ch14.doc

[Osborn] chapter 14

Learning Outcomes [Number and Title] Learning Outcome 1 Explain components of a comprehensive nutrition assessment

as part of the nursing care process.Learning Outcome 2 Apply the nutritional component of national standards for

disease prevention and treatment.Learning Outcome 3 Discuss the metabolic effects of physiological stress and the

potential impact on nutrition status.Learning Outcome 4 Outline the nutrition therapy guidelines for patients with

physiological stress, such as postoperative wound healing and burn injury.

Learning Outcome 5 Differentiate among the principles of medical nutrition therapy in treating general medical conditions.

Learning Outcome 6 Explain the indications and nursing interventions associated with enteral and parenteral nutrition support.

Learning Outcome 7 Defend the important role of nursing care in successful medical nutrition therapy.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for PracticeCopyright 2010 by Pearson Education, Inc.

1. A patient asks why her waist circumference measurement is needed. Which of the following is the nurse’s best response to this patient?

1. “It helps in determining the risk for cardiovascular disease.”2. “It helps determine if the BMI is accurate.”3. “It is more reliable that using skinfold measurements.”4. “It is the only tool that can reliably provide information on nutritional status.”

Answer: “It helps in determining the risk for cardiovascular disease.”

Rationale: Waist circumference is one measurement used to help determine a patient’s risk for the development of cardiovascular disease. Body mass index (BMI) is used to calculate appropriate weight for height. Skinfold measurements determine body composition. There is no single measurement or parameter to determine a patient’s nutritional status.

Cognitive Level: ApplyingNursing Process: AssessmentClient Need: Health Promotion and MaintenanceLO: 1


2. The nurse has identified a nutritional learning need for a patient. Which of the following is the best instruction for the nurse to give this patient?

1. Use the WAVE or REAP tool.2. Provide the results of laboratory data.3. Ask the patient to complete a 1-day food diary.4. Discuss the importance of skinfold testing.

Correct Answer: Use the WAVE or REAP tool.

Rationale: The Rapid Eating and Activity of Patients (REAP) and Weight, Activity, Variety and Excess (WAVE) validated tools were developed to improve nutrition assessment and education during clinical encounters. Laboratory data is useful as an adjunct to determining the nutritional status of a patient. A 1-day food recall diary is helpful when assessing a patient’s nutritional status. Skinfold testing is used to determine body fat and muscle mass.

Cognitive Level: AnalyzingNursing Process: PlanningClient Need: Physiological IntegrityLO: 1


3. A nurse is conducting a nutrition assessment on a client who is admitted for hip replacement surgery. The client reports that he is Jewish and follows the kosher dietary tradition. Which of the following statements by the nurse will have the greatest impact on the client’s nutritional health during his hospitalization?

1. “Please tell me more about your preferred eating habits.”2. “Remember that you will need to increase your protein input postsurgery.”3. “I’ll arrange for a dietitian to come and discuss your food requirements with

you.”4. “Would you be more comfortable with having your family bring you food

from home?”

Correct Answer: “Please tell me more about your preferred eating habits.”

Rationale: Asking the client to discuss preferred eating habits and requirements facilitates a discussion between the nurse and client that will assistant in meeting the client’s cultural and religious food needs. While the remaining options are not inappropriate, they do not best facilitate the exchange of dietary-related information between nurse and client. Focusing on protein consumption limits the exchange, while arranging for the dietitian to discuss the situation allows the nurse to avoid the conversation. Placing the responsibility to properly nourish the client upon the family is not appropriate since it neglects a vital nursing duty.

Cognitive Level: AnalyzingNursing Process: ImplementationClient Need: Health Promotion and MaintenanceLO: 1


4. A nurse is advising a client who is concerned about losing weight. When discussing daily nutritional requirements, the client reports hating vegetables. Which of the following statements best reflects the nurse’s understanding of the current recommendations appropriate for this client?

1. “Can you try eating a serving of carrots or spinach either cooked or in a salad daily?”

