Lewis Chapter 40: Nursing Management: Nutritional Problems

A 22-year-old female is admitted with anorexia nervosa and a serum potassium level of 2.4 mEq/L. What complication is most important for the nurse to observe for in this patient? -Muscle weakness -Cardiac dysrhythmias -Increased urine output -Anemia and leukopenia

Cardiac dysrhythmias A serum potassium level less than 2.5 mEq/L indicates severe hypokalemia, which can lead to life-threatening cardiac dysrhythmias (e.g., bradycardia, tachycardia, ventricular dysrhythmias). Other manifestations of potassium deficiency include muscle weakness and renal failure. Patients with anorexia nervosa commonly have iron-deficiency anemia and an elevated blood urea nitrogen level related to intravascular volume depletion and abnormal renal function.

A patient received a small-bore nasogastric (NG) tube after a laryngectomy. What should be the nurse's priority intervention before starting the enteral feeding? - Aspiration - Auscultation of air - Set head of bed at 40 degrees. - Verify NG tube placement on x-ray.

Verify NG tube placement on x-ray. It is imperative to ensure that an NG tube is situated in the GI tract rather than the patient's lungs. When an NG tube has been recently inserted, it is important to confirm this placement with an x-ray that will identify the tube's radiopaque tip. Aspiration and air auscultation may not differentiate between gastric and respiratory placement of the tube. The head of bed elevated at least 30 degrees is to prevent aspiration. To determine the maintenance of the feeding tube's proper position, the exit site of the tube is marked at the time of the x-ray and the external portion measured to allow for assessment of a change position with a change in the length of the tube.

The patient cannot afford to buy the food she needs for her family, so she makes sure her children eat first, and then she eats. When she comes to the clinic, she reports bleeding gums, loose teeth, and dry, itchy skin. The nurse should know that this patient is most likely lacking which vitamin? Folic acid Vitamin C Vitamin D Vitamin K

Vitamin C This patient is lacking Vitamin C as evidenced by the bleeding gums, loose teeth, and dry, itchy skin. Clinical manifestations of folic acid deficiency include megaloblastic anemia, anorexia, fatigue, sore tongue, diarrhea, or forgetfulness. Clinical manifestations of Vitamin D deficiency include muscular weakness, excess sweating, diarrhea, bone pain, rickets, or osteomalacia. Clinical manifestations of Vitamin K deficiency include defective blood coagulation.

The patient being admitted has been diagnosed with anorexia nervosa. What clinical manifestations should the nurse expect to see on admission assessment? -Tan skin, blonde hair, and diarrhea -Sensitivity to heat, fatigue, and polycythemia - Dysmenorrhea, gastric ulcer pain, and hunger -Hair loss; dry, yellowish skin; and constipation

Hair loss; dry, yellowish skin; and constipation 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 are also noted during physical examination.

The stable patient has a gastrostomy tube for enteral feeding. Which care could the RN delegate to the LPN (select all that apply)? - Administer bolus or continuous feedings. - Evaluate the nutritional status of the patient. - Administer medications through the gastrostomy tube. - Monitor for complications related to the tube and enteral feeding. - Teach the caregiver about feeding via the gastrostomy tube at home.

- Administer bolus or continuous feedings. - Administer medications through the gastrostomy tube. For the stable patient, the LPN 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.

The patient has parenteral nutrition infusing with amino acids and dextrose. In report, the oncoming nurse is told that the tubing, the bag, and the dressing were changed 22 hours ago. What care should the nurse coming on be prepared to do (select all that apply)? - Give the patient insulin. - Check amount of feeding left in the bag. - Check that the next bag has been ordered. - Check the insertion site and change the tubing. - Check the label to ensure ingredients and solution are as ordered.

- Check amount of feeding left in the bag. - Check that the next bag has been ordered. - Check the label to ensure ingredients and solution are as ordered. The nurse should check the amount of feeding left in the bag, and that the next bag has been ordered to be sure the solution will not run out before the next bag is available. Parenteral nutrition solutions are only good for 24 hours and usually take some time for the pharmacy to mix for each patient. The label on the bag should be checked to ensure that the ingredients and solution are what was ordered. The patient would only receive insulin if the patient is experiencing hyperglycemia and was receiving sliding scale insulin or had diabetes mellitus. The insertion site should be checked, but the tubing is only changed every 72 hours unless lipids are being used.

