malnutrition? Select all that apply.

-An 88-year-old senior citizen on a fixed budget -A 60-year-old homeless Vietnam veteran complaining of pain -A 4-year-old child who lives with a single mom in a rooming house Explanation: Among the many causes of malnutrition are poverty and lack of knowledge, acute and chronic illness, and self-imposed dietary restrictions. Homeless people, the elderly, and the children of the poor often demonstrate the effects of protein and energy malnutrition, as well as vitamin and mineral deficiencies. Sexually active teenagers and working young adults are not usually at high risk for malnutrition.

Parents are concerned that their child may be at risk for the development of childhood obesity. Select the factors that would place a child at risk. Select all that apply.

-Heredity -Ethnicity -Mother had gestational diabetes during pregnancy Explanation: Childhood obesity is determined by a combination of hereditary and environmental factors. It is associated with obese parents, gestational diabetes and excessive weight gain during pregnancy, formula feeding, parenting style, parental eating habits, energy-dense food choices, erratic eating patterns, ethnicity, and a sedentary lifestyle.

Which individualized plan does the nurse understand will be included in the initial plan of treatment for the client who seeks treatment for obesity? Select all that apply.

-Lifestyle modification with behavioral therapy -Reduced-calorie diet -Increased physical activity Explanation: Treatment should focus on individualized lifestyle modifications through a combination of a reduced calorie diet, increased physical activity, and behavior therapy. These three modes of therapy form the basis of all weight management programs. Pharmacotherapy and surgery are available as adjuncts to lifestyle changes in people who meet specific criteria.

When explaining the role of protein and the nine essential amino acid needs of the human body to a group of students, the nurse should emphasize that which foods are complete proteins (foods that provide the essential amino acids in adequate amounts)? Select all that apply

-Milk -fish -poultry Explanation: Complete proteins most often are derived from animal sources and include milk, eggs, meats, fish, and poultry. There are a few vegetables that provide complete protein sources, including soy and quinoa. Peas, beans, nuts, seeds, and grains contain all the essential amino acids but in LESS than adequate proportions, therefore they are not complete proteins.

the 9 essential amino acids

1. Histidine 2. Isoleucine 3. Leucine 4. Lysine 5. Methionine 6. Phenylalanine 7. Threonine 8. Tryptophan 9. Valine

Fat is a necessary part of the diet. The Health and Medicine Division's Food and Nutrition Board has set what adult Acceptable Macronutrient Distribution Ranges (AMDR) for fats?

25% - 35% Explanation: The Food and Nutrition Board has set an adult acceptable macronutrient distribution range for fat of 25% - 35%, with a minimum of 20% to prevent the fall of HDL cholesterol with very-low-fat diets.

When counseling a group of overweight individuals, the nurse should stress that during parties, the oxidation of alcohol provides how many kilocalorie/gram to one's diet?

7 kcal/g Explanation: The oxidation of proteins provides 4 kcal/g; fats, 9 kcal/g; carbohydrates, 4 kcal/g; and alcohol, 7 kcal/g.

A nurse is assigned to care for a group of clients. Which client is most likely to be diagnosed with malabsorption syndrome?

A 40-year-old with severe inflammatory bowel disease Explanation: Some types of malnutrition are caused by acute and chronic illnesses, such as occurs in people with Crohn disease who are unable to absorb nutrients from their food. Lactose intolerance does not cause malnutrition and can be controlled with deleting lactose from the diet. Acute pancreatitis will cause a short-term electrolyte imbalance. Pancreatic enzyme replacement does not cause malnutrition.

The nurse is caring for a client diagnosed with a vitamin K deficiency. Which other finding should the nurse anticipate?

Altered coagulation Explanation: The nurse should anticipate altered coagulation in the client with vitamin K deficiency, as this nutrient plays a key role in this physiologic function. Vitamin A plays a role in maintenance of visual pigment and photoreception. Calcium and phosphorus absorption is supported by vitamin D. Resistance to infection is supported by vitamin C.

The body mass index (BMI) is the measurement used to determine a person's healthy weight. A BMI between 18.5 and 24.9 is considered the lowest health risk in relation to the weight of a person. How is the BMI calculated?

BMI = weight [kg]/height [meter2] Explanation: The body mass index (BMI) uses height and weight to determine healthy weight. It is calculated by dividing the weight in kilograms by the height in meters squared (BMI = weight [kg]/height [m2]).

