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|Test Bank for Priorities in Critical Care Nursing 7th Edition Urden – Stacy – Lough|
Chapter 06: Nutritional Alterations
- A patient with poorly controlled diabetes mellitus is to be started on enteral tube feeding. What type of formula would be most appropriate?
|a.||Whole proteins and glucose polymers|
|b.||Concentrated in calories|
|d.||High fat, low carbohydrate|
Individuals with diabetes mellitus whose blood sugar is poorly controlled with standard formulas should be given a glucose intolerance formula that is high in fat and low in carbohydrate. High protein is associated with polymeric formulas. Concentrated calories is associated with renal failure. Low sodium is associated with hepatic failure.
- Most of the energy produced from carbohydrate metabolism is used to form what substance?
Most of the energy produced from carbohydrate metabolism is used to form adenosine triphosphate (ATP), the principal form of immediately available energy within all body cells. One gram of carbohydrate provides approximately 4 kcal of energy. Through the process of digestion, carbohydrates are broken down into glucose, fructose, and galactose. Antibodies are produced through the immune system.
- A patient has a new order for intermittent nasogastric feedings every 4 hours. The nasogastric tube is placed by the nurse. The best method for confirming the placement of the tube before feeding would be to
|a.||obtain radiography of the abdomen.|
|b.||check the pH of fluid aspirated from the tube.|
|c.||auscultate the left upper quadrant of the abdomen while injecting air into the tube.|
|d.||auscultate the right upper quadrant of the abdomen while injecting air into the tube.|
After the tube has been placed, correct location must be confirmed before feedings are started and regularly throughout the course of enteral feedings. Radiographs are the most accurate way of assessing tube placement.
- A person with a BMI of 28 would be considered
|b.||overweight or pre-obese.|
|c.||of normal weight.|
A body mass index between 25 and 30 is considered overweight or pre-obese. The other BMIs are underweight = 2; normal = 18.5 to 24.99 kg/m2; overweight = ?5=25 kg/m2; pre-obese = 25 to 29.99 kg/m2; obese class I = 30 to 34.99 kg/m2; obese class II = 35 to 39.99 kg/m2; and obese class III = ?5=40 kg/m2.
- Diet therapy for a person with hypertension 1 day after a myocardial infarction would include
|a.||three meals a day with two snacks.|
|b.||a low-protein diet.|
|c.||a low-salt, low-cholesterol diet.|
|d.||a high-carbohydrate diet.|
Because fluid accompanies sodium, limitation of sodium is necessary to reduce fluid retention. Specific interventions include limiting salt intake, usually to 2 g a day or less, and limiting fluid intake because appropriate meal size, caffeine intake, and food temperatures are some of the dietary factors that are of concern. Small, frequent snacks are preferable to larger meals for patients with severe myocardial compromise or postprandial angina.
- Two types of protein-caloric malnutrition are kwashiorkor and marasmus. Kwashiorkor results in
|a.||weight loss and muscle wasting.|
|b.||low levels of serum proteins, low lymphocyte count, and hair loss.|
|c.||elevated serum albumin and increased creatinine excretion in the urine.|
|d.||hyperpigmentation and a hard, easily palpated liver margin.|
Kwashiorkor results in low levels of serum proteins, low lymphocyte count, low immunity and edema from low plasma oncotic pressure, and hair loss. Marasmus is recognizable by weight loss, loss of subcutaneous fat, and muscle wasting.
- The patient history plays an important role in assessing the patient’s nutritional status. Significant laboratory and clinical findings in the patient with cardiovascular disease include
|a.||low levels of high-density lipoprotein (HDL) cholesterol and transferrin.|
|b.||elevated low-density lipoprotein (LDL) cholesterol and decreased subcutaneous fat.|
|c.||elevated sodium levels and a soft, fatty liver on palpation.|
|d.||normal triglyceride levels and the presence of S3 on auscultation.|
Laboratory and clinical findings in patients with cardiovascular disease include elevated total cholesterol and triglycerides as well as cardiac cachexia (muscle and subcutaneous fat wasting).