2. “If you want to maintain a healthy weight, eating vegetables will help tremendously.”

3. “Vegetables are generally low in calories, and should be incorporated in the daily diet.”

4. “Would you consider drinking a vegetable juice in place of whole vegetables?”

Correct Answer: “Can you try eating a serving of carrots or spinach either cooked or in a salad daily?”

Rationale: Asking if the client is willing to eat carrots and/or spinach reflects an understanding of the importance of consuming at least one serving of either dark green or orange vegetables daily. This is especially important for a client who is likely to not regularly consume adequate amounts of vegetables, and offers suggestions regarding vegetables the client may identify as being ones he will eat. While the remaining options are not inappropriate, they do not best address the client’s need to add vegetables into the daily diet. Encouraging the consumption of vegetables because they are helpful, they are low in calories, or suggesting an alternative to whole vegetables does not directly address the client’s reluctance to eat vegetables.

Cognitive Level: AnalyzingNursing Process: EvaluationClient Need: Health Promotion and MaintenanceLO: 2


5. A patient of childbearing age asks the nurse what the most important thing she can do to improve her nutritional status is. The nurse should suggest that the patient:

1. Ask her doctor if she has iron deficiency anemia; if so, begin treatment.2. Be physically active every day.3. Consume low-fat milk products.4. Choose foods with little salt.

Answer: Ask her doctor if she has iron deficiency anemia; if so, begin treatment.

Rationale: According to the National Guidelines Healthy People 2010 Nutritional Objectives, iron deficiency anemia needs to be reduced in females of childbearing age. Although important, being physically active, consuming low-fat milk products, and choosing foods with little salt will not assist with the treatment of iron deficiency anemia.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Health Promotion and MaintenanceLO: 2


6. The nurse has been asked to review written material on nutrition that is being distributed at a senior citizen center. The nurse recognizes that which of the following statements does not accurately reflect the Healthy People 2010 Nutrition Objectives and should be revised?

1. Saturated fats should account for no more than 30% of one’s daily calories.2. Sodium intake should be less than 2400 mg daily.3. An adult should consume at least two servings of fruit daily. 4. The typical diet should contain at least three whole-grain choices daily.

Correct Answer: Saturated fats should account for no more than 30% of one’s daily calories.

Rationale: Saturated fats should account for no more than 10% of one’s daily calories; the information should be revised. The remaining options reflect recommendations currently included in the Healthy People 2010 Nutrition Objectives.

Cognitive Level: ApplyingNursing Process: PlanningClient Need: Health Promotion and MaintenanceLO: 2


7. The nurse is planning care for a postoperative patient. Which of the following should be included when planning for this patient’s nutritional needs?

1. Daily caloric intake should be increased.2. Calories should be limited because of reduced activity.3. Protein intake should be restricted. 4. Carbohydrate intake should be restricted.

Answer: Daily caloric intake should be increased.

Rationale: Major surgery is considered a physiological stress. Physiological stress can lead to hypermetabolism, which is an increase in resting energy needs. Physiological stress also causes hypercatabolism, which is the breakdown of skeletal muscle to meet the body’s energy needs. Calories, protein, and carbohydrates should not be restricted.

Cognitive Level: AnalyzingNursing Process: PlanningClient Need: Physiological IntegrityLO: 3


8. A patient undergoing treatment for cancer is admitted to the burn unit. To support this patient’s nutritional needs, the nurse should:

1. Discuss nutritional needs with a dietitian to ensure all physiological needs are met.

2. Plan to provide extra protein to support the burn injuries.3. Monitor the patient for signs of deteriorating nutritional status.4. Restrict protein while increasing calories.

Correct Answer: Discuss nutritional needs with a dietitian to ensure all physiological needs are met.

Rationale: The nurse should consult with a dietitian to ensure that all of the patient’s physiological needs are met. Physiological stress includes thermal injuries, trauma, sepsis, and major surgeries. Cancer treatment could cause physiological changes to the body. The focus of care should not be just on the burn injury. The patient is undergoing treatment for cancer and could be at a nutritional disadvantage, so monitoring the patient would not be sufficient to meet the patient’s needs. Protein should not be restricted in the presence of a physiological stress.