Which client has the greatest caloric needs?

Breast-feeding mother who delivered 1 month ago Explanation: Energy requirements are greater during growth periods. A person requires approximately 115 kcal/kg of body weight at birth, 105 kcal/kg at 1 year of age, and 80 kcal/kg from 1 to 10 years of age. During adolescence, boys require 45 kcal/kg of body weight and girls require 38 kcal/kg. During pregnancy, a woman needs an extra 300 kcal/day above her usual requirement, and during the first 3 months of breast-feeding she requires an additional 500 kcal.

Which enzymes adhere to the border of the villus structures to allow access to carbohydrate and protein molecules?

Brush border Explanation: The brush border enzymes adhere to the border of the villus structures to allow access to carbohydrate and protein molecules as they come in contact with the absorptive surface of the intestines.

A client asks the nurse the best way to estimate protein utilization by the body. The best response would be:

By measuring the amount of nitrogen excreted in the urine Explanation: Nitrogen excretion is an indicator of protein intake. About 90% of this is excreted in the urine as urea, uric acid, creatinine, and other less important nitrogen breakdown products, with the rest being excreted in the feces. Therefore, the rate of protein breakdown can be estimated by measuring the amount of nitrogen in the urine.

A client asks the nurse what the body's primary source of immediate energy is. The best response would be:

Carbohydrates Explanation: Carbohydrates are the body's primary source of immediate energy. They supply 4 kcal/g, are stored in limited quantities as glycogen, and can be converted to fatty acids. -Fats are a concentrated water-free energy source. They contain 9 kcal/g and are stored in fat cells as triglycerides. -Proteins, which are broken down into amino acids, generate 4 kcal/g. Their main role is in building functional and structural body proteins. Excesses of any of the macronutrients will be stored as triglycerides in adipose tissue.

Which of these reflects a positive outcome to interventions provided for a 20-year-old woman undergoing treatment for anorexia nervosa?

Client has monthly menses. Explanation: The individual with anorexia nervosa is expected to maintain a minimally normal body weight (e.g., at least 85% of minimal expected weight). The individual has an excessive concern over gaining weight and how the body is perceived in terms of size and shape, and amenorrhea (in girls and women after menarche). A positive outcome is reflected in less obsession over weight or appearance, and return of menses.

A nurse is educating a group of clients about adequate nutrition. Which information should the nurse include when discussing diets that are adequate in calories but deficient in protein?

Clients may be at risk for developing kwashiorkor. Explanation: Diets that are adequate in calories but inadequate in protein can result in kwashiorkor. If both calories and protein are inadequate, protein-calorie malnutrition occurs. Clients will not be at risk for the development of obesity. A diet high in fats may result in the development of obesity. Diets low in iron may increase the risk for the development of anemia.

Anorexia nervosa, bulimia nervosa, and binge-eating disorder are becoming more and more common, with assessments for these disorders being made as young as 9 years of age. In the adult population, what means of controlling binge eating is most prevalent in men?

Compulsive exercise Explanation: Compared with women, men tend to experience less pressure to engage in behaviors such as self-induced vomiting or laxative use when overeating, less on a subjective sense or loss of control when binge eating, and a greater tendency to use compulsive exercise rather than purging for weight control.

A large, high-calorie meal has resulted in the intake of far more energy than a person requires. What will the individual's body do with the excess carbohydrates provided by this meal?

Convert them into glucose and store them in the liver and muscles Explanation: Dietary carbohydrates are largely converted to glucose, which is stored as glycogen in the liver and skeletal muscle cells. They are not excreted by the kidneys, and carbohydrates cannot be directly converted into amino acids or structural proteins.

A nurse is speaking at a weight loss meeting about the dangers to one's health from obesity. Which condition is directly attributed to being obese?

Coronary heart disease Explanation: Overweight and obesity have become global health problems and are associated with increased health problems, including cardiac disease. Bone resorption is not directly affected and obese individuals are not noted to have recurrent infections. Dysrhythmias are not an identified effect of obesity.

Which aspect of gastrointestinal function is performed by the brush border enzymes of the villus structures?

