(MBAA 604) Chapter 60: Care of Patients with Malnutrition: Undernutrition and Obesity Ignatavicius: Medical-Surgical Nursing, 8th Edition

Chapter 60: Care of Patients with Malnutrition: Undernutrition and Obesity Ignatavicius: Medical-Surgical Nursing, 8th Edition MULTIPLE CHOICE 1. A client is in the family practice clinic. To day the client weighs 186.4 pounds (84.7 kg). Six months ago the client weighed 211.8 pounds (96.2 kg). What action by the nurse is best? a. Ask the client if the weight loss was intentional. b. Determine if there are food allergies or intolerances. c. Perform a comprehensive nutritional assessment. d. Perform a rapid bedside blood glucose test. ANS: A This client has had a 12% weight loss. The nurse first determines if the weight loss was intentional. If not, then the nurse proceeds to a comprehensive nutritional assessment. Food intolerances are part of this assessment. Depending on risk factors and other findings, a blood glucose test may be warranted. DIF: Applying/Application REF: 1236 KEY: Nutrition| nutritional disorders| nutritional assessment| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. A nursing student is studying nutritional problems and learns that kwashiorkor is distinguished from marasmus with which finding? a. Deficit of calories b. Lack of all nutrients c. Specific lack of protein d. Unknown cause of malnutrition ANS: C Kwashiorkor is a lack of protein when total calories are adequate. Marasmus is a caloric malnutrition. DIF: Remembering/Knowledge REF: 1236 KEY: Nutritional disorders| nutritional assessment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse is reviewing laboratory values for several clients. Which value causes the nurse to conduct nutritional assessments as a priority? a. Albumin: 3.5 g/dL b. Cholesterol: 142 mg/dL c. Hemoglobin: 9.8 mg/dL d. Prealbumin: 28 mg/dL ANS: B A cholesterol level below 160 mg/dL is a possible indicator of malnutrition, so this client would be at highest priority for a nutritional assessment. The albumin and prealbumin levels are normal. The low hemoglobin could be from several problems, including dietary deficiencies, hemodilution, and bleeding. DIF: Remembering/Knowledge REF: 1239 KEY: Nutritional disorders| nutritional assessment| laboratory values MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A client is receiving bolus feedings through a Dobhoff tube. What action by the nurse is most important? a. Auscultate lung sounds after each feeding. b. Check tube placement before each feeding. c. Check tube placement every 8 hours. d. Weigh the client daily on the same scale. ANS: B For bolus feedings, the nurse checks placement of the tube per institutional policy prior to each feeding, which is more often than every 8 hours during the day. Auscultating lung sounds is also important, but this will indicate a complication that has already occurred. Weighing the client is important to determine if nutritional goals are being met. DIF: Applying/Application REF: 1243 KEY: Nutritional disorders| tube feedings| equipment safety MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 5. A client having a tube feeding begins vomiting. What action by the nurse is most appropriate? a. Administer an antiemetic. b. Check the client’s gastric residual. c. Hold the feeding until the nausea subsides. d. Reduce the rate of the tube feeding by half. ANS: C The nurse should hold the feeding until the nausea and vomiting have subsided and consult with the provider on the rate at which to restart the feeding. Giving an antiemetic is not appropriate. After vomiting, a gastric residual will not be accurate. The nurse should not continue to feed the client while he or she is vomiting. DIF: Applying/Application REF: 1244 KEY: Nutritional disorders| tube feedings MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A nurse is caring for a client receiving enteral feedings through a Dobhoff tube. What action by the nurse is best to prevent hyperosmolarity? a. Administer free-water boluses. b. Change the client’s formula. c. Dilute the client’s formula. d. Slow the rate of infusion. ANS: A Proteins and sugar molecules in the enteral feeding product contribute to dehydration due to increased osmolarity. The nurse can administer free-water boluses after consulting with the provider on the appropriate amount and timing of the boluses, or per protocol. The client may not be able to switch formulas. Diluting the formula is not appropriate. Slowing the rate of the infusion will not address the problem. DIF: Analyzing/Analysis REF: 1242 KEY: Nutritional disorders| tube feedings MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 7. A nurse is caring for four clients receiving enteral tube feedings. Which client should the nurse see first? a. Client with a blood glucose level of 138 mg/dL b. Client with foul-smelling diarrhea c. Client with a potassium level of 2.6 mEq/L d. Client with a sodium level of 138 mEq/L ANS: C The potassium is critically low, perhaps due to hyperglycemia-induced hyperosmolarity. The nurse should see this client first. The blood glucose reading is high, but not extreme. The sodium is normal. The client with the diarrhea should be seen last to avoid cross- contamination. DIF: Applying/Application REF: 1244 KEY: Nutritional disorders| tube feedings| electrolyte imbalances MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 8. A nurse and a registered dietitian are assessing clients for partial parenteral nutrition (PPN). For which client would the nurse suggest another route of providing nutrition? a. Client with congestive heart