The nurse is caring for a patient admitted to the hospital for asthma who weighs 186 lb (84.5 kg). During dietary counseling, the patient asks the nurse how much protein he should ingest each day. How many grams of protein does the nurse recommend should be included in the diet based on the patient's current weight? 24 41 68 93

68 The daily intake of protein should be between 0.8 and 1 g/kg of body weight. Thus this patient should take in between 68 and 84 g of protein per day in the diet.

The nurse is reviewing the laboratory test results for a 71-year-old patient with metastatic lung cancer. The patient was admitted with a diagnosis of malnutrition. The serum albumin level is 4.0 g/dL, and prealbumin is 10 mg/dL. What should this indicate to the nurse? - The albumin level is normal, and therefore the patient does not have protein malnutrition. - The albumin level is increased, which is a common finding in patients with cancer who have malnutrition. - Both the serum albumin and prealbumin levels are reduced, consistent with the admitting diagnosis of malnutrition. - Although the serum albumin level is normal, the prealbumin level more accurately reflects the patient's nutritional status.

Although the serum albumin level is normal, the prealbumin level more accurately reflects the patient's nutritional status. Prealbumin has a half-life of 2 days and is a better indicator of recent or current nutritional status. Serum albumin has a half-life of approximately 20 to 22 days. The serum level may lag behind actual protein changes by more than 2 weeks and is therefore not a good indicator of acute changes in nutritional status.

A patient who has suffered severe burns in a motor vehicle accident will soon be started on parenteral nutrition (PN). Which principle should guide the nurse's administration of the patient's nutrition? - Administration of PN requires clean technique. - Central PN requires rapid dilution in a large volume of blood. - Peripheral PN delivery is preferred over the use of a central line. - Only water-soluble medications may be added to the PN by the nurse.

Central PN requires rapid dilution in a large volume of blood. Central PN is hypertonic and requires rapid dilution in a large volume of blood. Because PN is an excellent medium for microbial growth, aseptic technique is necessary during administration. Administration through a central line is preferred over the use of peripheral PN, and the nurse may not add any medications to PN.

The nurse is teaching a female patient with type 1 diabetes mellitus about nutrition before discharge. She had surgery to revise a lower leg stump with a skin graft. What food should the nurse teach the patient to eat to best facilitate healing? Non-fat milk Chicken breast Fortified oatmeal Olive oil and nuts

Chicken breast High quality protein such as chicken breast is important for tissue repair. Although the non-fat milk, nuts, and fortified oatmeal have some protein, they do not have as much as the chicken breast.

When the nurse identifies an individual at risk for malnutrition with nutritional screening, what is the next step for the nurse to take? - Supply supplements between meals. - Encourage eating meals with others. - Have family bring in food from home. - Complete a full nutritional assessment.

Complete a full nutritional assessment. 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. The interventions may include supplements if ordered, family bringing food from home, and socializing with meals.

A patient who has dysphagia as a consequence of a stroke is receiving enteral feedings through a percutaneous endoscopic gastrostomy (PEG). What intervention should the nurse integrate into this patient's care? - Flush the tube with 30 mL of normal saline every 4 hours. - Flush the tube before and after feedings if the patient's feedings are intermittent. - Flush the PEG with 100 mL of sterile water before and after medication administration. - To prevent fluid overload, avoid flushing when the patient is receiving continuous feeding.

Flush the tube before and after feedings if the patient's feedings are intermittent. The nurse should flush feeding tubes with 30 mL of water (not normal saline) every 4 hours and before and after medication administration during continuous feeding or before and after intermittent feeding. Flushes of 100 mL are excessive and may cause fluid overload in the patient..

Which assessment should the nurse prioritize in the care of a patient who has recently begun receiving parenteral nutrition (PN)? - Skin integrity and bowel sounds - Electrolyte levels and daily weights - Auscultation of the chest and tests of blood coagulability - Peripheral vascular assessment and level of consciousness (LOC)

Electrolyte levels and daily weights The use of PN necessitates frequent and thorough assessments. Key focuses of these assessments include daily weights and close monitoring of electrolyte levels. Assessments of bowel sounds, integument, peripheral vascular system, LOC, chest sounds, and blood coagulation may be variously performed, but close monitoring of fluid and electrolyte balance supersedes these in importance.