Digestion of carbohydrates Explanation: Brush border enzymes aid in the digestion of carbohydrates and proteins. They do not metabolize fat or synthesize vitamin A, and they do not directly contribute to fluid and electrolyte balance.

Childhood obesity has now been recognized as a major problem in the pediatric population. What diseases are pediatricians now seeing in their clients as a direct result of childhood obesity?

Dyslipidemia Explanation: Pediatricians are now beginning to see hypertension, dyslipidemia, type II diabetes, and psychosocial stigma in obese children and adolescents. The other answers are not correct.

Similarities between women with anorexia nervosa and bulimia nervosa include which clinical manifestation?

Electrolyte imbalances Explanation: Diagnostic criteria for anorexia nervosa and bulimia nervosa are distinctly different. Anorexia nervosa is a form of starvation that causes complications that include low estrogen levels with osteoporosis and life-threatening electrolyte imbalances. Bulimia nervosa (unbalanced binge eating) also causes life-threatening electrolyte imbalances. The self-induced vomiting of bulimia causes acid-related periodontal disease and enlarged parotid glands.

Which response by the nurse best answers a client's question regarding the purpose of white fat?

Energy storage Explanation: There are two types of adipose tissue: white (unilocular) and brown (multilocular). White fat is the predominant form of adipose tissue in adults. The functions of white fat include energy storage, insulation, and cushioning of vital organs.

Which measures would likely be rejected as part of a first-line weight loss plan for a client with a BMI of 30.2, type 2 diabetes, and hypertension?

Gastric bypass Explanation: Weight loss surgery should be limited to individuals with a BMI greater than 40 or those with a BMI greater than 35 with comorbid conditions in whom medical therapy has failed. Calorie reduction is appropriate for anyone with a BMI of 25 to 29.9 plus two risk factors (in this case, type 2 diabetes and hypertension). Prescription drug therapy can be considered for those with a BMI of 30 or more, and increased physical activity — although it does not lead to significant weight loss — helps prevent further weight gain and reduces cardiovascular and diabetes risk beyond that achieved by weight loss alone.

The body converts dietary carbohydrates into which substance?

Glucose Explanation: Dietary carbohydrates are largely converted to glucose, which is stored as glycogen in the liver and skeletal muscle cells.

In collecting assessment data on the school-aged population, which factor could be the most significant predictor of childhood obesity?

Having parents who are obese Explanation: Though genetic research gives new insight into the genesis of obesity, environmental influence remains the major contributor to this worldwide issue. Influences such as family eating patterns contribute to overweight trends. The most significant risk for childhood obesity is having parents who are obese. This variable is more important than socioeconomic status, low self-esteem, or a rural or inner-city residence.

Which substance necessary for vitamin B12 absorption is produced by the parietal cells in the stomach?

Intrinsic factor Explanation: Intrinsic factor is produced by the parietal cells in the stomach and is necessary for the absorption of vitamin B12. Hydrochloric acid activates pepsinogen into the enzyme pepsin, which then helps digestion by breaking the bonds linking amino acids, a process known as proteolysis. An enzyme present in red blood cells, carbonic anhydrase, aids in the conversion of carbon dioxide to carbonic acid and bicarbonate ions.

A client on a diet that is very low in carbohydrates and high in protein submitted a urine specimen for analysis. Which of the following does the nurse expect to see when the results come back?

Ketones Explanation: A carbohydrate-deficient diet usually results in the loss of tissue proteins and the development of ketosis. Because protein and fat metabolism increase the production of osmotically active metabolic wastes that must be eliminated through the kidneys, there is a danger of dehydration and electrolyte imbalances. The specific gravity would be high. Bacteria in the urine would indicate an infectious process.

Which body mechanism is necessary for food intake control?

Leptin receptor stimulation Explanation: Leptin receptor stimulation of the hypothalamus causes decreased appetite and increased metabolic rate/energy consumption. Natural appetite suppression is a response to cholecystokinin release and increased ketoacids. Decreased blood glucose causes a hunger response.

An older adult client is frail and has been diagnosed with severe protein-energy malnutrition. Which laboratory value is correlated with this diagnosis?

Low prealbumin Explanation: Prealbumin levels are a reliable indicator of calorie-protein malnutrition. Low blood sugar does not necessarily indicate malnutrition, and neither C-reactive protein nor bilirubin levels are sensitive or specific indicators of nutritional status.