Cognitive Level: ApplyingNursing Process: PlanningClient Need: Physiological IntegrityLO: 3


9. The nurse is caring for a client receiving an extensive regime of chemotherapy. The nurse recognizes that the client’s ability to avoid muscle wasting during this treatment is most affected by:

1. His pretreatment nutritional status.2. His general attitude related to food.3. The management of any nausea and vomiting.4. The nutritional value of the foods the client is likely to eat.

Correct Answer: His pretreatment nutritional status.

Rationale: The patient who is already malnourished before surgery, injury, or disease will have less available body stores to draw on during a metabolically challenging circumstance. The remaining options are applicable to all clients and not specifically related to muscle wasting.



10. The nurse is providing care to a patient in the burn unit. Which of the following should the nurse do to ensure an adequate nutritional status for this patient?

Select all that apply.

1. Calculate total body surface burned to ensure 35 to 40 calories per kg of body weight is provided.

2. Report daily weights to ensure that a weight loss of >10% does not occur.3. Plan for a parenteral nutrition access site.4. Keep the patient NPO.5. Ensure 5 gm protein per kg is provided daily.

Answers: 1. Calculate total body surface burned to ensure 35 to 40 calories per kg of body

weight is provided.2. Report daily weights to ensure that a weight loss of >10% does not occur.

Rationale: Calculate total body surface burned to ensure 35 to 40 calories per kg of body weight is provided. The patient’s nutritional needs, as well as wound-healing needs, must be met. The percentage of body surface burned needs to be calculated to ensure that 35 to 40 calories per kg of body weight are provided. Report daily weights to ensure that a weight loss of >10% does not occur. Daily weights are to be done to ensure the patient is not losing weight. Weight loss of >10% will lead to impaired healing. Plan for a parenteral nutrition access site. Enteral feedings are recommended for burn patients. Keep the patient NPO. The patient should not be kept NPO. Ensure 5 gm protein per kg is provided daily. Up to 2 grams of protein per kg of weight per day is suggested for healing.



11. The nurse caring for a patient recovering from a total hip replacement should do which of the following to best ensure this patient’s nutritional needs?

1. Assess for tolerance to diet and progress from clear liquid to another level as tolerated.

2. Maintain clear liquid diet with intravenous fluid supplementation.3. Plan to support nutritional status with enteral feedings.4. Plan to support nutritional status with parenteral supplements.

Correct Answer: Assess for tolerance to diet and progress from clear liquids to another level as tolerated.

Rationale: Adequate nutrition in the postoperative period is essential for normal metabolic functioning and wound healing. The patient should be transitioned to an oral diet or enteral feedings as quickly as possible. Prolonged NPO status, peripheral intravenous fluids, or extensive use of clear liquids is not sufficient to support nutritional needs. There is no evidence to suggest that the patient will need enteral feedings or parenteral supplementation.



12. The wife of a client who has experienced third-degree burns on major portions of both arms asks the nurse, “Why is it so important for my husband to eat so much? He’s had hypertension for several years and was just successful at losing 15 pounds.” Which of the following responses shows the nurse has an understanding of this client’s nutritional needs?

1. “His body is using up all the calories to meet the energy needs he has right now.”

2. “The dietitian is careful to give him only the calories he needs.”3. “His health care team is monitoring his blood pressure to be sure he is safe.”4. “There will be time after he recovers to concentrate on losing any weight he

gains.”

Correct Answer: “His body is using up all the calories to meet the energy needs he has right now.”