A frail 74-year-old man with recent severe weight loss is instructed to eat a high-protein, high-calorie diet at home. If the man likes all of the items below, which would be the most appropriate for the nurse to suggest? -Orange juice and dry toast -Oatmeal, butter, and cream -Steamed carrots and chicken broth -Banana and unsweetened applesauce

Oatmeal, butter, and cream Oatmeal, butter, and cream are examples of food items that would be appropriate to include for a patient on a high-protein, high-calorie diet.

The nurse recognizes that the majority of patients' caloric needs should come from which source? Fats Proteins Polysaccharides Monosaccharides

Polysaccharides Carbohydrates should constitute between 45% and 65% of caloric needs, compared with 20% to 35% from fats and 10% to 35% from proteins. Polysaccharides are the complex carbohydrates that are contained in breads and grains. Monosaccharides are simple sugars. Central PN requires rapid dilution in a large volume of blood.

A patient who is unable to swallow because of progressive amyotrophic lateral sclerosis is prescribed enteral nutrition through a newly placed gastrostomy tube. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? - Irrigate the tube between feedings. - Provide wound care at the gastrostomy site. - Administer prescribed liquid medications through the tube. - Position the patient with a 45-degree head of bed elevation.

Position the patient with a 45-degree head of bed elevation. Rationale: Unlicensed assistive personnel (UAP) may position the patient receiving enteral feedings with the head of bed elevated. A licensed practical nurse/licensed vocational nurse (LPN/LVN) or an RN could perform the other activities.

An older patient was admitted with a fractured hip after being found on the floor of her home. She was extremely malnourished and started on parenteral nutrition (PN) 3 days ago. Which assessment finding would be of most concern to the nurse? - Blood glucose level of 125 mg/dL - Serum phosphate level of 1.9 mg/dL - White blood cell count of 10,500/µL - Serum potassium level of 4.6 mEq/L

Serum phosphate level of 1.9 mg/dL Refeeding syndrome can occur if a malnourished patient is started on aggressive nutritional support. Hypophosphatemia (serum phosphate level less than 2.4 mg/dL) is the hallmark of refeeding syndrome and could result in cardiac dysrhythmias, respiratory arrest, and neurologic problems. An increase in the blood glucose level is expected during the first few days after PN is started. The goal is to maintain a glucose range of 110 to 150 mg/dL. An elevated white blood cell count (greater than 11,000/µL) could indicate an infection. Normal serum potassium levels are between 3.5 and 5.0 mEq/L.

The nurse is evaluating the nutritional status of a 55-year-old man who is undergoing radiation treatment for oropharyngeal cancer. Which laboratory test would be the best indicator to determine if the patient has protein-calorie malnutrition? Serum transferrin C-reactive protein Serum prealbumin Alanine transaminase (ALT)

Serum prealbumin In the absence of an inflammatory condition, the best indicator of protein-calorie malnutrition (PCM) is prealbumin; prealbumin is a protein synthesized by the liver and indicates recent or current nutritional status. Decreased albumin and transferrin levels are other indicators that protein is deficient. C-reactive protein (CRP) is elevated during inflammation and is used to determine if prealbumin, albumin, and transferrin are decreased related to protein deficiency or an inflammatory process. Other indicators of protein deficiency include elevated serum potassium levels, low red blood cell counts and hemoglobin levels, decreased total lymphocyte count, elevated liver enzyme levels (ALT), and decreased levels of both fat-soluble and water-soluble vitamins.

The nurse is providing care for a 23-year-old woman who is a strict vegetarian. To prevent the consequences of iron deficiency, what should the nurse recommend? - Brown rice and kidney beans - Cauliflower and egg substitutes - Soybeans and hot breakfast cereal - Whole-grain bread and citrus fruits

Soybeans and hot breakfast cereal Vegetarians are at a particular risk for iron deficiency, a problem that can be prevented by regularly consuming high-iron foods such as hot cereals and soybeans. The other foods listed are not classified as high sources of iron.