The nurse is providing education to a client who has been instructed to increase the amount of protein in her diet. Which foods should the nurse recommend?

Milk and eggs Explanation: While all the options will provide more protein to the diet, essential amino acids can be provided by milk, eggs, meat, fish, and poultry.

When examining types of energy expenditure, which statement is accurate?

More active people and those who fidget may have less fat gain than those with decreased non-exercise activity thermogenesis (NEAT). Explanation: Non-exercise activity thermogenesis includes the energy expended in maintaining posture and in activities such as fidgeting. People with increased NEAT may have less fat gain than those with decreased NEAT. Sympathetic stimulation causes brown fat to generate more heat. Research shows obese clients with excess caloric intake have increased sympathetic activity. Proteins, not carbs, increase metabolic rate more significantly.

Protein contains nitrogen. A negative nitrogen balance represents:

More nitrogen excreted than consumed Explanation: Negative nitrogen balance represents more excretion of nitrogen than consumed as protein. It represents a state of tissue breakdown. Positive nitrogen balance is when more protein (nitrogen) is consumed than is needed or excreted. A normal nitrogen balance is when protein intake is equivalent to nitrogen output.

A nurse is caring for a client who is being treated for anorexia nervosa. Which personality traits are associated with this eating disorder?

Perfectionist and compulsive Explanation: The causes of anorexia appear to be multifactorial, with determinants that include genetic influence; personality traits of perfectionism and compulsiveness; anxiety disorders; family history of depression and obesity; and peer, familial, and cultural pressures with respect to appearance. Being easily angered, paranoid, aggressive, extroverted, introverted, and shy are not necessarily associated with the typical personality traits of anorexia nervosa

The health care provider needs to assess a client for protein-calorie malnutrition. The best diagnostic measure would be:

Prealbumin Explanation: Serum albumin and prealbumin are used in the diagnosis of protein-calorie malnutrition. Albumin, which has historically been used as a determinant of nutrition status, has a relatively large body pool, a half-life of 20 days, and is less sensitive to changes in nutrition than prealbumin, which has a shorter half-life and a relatively small body pool. The other measures would not specifically identify malnutrition.

A client presents to the clinic with severe edema. Which type of deficiency should be suspected in this client?

Protein Explanation: Severe protein deficiency is associated with extensive loss of the visceral protein compartment with a resultant hypoalbuminemia that gives rise to generalized or dependent edema.

A nurse is working in an eating disorder inpatient clinic. What does the nurse recognize as one of the most challenging aspects of treatment of anorexia nervosa?

Recognizing that there is a problem Explanation: One of the most challenging aspects of the treatment of anorexia is the inability of the person with anorexia to recognize that there is a problem. While overcoming depression is important to any treatment plan, it is not specific to the treatment of anorexia. Socialization with other clients is not essential to the treatment plan but may help the client adjust to the treatment facility. Gaining weight is important but will not occur without the client recognizing that there is a problem.

Which assessment should be the priority when caring for a client with anorexia nervosa?

Serum electrolyte levels Explanation: Electrolyte disturbances are common and potentially severe in clients with anorexia nervosa. The importance of close monitoring supersedes the need to auscultate the client's chest or monitor white blood cells (WBCs) and blood pressure, although all of these may be relevant and appropriate parameters for assessment.

The nurse is teaching a basic nutrition course for the community. Which statement should the nurse include about fat-soluble vitamins?

The fat-soluble vitamins are stored in adipose tissue and may reach toxic levels. Explanation: The four fat-soluble vitamins are vitamins A, D, E, and K. They require dietary fat for absorption and transport. The nine water-soluble vitamins are vitamin C and the B vitamins, which are thiamine, riboflavin, niacin, vitamin B6, pantothenic acid, vitamin B12, folate, and biotin. Because excess amounts of the water-soluble vitamins are excreted in the urine, it is less likely that they may become toxic to the body, but the fat-soluble vitamins are stored in adipose tissue and may reach toxic levels.

The nurse is providing nutritional support education to the family of an obese 10-year-old. The most important information to provide would be:

The weight loss intervention should include all family members. Explanation: The goal should be healthy eating and activity, not achievement of ideal body weight. The child's activities should be more active than watching television or using the computer. Skipping breakfast would not be recommended and should be eaten each day. The family should eat the same foods so as not to alienate the obese child.