Rationale: The client is experiencing calorie needs for both the metabolic response to a burn as well as the healing process. The remaining options do not provide an adequate explanation for the wife’s concerns. Replying that the dietitian is responsible for determining caloric needs and suggesting the weight gain should be addressed later are examples of demeaning the wife’s concerns. The statement that the health team is monitoring his blood pressure ignores the wife’s concerns about weight gain.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Health Promotion and MaintenanceLO: 4


13. The nurse recognizes that a postoperative nutritional objective specifically appropriate for a client who experienced a kidney transplant is to:


1. Correct any preexisting deficiencies. 2. Begin the introduction of previously restricted foods.3. Provide necessary support to promote wound healing.4. Meet the demands of any existing hypermetabolic process.5. Minimize the affects of postsurgical nausea and vomiting.

Correct Answer: 1. Correct any preexisting deficiencies. 2. Begin the introduction of previously restricted foods.3. Provide necessary support to promote wound healing.4. Meet the demands of any existing hypermetabolic process.

Rationale: Correct any preexisting deficiencies. This client’s postoperative recovery requires adequate nutrition for wound healing, repletion of nutrition stores, and support for the hypermetabolic demands of the surgery. Begin the introduction of previously restricted foods. Patients undergoing renal or hepatic transplantation may have been on a restrictive diet that potentially may be liberalized following surgery when organ function improves. Provide necessary support to promote wound healing. This client’s postoperative recovery requires adequate nutrition for wound healing. Meet the demands of any existing hypermetabolic process. This client’s postoperative recovery requires adequate nutrition to support the hypermetabolic demands of the surgery. Minimize the affects of postsurgical nausea and vomiting. To minimize the affects of post surgical nausea and vomiting is a goal appropriate for all postsurgical clients, and is not specific to this client.

Cognitive Level: AnalyzingNursing Process: PlanningClient Need: Health Promotion and MaintenanceLO: 5


14. The nurse is planning care for a patient with liver cirrhosis. Which of the following should be included to best ensure an adequate nutritional status for this patient?

1. Provide small, more frequent, high-protein meals.2. Limit protein and B vitamin intake.3. Ensure caloric intake of 10 to 15 calories per kg of body weight.4. Encourage foods higher in sodium.

Correct Answer: Provide small, more frequent, high-protein meals.

Rationale: Nutrition therapy in cirrhosis cases should include adequate protein intake to support hepatic regeneration. The B vitamins are depleted in liver cirrhosis and should not be restricted. Calorie needs can vary but are estimated to be between 35 to 40 calories per kg of body weight. Sodium intake will depend on the presence or absence of ascites or edema.



15. A patient is admitted with celiac sprue. Which of the following should be done to address this patient’s nutritional needs?

1. Identify gluten-containing foods and eliminate them from the diet.2. Limit iron and B vitamin intake.3. Encourage the use of distilled vinegar.4. Instruct the patient to consume products identified as “new and improved.”

Answer: Identify gluten-containing foods and eliminate them from the diet.

Rationale: Celiac sprue is a lifelong condition in which the villi in the small intestines are damaged from gluten in the diet. Gluten-containing foods must be eliminated from the diet to avoid disease symptoms. Iron and B vitamins are often added to wheat-based products. When wheat-based products are not consumed, iron and B vitamin deficiencies can result. Distilled vinegar can contain gluten and should be avoided. Food products labeled as “new and improved” should be studied for the contents, since they might contain gluten products.



16. A patient with a nasogastric tube for enteral feedings was coughing. Which of the following should the nurse do prior to using the tube?

1. Reassess for tube placement.2. Flush the tube with sterile water.3. Provide a bolus feeding to assess for patient tolerance.4. Place the head of the bed at a 10-degree angle.

Answer: Reassess for tube placement.

Rationale: Severe coughing can lead to nasal tube displacement. The tube placement should be reassessed before using. Nothing that could cause aspiration should be placed into the tube until placement has been ensured. The head of the bed should be placed at a 45-degree angle to reduce the risk of aspiration.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Physiological IntegrityLO: 6


17. A patient is being weaned from parenteral nutrition. Which of the following interventions would support the weaning process?

1. Reduce the rate according to protocol.2. Discontinue the nutrition and provide regular meals.3. Discontinue parenteral nutrition and begin enteral nutrition.4. Discontinue parenteral nutrition and begin peripheral nutrition with dextrose

20%.