The percentage of daily calories for a healthy individual consists of: a. 50% carbohydrates, 25% protein, 25% fat, and <10% of fat from saturated fatty acids b. 65% carbohydrates, 25% protein, 25% fat, and >10% of fat from saturated fatty acids c. 50% carbohydrates, 40% protein, 10% fat, and <10% of fat from saturated fatty acids d. 40% carbohydrates, 30% protein, 30% fat, and >10% of fat from saturated fatty acids

a. 50% carbohydrates, 25% protein, 25% fat, and <10% of fat from saturated fatty acids Rationale: The 2005 Dietary Guidelines for Americans recommend that 45% to 65% of total calories should come from carbohydrates. Ideally, 10% to 35% of daily caloric needs should come from protein. Individuals should limit their fat intake to 20% to 35% of total calories. Additional recommendations focus on the type of fat consumed because diets high in excess calories, usually in the form of fats, contribute to the development of obesity. Individuals should consume less than 10% of calories from saturated fatty acids, limit intake of fat and oils high in trans fatty acids, and should limit intake of dietary cholesterol to 300 mg/day.

The nurse confirms initial placement of a blindly inserted small bore NG feeding tube by: a. x-ray b. air insufflation c. observing patient for coughing d. pH measurement of gastric aspirate

a. x-ray Rationale: The nurse should obtain x-ray confirmation to determine whether a blindly placed nasogastric or orogastric tube (small bore or large bore) is properly positioned in the gastrointestinal tract before administering feedings or medications.

A patient is receiving peripheral parenteral nutrition. The parenteral nutrition solution is completed before the new solution arrives on the unit. The nurse administers: a. 20% intralipids b. 5% dextrose solution c. 0.45% normal saline solution d. 5% lactated Ringer's solution

b. 5% dextrose solution Rationale: If a peripheral parenteral nutrition (PPN) formula bag empties before the next solution is available, a 5% dextrose solution (based on the amount of dextrose in the peripheral PN solution) may be administered to prevent hypoglycemia.

During starvation, the order in which the body obtains substrate for energy is: a. visceral protein, skeletal protein, fat, glycogen b. glycogen, skeletal protein, fat stores, visceral protein c. visceral protein, fat stores, glycogen, skeletal protein d. fat stores, skeletal protein, visceral protein, glycogen

b. glycogen, skeletal protein, fat stores, visceral protein Rationale: Initially, the body selectively uses carbohydrates (e.g., glycogen) rather than fat and protein to meet metabolic needs. These carbohydrate stores, found in the liver and muscles, are minimal and may be totally depleted within 18 hours. After carbohydrate stores are depleted, skeletal protein begins to be converted to glucose for energy. Within 5 to 9 days, body fat is fully mobilized to supply much of the needed energy. In prolonged starvation, up to 97% of calories are provided by fat, and protein is conserved. Depletion of fat stores depends on the amount available, but fat stores typically are used up in 4 to 6 weeks. After fat stores are used, body or visceral proteins, including those in internal organs and plasma, can no longer be spared and rapidly decrease because they are the only remaining body source of energy available.

A patient with anorexia nervosa shows signs of malnutrition. During initial referring, the nurse carefully assesses the patient for: a. hyperkalemia b. hypoglycemia c. hypercalcemia d. hypophosphatemia

d. hypophosphatemia Rationale: Refeeding syndrome is characterized by fluid retention, electrolyte imbalances (e.g., hypophosphatemia, hypokalemia, hypomagnesemia), and hyperglycemia. Conditions that predispose patients to refeeding syndrome include long-standing malnutrition states such as those induced by chronic alcoholism, vomiting and diarrhea, chemotherapy, and major surgery. Refeeding syndrome can occur any time a malnourished patient is started on aggressive nutritional support. Hypophosphatemia is the hallmark of refeeding syndrome, and it is associated with serious outcomes, including cardiac dysrhythmias, respiratory arrest, and neurologic disturbances (e.g., paresthesias).

A complete nutritional assessment including anthropometric measurements is important for the patient who: a. has a BMI of 25.5 kg/m2. b. complains of frequent nocturne c. reports a 5-year history of constipation d. reports an unintentional weight loss of 10lb in 2 months

d. reports an unintentional weight loss of 10lb in 2 months Rationale: A loss of more than 5% of usual body weight over 6 months, whether intentional or unintentional, is a critical indicator for further assessment.