The nurse is caring for an obese client. It would be most important for the nurse to assess the client for which possible psychological factor that contributes to obesity?

Using food as a coping strategy Explanation: Psychological factors include using food as a reward, comfort, or means of getting attention. Eating may be a way to cope with tension, anxiety, and mental fatigue. The other choices are environmental influences.

The nurse is reviewing the care plan for altered nutritional status with a client who is exhibiting signs of impaired calcium and phosphorus absorption. Which nutritional deficiency should the nurse suspect?

Vitamin D Explanation: Vitamin D is responsible for supporting the adequate absorption and metabolism of calcium and phosphorus, and is the nutritional deficiency that the nurse should suspect. Vitamin A is responsible for the maintenance of visual pigment, photoreception, and many other physiological functions. Vitamin K plays a key role in coagulation and the formation of bone. Vitamin C supports the synthesis of collagen and mucous membrane integrity, and plays a key role in many other functions.

While the nurse is removing the IV catheter for a client with altered nutritional status, the nurse notes that the client exhibits prolonged bleeding. For which nutrient does the nurse anticipate a deficiency?

Vitamin K Explanation: Prolonged bleeding in a client may be due to impaired coagulation related to vitamin K deficiency. Vitamin E plays a key role in protection against oxidative degradation from reactive oxygen species (free radicals). Vitamin A is involved in the maintenance of visual pigment, photoreception, and many other physiologic processes. Vitamin B6 plays a key role in amino acid metabolism.

Two types of obesity are recognized: upper body obesity and lower body obesity. How is the type of obesity determined?

Waist/hip circumference Explanation: The obesity type is determined by dividing the waist circumference by the hip circumference.

Dyslipidemia

abnormal blood lipid levels, including high total, low-density lipoprotein, and triglyceride levels as well as low high-density lipoprotein levels -increases the chance of clogged arteries (atherosclerosis) and heart attacks, stroke, or other circulatory concerns, especially in smokers. In adults, it's often related to obesity, unhealthy diet, and lack of exercise.

The nurse is assessing the body mass index (BMI) of an adult who is considered to be underweight. Which BMI result correlates with underweight status?

less than 18.5 Explanation: A BMI less than 18.5 is classified as being underweight. A BMI between 25 and 29.9 is considered overweight. A BMI greater than 30.0 is diagnosed as obesity and is further divided into classes I (BMI 30.0 to 34.9), II (BMI 35.0 to 39.9), and III or extreme obesity (BMI >40). Body weight reflects both lean body mass and adipose tissue and cannot be used as a method for describing body composition or the percentage of fat tissue present.

The nurse is caring for a client diagnosed with marasmus. The nurse would expect the client to manifest:

loss of subcutaneous tissue, stunted growth, protuberant abdomen. Explanation: Loss of subcutaneous tissue, stunted growth, and a protuberant abdomen are present in marasmus. There is inadequate food intake that leads to deficiency in calories and protein. Unlike marasmus, severe protein deficiency is associated with severe loss of the visceral protein compartment with a resultant hypoalbuminemia that gives rise to generalized or dependent edema.

Vitamin B6

plays a key role in amino acid metabolism

Vitamin K

plays a key role in coagulation and the formation of bone (fat-soluable)

Vitamin E

plays a key role in protection against oxidative degradation from reactive oxygen species (free radicals)

When educating students about the differences between brown fat versus white fat, the instructor will share that brown fat has iron in its mitochondria that will facilitate:

production of a protein that releases the energy generated from metabolism as heat. Explanation: Brown fat differs from white fat in terms of its thermogenic capacity (its ability to produce heat). The color of brown fat reflects the presence of iron in its abundant mitochondria. Brown fat mitochondria produce a specific protein called uncoupling protein-1 (UCP-1) that releases the energy generated from metabolism as heat. The functions of white fat include energy storage, endocrine and adipocytokine secretion, insulation, and cushioning of vital organs. Internally, white adipose tissue is preferentially located in the greater omentum, mesentery, and retroperitoneal space and is usually abundant around the kidney.

Vitamin D

responsible for supporting the adequate absorption and metabolism of calcium and phosphorus (fat-soluble)

Vitamin A

responsible for the maintenance of visual pigment, photoreception, and many other physiological functions (fat-soluble)