Correct Answer: Reduce the rate according to protocol.

Rationale: Weaning should be conducted according to the organization’s protocol. Weaning a patient from parenteral nutrition can be accomplished by either reducing the amount administered per hour or by substituting with a high-dextrose solution administered peripherally. Parenteral nutrition should not be discontinued without assessing the patient’s tolerance for a diet or enteral nutrition. Solutions higher than 10% dextrose are hypertonic and cannot be administered peripherally.

Cognitive Level: AnalyzingNursing Process: ImplementationClient Need: Physiological IntegrityLO: 6


18. A client receiving enteral feeding via a nasogastric tube (NG) has also been prescribed several medications. The nurse caring for this client recognizes that the initial intervention regarding the use of the NG for medication administration is to:

1. Determine whether this administration route is appropriate for the prescribed

medications.2. Flush the NG tube before, between, and after medication delivery.3. Confirm that there are no incompatibility issues between the medications and

the enteral formula.4. Place the head of the client’s bed at a 45-degree angle during and immediately

after medication delivery.

Correct Answer: Determine whether this administration route is appropriate for the prescribed medications.

Rationale: Determining whether this administration route is appropriate for the prescribed medications is the correct initial intervention; many but not all medications may be administered via the NG route. The nurse should then confirm that no incompatibility issue exists, elevate the client’s bed to 45 degrees, and flush the tubing before, between, and after medication delivery.



19. The nurse is evaluating the client’s knowledge related to healthy food choices appropriate for a weight-loss diet. The nurse recognizes a need for further education when the client selects which of the following from the dinner menu?

1. Pork sparerib and garlic mashed potatoes2. Grilled tuna and green salad3. Pasta with olive oil, tomatoes, and garlic4. Baked rosemary chicken and sautéed spinach

Correct Answer: Pork sparerib and garlic mashed potatoes

Rationale: Pork sparerib and garlic mashed potatoes is a high-calorie meal selection and would suggest needed reinforcement of healthy, low-calorie food choices. The remaining options reflect low-calorie food selections.

Cognitive Level: AnalyzingNursing Process: EvaluationClient Need: Health Promotion and MaintenanceLO: 7


20. The nurse is planning care for a patient who is at risk for developing a pressure ulcer. Which of the following should be done to best address this patient’s nutritional needs?

1. Consult with a dietitian regarding caloric needs to support this patient’s risk.2. Conduct a 3-day food diary.3. Guide the patient to select foods high in B vitamins.4. Guide the patient to select low-protein foods.

Answer: Consult with a dietitian regarding caloric needs to support this patient’s risk.

Rationale: The patient has been identified as being at risk for developing a pressure ulcer. Efforts should be made to support this patient’s risk; this is best done by consulting with a dietitian regarding caloric needs. Conducting a 3-day food diary might provide additional information regarding the patient’s actual caloric intake. Foods higher in vitamin C and zinc are necessary for wound healing. The patient should not be encouraged to select or avoid any specific foods.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Physiological IntegrityLO: 7


21. The nurse caring for an elderly client who recently experienced a cerebral vascular accident (CVA or stroke) will recognize which of the following as signs of dysphagia?


1. Drooling2. Frequent throat clearing3. Pocketing of food in the cheeks4. Anorexia 5. Slurred speech

Correct Answer: 1. Drooling2. Frequent throat clearing3. Pocketing of food in the cheeks

Rationale: Drooling. Drooling is typically associated with dysphagia. Frequent throat clearing. Frequent throat clearing is typically associated with dysphagia. Pocketing of food in the cheeks. Pocketing of food in the cheeks is typically associated with dysphagia. Anorexia. Anorexia is noted in clients with eating disorders or severe medical disease processes. Slurred speech. Slurred speech is more likely observed in a client with neurological deficits.

Cognitive Level: ApplyingNursing Process: AssessmentClient Need: Health Promotion and MaintenanceLO: 7


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