failure b. Older client with dementia c. Client who has multiorgan failure d. Client who is post gastric resection ANS: A Clients receiving PPN typically get large amounts of fluid volume, making the client with heart failure a poor candidate. The other candidates are appropriate for this type of nutritional support. DIF: Analyzing/Analysis REF: 1244 KEY: Nutritional disorders| heart failure| parenteral nutrition| nursing assessment MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 9. A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes the client’s pulse is 128 beats/min, blood pressure is 98/56 mm Hg, and skin turgor is dry. What action should the nurse perform next? a. Assess the 24-hour fluid balance. b. Assess the client’s oral cavity. c. Prepare to hang a normal saline bolus. d. Turn up the infusion rate of the TPN. ANS: A This client has clinical indicators of dehydration, so the nurse calculates the client’s 24-hour intake, output, and fluid balance. This information is then reported to the provider. The client’s oral cavity assessment may or may not be consistent with dehydration. The nurse may need to give the client a fluid bolus, but not as an independent action. The client’s dehydration is most likely due to fluid shifts from the TPN, so turning up the infusion rate would make the problem worse, and is not done as an independent action. DIF: Analyzing/Analysis REF: 1245 KEY: Nutritional disorders| parenteral nutrition| intake and output MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. A client tells the nurse about losing weight and regaining it multiple times. Besides eating and exercising habits, for what additional data should the nurse assess as the priority? a. Economic ability to join a gym b. Food allergies and intolerances c. Psychosocial influences on weight d. Reasons for wanting to lose weight ANS: C While all topics might be important to assess, people who lose and gain weight in cycles often are depressed or have poor self-esteem, which has a negative effect on weight-loss efforts. The nurse assesses the client’s psychosocial status as the priority. DIF: Applying/Application REF: 1247 KEY: Nutritional disorders| psychosocial response| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Psychosocial Integrity 11. A client asks the nurse about drugs for weight loss. What response by the nurse is best? a. “All weight-loss drugs can cause suicidal ideation.” b. “No drugs are currently available for weight loss.” c. “Only over-the-counter medications are available.” d. “There are three drugs currently approved for this.” ANS: D There are three drugs available by prescription for weight loss, including orlistat (Xenical), lorcaserin (Belviq), and phentermine-topiramate (Qsymia). Suicidal thoughts are possible with lorcaserin and phentermine-topiramate. Orlistat is also available in a reduced-dose over-the-counter formulation. DIF: Understanding/Comprehension REF: 1249 KEY: Nutritional disorders| obesity| anorectic drugs MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 12. A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority? a. Assess the client’s pain. b. Check the surgical incision. c. Ensure an adequate airway. d. Program the morphine pump. ANS: C All actions are appropriate care measures for this client; however, airway is always the priority. Bariatric clients tend to have short, thick necks that complicate airway management. DIF: Applying/Application REF: 1251 KEY: Nutritional disorders| obesity| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 13. A morbidly obese client is admitted to a community hospital that does not typically care for bariatric-sized clients. What action by the nurse is most appropriate? a. Assess the client’s readiness to make lifestyle changes. b. Ensure adequate staff when moving the client. c. Leave siderails down to prevent pressure ulcers. d. Reinforce the need to be sensitive to the client. ANS: B Many hospitals that see bariatric-sized clients have appropriate equipment for this population. A hospital that does not typically see these clients is less likely to have appropriate equipment, putting staff and client safety at risk. The nurse ensures enough staffing is available to help with all aspects of mobility. It may or may not be appropriate to assess the client’s willingness to make lifestyle changes. Leaving the siderails down may present a safety hazard. The staff should be sensitive to this client’s situation, but safety takes priority. DIF: Applying/Application REF: 1250 KEY: Nutritional disorders| obesity| patient safety| staff safety MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 14. A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says “I didn’t know it would be this hard to live like this.” What response by the nurse is best? a. Assess the client’s coping and support systems. b. Inform the client that things will get easier. c. Re-educate the client on needed dietary changes. d. Tell the client lifestyle changes are always hard. ANS: A The nurse should assess this client’s coping styles and support systems in order to provide holistic care. The other options do not address the client’s distress. DIF: Applying/Application REF: 1252 KEY: Nutritional disorders| obesity| psychosocial response| coping MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Psychosocial Integrity 15. A client has been prescribed lorcaserin (Belviq). What teaching is most appropriate? a. “Increase the fiber and water in your diet.” b. “Reduce fat to less than 30% each day.” c. “Report dry mouth and decreased sweating.” d. “Lorcaserin may cause