- Proteins serve the function of
|a.||maintaining osmotic pressure.|
|b.||providing minerals in the body.|
|c.||maintaining blood glucose.|
|d.||providing a stored source of energy.|
Proteins are the basis for lean body mass and are important for chemical reactions, transportation of other substances, preservation of immune function, and maintenance of osmotic pressure (albumin) and blood neutrality (buffers) in the body. Carbohydrates help with maintaining osmotic pressure, gluconeogenesis, and providing minerals to the body. Lipids provide source of energy.
- The loss of exocrine function of pancreatitis results in
The loss of exocrine function leads to malabsorption and steatorrhea. In chronic pancreatitis, the loss of endocrine function results in impaired glucose intolerance. Anorexia is the result of an inability to eat or not eating. Obesity would result from consuming more than the RDA of calories based on one’s body type.
- Obtaining height and weight measurements for the critically ill patient
|a.||should be deferred until the medical condition stabilizes.|
|b.||should be measured rather than obtained through patient or family report.|
|c.||requires consistent weights in pounds.|
|d.||requires weight, but height can be deferred.|
Height and current weight are essential anthropometric measurements that should be measured rather than obtained through patient or family report. The most important reason for obtaining anthropometric measurements is to detect changes in the measurements over time (e.g., response to nutritional therapy). Weight is measured in kilograms and height in meters. BMI values are independent of age and gender and are used for assessing health risk.
- A patient on mechanical ventilation is receiving total parenteral nutrition (TPN). Which of the following is true?
|a.||Excessive calorie intake can cause an increase in PaCO2.|
|b.||The patient’s head should remain elevated at 45 degrees to avoid aspiration.|
|c.||Lipid intake should be maintained at greater than 2 g/kg/day.|
|d.||TPN is preferred over the use of enteral feeding to avoid the complication of aspiration.|
Excessive calorie intake can raise PaCO2 sufficiently to make it difficult to wean a patient from the ventilator. A balanced regimen with both lipids and carbohydrates providing the nonprotein calories is optimal for patients with respiratory compromise, and these patients need to be reassessed continually to ensure that caloric intake is not excessive.
- A primary nutritional intervention for hypertension is
For hypertensive cardiac disease, sodium chloride restriction is recommended. Some individuals are more salt sensitive than others, and this salt sensitivity contributes to hypertension.
- Patients with coronary artery disease should be taught about cholesterol. Which situation is most desirable?
|a.||Low levels of HDL cholesterol|
|b.||Low levels of LDL cholesterol|
|d.||Low levels of both HDL and LDL cholesterol|
Interventions for patients with coronary artery disease are geared toward lowering the LDL cholesterol to desirable levels.
- An effect of malnutrition on respiratory function is
|b.||increased vital capacity.|
Malnutrition has extremely adverse effects on respiratory function, decreasing both surfactant production and vital capacity. Excessive lipid intake can impair capillary gas exchange in the lungs, although this is not usually sufficient to produce an increase in PaCO2 or decrease in PaO2; this results in decreased respiratory function.
- What is the rationale for careful intake and output for patients with pulmonary alterations?
|a.||Fluid retention occurs with tachypnea.|
|b.||Hemodilution may cause deleterious hypernatremia.|
|c.||Fluid volume excess can lead to right-sided heart failure.|
|d.||Excessive fluid losses may lead to dehydration and hypovolemic shock.|
Pulmonary edema and failure of the right side of the heart may result from fluid volume excess, which can further worsen the status of patients with respiratory compromise.
- A patient who has sustained a head injury has increased nutritional needs related to the
|a.||decrease in metabolism as a result of coma.|
|b.||decrease in blood sugar from a lack of dietary supplementation.|
|c.||anabolism and wound healing.|
|d.||hypermetabolism and catabolism associated with the injury.|
Patients with neurologic alterations have increased needs because of hypermetabolism and catabolism after head injury. Poor food intake is related to altered state of consciousness, dysphagia or other chewing or swallowing difficulties, or ileus resulting from spinal cord injury or use of pentobarbital.
- The patient is receiving corticosteroid treatment for neurologic alterations. The nurse should assess the patient for episodes of
Hyperglycemia is a common complication in patients receiving corticosteroids. Needs for protein and calories are increased by infection and fever, as may occur in the patient with encephalitis or meningitis. Needs for protein, calories, zinc, and vitamin C are increased during wound healing, as occurs in trauma patients and patients with pressure ulcers.