loose stools for a few days.” ANS: A This drug can cause constipation, so the client should increase fiber and water in the diet to prevent this from occurring. Reducing fat in the diet is important with orlistat. Lorcaserin can cause dry mouth but not decreased sweating. Loose stools are common with orlistat. DIF: Understanding/Comprehension REF: 1249 KEY: Nutritional disorders| obesity| patient education| anorectic drugs MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 16. Several nurses have just helped a morbidly obese client get out of bed. One nurse accesses the client’s record because “I just have to know how much she weighs!” What action by the client’s nurse is most appropriate? a. Make an anonymous report to the charge nurse. b. State “That is a violation of client confidentiality.” c. Tell the nurse “Don’t look; I’ll tell you her weight.” d. Walk away and ignore the other nurse’s behavior. ANS: B Ethical practice requires the nurse to speak up and tell the other nurse that he or she is violating client confidentiality rules. The other responses do not address this concern. DIF: Applying/Application REF: 1248 KEY: Ethics| confidentiality MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 17. A nurse attempted to assist a morbidly obese client back to bed and had immediate pain in the lower back. What action by the nurse is most appropriate? a. Ask another nurse to help next time. b. Demand better equipment to use. c. Fill out and file a variance report. d. Refuse to assist the client again. ANS: C The nurse should complete a variance report per agency policy. Asking another nurse to help and requesting better equipment are both good ideas, but the nurse may have an injury that needs care. It would be unethical to refuse to care for this client again. DIF: Applying/Application REF: 1246 KEY: Nutritional disorders| obesity| variance report MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 18. A nurse is caring for a morbidly obese client. What comfort measure is most important for the nurse to delegate to the unlicensed assistive personnel (UAP)? a. Designating “quiet time” so the client can rest b. Ensuring siderails are not causing excess pressure c. Providing oral care before and after meals and snacks d. Relaying any reports of pain to the registered nurse ANS: B All actions are good for client comfort, but when dealing with an obese client, the staff should take extra precautions, such as ensuring the siderails are not putting pressure on the client’s tissues. The other options are appropriate for any client, and are not specific to obese clients. DIF: Applying/Application REF: 1246 KEY: Nutritional disorders| obesity| comfort measures| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 19. A client is awaiting bariatric surgery in the morning. What action by the nurse is most important? a. Answering questions the client has about surgery b. Beginning venous thromboembolism prophylaxis c. Informing the client that he or she will be out of bed tomorrow d. Teaching the client about needed dietary changes ANS: B Morbidly obese clients are at high risk of venous thromboembolism and should be started on a regimen to prevent this from occurring as a priority. Answering questions about the surgery is done by the surgeon. Teaching is important, but safety comes first. DIF: Applying/Application REF: 1251 KEY: Nutritional disorders| obesity| venous thromboembolism MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 20. A client is receiving total parenteral nutrition (TPN). What action by the nurse is most important? a. Assessing blood glucose as directed b. Changing the IV dressing each day c. Checking the TPN with another nurse d. Performing appropriate hand hygiene ANS: D Clients on TPN are at high risk for infection. The nurse performs appropriate hand hygiene as a priority intervention. Checking blood glucose is also an important measure, but preventing infection takes priority. The IV dressing is changed every 48 to 72 hours. TPN does not need to be double-checked with another nurse. DIF: Applying/Application REF: 1245 KEY: Nutritional disorders| parenteral nutrition| infection control MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 21. A nurse is weighing and measuring a client with severe kyphosis. What is the best method to obtain this client’s height? a. Add the trunk and leg measurements. b. Ask the client how tall he or she is. c. Estimate by measuring clothing. d. Use knee-height calipers. ANS: D A sliding blade knee-height caliper is used to obtain the height of a client who cannot stand upright, such as those with kyphosis or lower extremity contractures. The other methods will not yield accurate data. DIF: Remembering/Knowledge REF: 1236 KEY: Nutritional assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 1. The nurse understands that malnutrition can occur in hospitalized clients for several reasons. Which are possible reasons for this to occur? (Select all that apply.) a. Cultural food preferences b. Family bringing snacks c. Increased need for nutrition d. Need for NPO status e. Staff shortages ANS: A, C, D, E Many factors increase the hospitalized client’s risk for nutritional deficits. Cultural food preferences may make hospital food unpalatable. Ill clients have increased nutritional needs but may be NPO for testing or treatment, or have a loss of appetite from their illness. Staff shortages impact clients who need to be fed or assisted with meals. The family may bring snacks that are either healthy or unhealthy, so without further information, the nurse cannot assume the snacks are leading to malnutrition. DIF: Remembering/Knowledge REF: 1237 KEY: Nutritional disorders MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. A nurse has delegated feeding a client to an unlicensed assistive personnel (UAP). What actions does the nurse include in the directions to the UAP? (Select all that apply.) a. Allow 30 minutes for eating so food doesn’t get spoiled. b. Assess the client’s mouth while providing premeal oral care. c. Ensure warm and cold items stay at appropriate temperatures. d. Remove bedpans, soiled linens, and other unpleasant items. e. Sit with the client, making the atmosphere more relaxed. ANS: C, D, E The UAP should make sure food items remain at the appropriate temperatures for maximum palatability. Removing items such as bedpans, urinals, or soiled linens helps make the atmosphere more conducive to eating. The UAP should sit, not stand, next to the client to promote a relaxing experience. The client, especially older clients who tend to eat more slowly, should not be rushed. Assessment is done by the nurse. DIF: Understanding/Comprehension REF: 1240 KEY: Nutritional disorders| nutrition| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 3. A nurse is designing a community education program to meet the Healthy People 2020 objectives for nutrition and weight status. What information about these goals does the nurse use to plan this event? (Select all that apply.) a. Decrease the amount of fruit to 1.1 cups/1000 calories. b. Increase the amount of vegetables to 1.1 cups/1000 calories. c. Increase the number of adults at a healthy weight by 25%. d. Reduce the number of adults who are obese by 10%. e. Reduce the consumption of saturated fat by nearly 10%. ANS: B, D, E Some of the goals in this initiative include increasing fruit consumption to 0.9 cups/1000 calories, increasing vegetable intake to 1.1 cups/1000 calories, increasing the number of people at a healthy weight by 10%, decreasing the number of adults who are obese by 10%, and reducing the consumption of saturated fats by 9.5%. DIF: Remembering/Knowledge REF: 1243 KEY: Nutritional disorders| obesity| health promotion MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Health Promotion and Maintenance 4. A client’s small-bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are best? (Select all that apply.) a. Attempt to dissolve the clog by instilling a cola product. b. Determine if any of the medications come in liquid form. c. Flush the tube before and after administering medications. d. Mix all medications in the formula and use a feeding pump. e. Try to flush the tube with 30 mL of water and gentle pressure. ANS: B, C, E If the tube is obstructed, use a 50-mL syringe and gentle pressure to attempt to open the tube. Cola products should not be used unless water is not effective. To prevent future problems, determine if any of the medications can be dispensed in liquid form and flush the tube with water before and after medication administration. Do not mix medications with the formula. DIF: Remembering/Knowledge REF: 1243 KEY: Nutritional disorders| tube feedings| medication administration MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. When working with older adults to promote good nutrition, what actions by the nurse are most appropriate? (Select all that apply.) a. Allow uninterrupted time for eating. b. Assess dentures for appropriate fit. c. Ensure the client has glasses on when eating. d. Provide salty foods that the client can taste. e. Serve high-calorie, high-protein snacks. ANS: A, B, C, E Older adults need unhurried and uninterrupted time for eating. Dentures should fit appropriately and glasses, if used, should be on. High-calorie, high-protein snacks are a good choice. Salty snacks are not recommended because all adults should limit sodium in their diets. DIF: Applying/Application REF: 1238 KEY: Nutritional disorders| older adult| nutrition MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Health Promotion and Maintenance SHORT ANSWER 1. A client weighs 228 pounds (103.6 kg) and is 5’3” (160 cm) tall. What is this client’s body mass index (BMI)? (Record your answer using a decimal rounded up to the nearest tenth.) ANS: 40.4 Using the formula : , or 40.4 rounded up to the nearest tenth. DIF: Applying/Application REF: 1236 KEY: Nutritional assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. A client wants to lose 1.5 pounds a week. After reviewing a diet history, the nurse determines the client typically eats 2450 calories a day. What should the client’s calorie goal be to achieve this weight loss? (Record your answer using a whole number.) calories/day ANS: 1700 calories/day To encourage a weight loss of 1 pound (2.2 kg) a week, 500 calories per day would be subtracted. To encourage a weight loss of 2 pounds (4.4 kg) a week, 1000 calories each day are subtracted. In this scenario, to lose 1.5 pounds a week the client needs to cut 750 calories per day from the diet: 2450 – 750 = 1700 calories. DIF: Applying/Application REF: 1249 KEY: Nutritional disorders| nutritional assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Health Promotion and Maintenance 3. A client is receiving continuous tube feeding at 70 mL/hr. When the bag is empty, how much formula does the nurse add? (Record your answer using a whole number.) mL ANS: 280 mL The nurse never adds more than 4 hours’ worth of formula to a hanging bag of enteral feedings. 70 mL/hr  4 hr = 280 mL. DIF: Applying/Application REF: 1242 KEY: Nutritional disorders| tube feedings MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control Show Less