- Which of the following nutritional interventions is a priority for the patient with renal disease who is receiving dialysis?
|a.||Increase fluids to replace losses.|
|b.||Encourage potassium-rich foods to replace losses.|
|c.||Ensure an adequate amount of protein to prevent catabolism.|
|d.||Limit all nutrients to account for altered renal excretion.|
Proteins and amino acids are removed during peritoneal dialysis, creating a greater nutritional requirement for protein. The renal patient must receive an adequate amount of protein to prevent catabolism of body tissues to meet energy needs. Approximately 1.5 to 2.0 g protein/kg/day is required. Certain nutrients such as potassium and phosphorus are restricted because they are excreted by the kidney. The patient has no specific requirement for the fat-soluble vitamins A, E, and K because they are not removed in appreciable amounts by dialysis, and restriction generally prevents development of toxicity.
- Prevention of pulmonary aspiration is best accomplished by
|a.||administering intermittent feedings.|
|b.||adding thickening agents to the tube feeding solution.|
|c.||suctioning the patient hourly.|
|d.||elevating the head of the bed 30 to 45 degrees.|
To reduce the risk of pulmonary aspiration during enteral tube feeding, keep the patient’s head elevated at least 30 to 45 degrees during feedings unless contraindicated.
- A patient is admitted to the critical care unit with severe malnutrition as a result of hepatic failure. A triple-lumen central venous catheter is placed in the right subclavian vein, and TPN is started. For which of the following complications should the patient be evaluated immediately after insertion of the catheter?
|c.||Central venous thrombosis|
Central vein TPN carries an increased risk of sepsis as well as potential insertion-related complications such as pneumothorax and hemothorax. Repeated traumatic catheterizations are most likely to result in thrombosis. To prevent hypoglycemia, administer oral carbohydrates or an IV bolus of dextrose. Elevate the head of bed 30 to 45 degrees to prevent pulmonary aspiration after the infusion has begun.
- A patient is admitted to the critical care unit with severe malnutrition as a result of hepatic failure. A triple-lumen central venous catheter is placed in the right subclavian vein, and TPN is started. On the third day of infusion, the patient develops symptoms of fever and chills. Which of the following complications should be suspected?
|c.||Central venous thrombosis|
Because TPN requires an indwelling catheter in a central vein, it carries an increased risk for sepsis and potential insertion-related complications such as pneumothorax and hemothorax. Signs and symptoms of catheter-related sepsis include fever, chills, glucose intolerance, and positive blood cultures. Air embolism is also more likely with central vein TPN.
- A patient is admitted to the critical care unit with severe malnutrition as a result of hepatic failure. A triple-lumen central venous catheter is placed in the right subclavian vein, and TPN is started. Which of the following dietary restrictions should be maintained for the patient?
|a.||Fat and magnesium|
|b.||Protein and sodium|
|c.||Carbohydrate and potassium|
|d.||Protein and calcium|
Protein should be restricted because it contributes to the development of encephalopathy; sodium should be restricted because it contributes to the development of edema. Release of lipids from their storage depots is accelerated, but the liver has decreased ability to metabolize them for energy. Moreover, inadequate production of bile salts by the liver results in malabsorption of fat from the diet.
- Which of the following medical interventions may be initiated with the onset of hyperglycemia?
|a.||Discontinuing the infusion|
|b.||Adding insulin to the TPN|
|c.||Weaning from the TPN over a 6-hour period|
|d.||Starting an infusion of 0.9% normal saline|
One method for controlling hyperglycemia in a patient receiving TPN is to add insulin to the infusion. Rapid cessation of TPN may not lead to hypoglycemia; however, tapering the infusion over 2 to 4 hours is recommended. Slow advancement of the rate of TPN (25 mL/hr) to the goal rate allows pancreatic adjustment to the dextrose load.
- A patient is mechanically ventilated and is receiving enteral nutrition via a nasogastric tube. To help ensure feeding tolerance, the nurse checks residual volumes every 4 hours. During a residual check later in the shift, the nurse aspirates a total residual volume of 350 mL. The nurse will
|a.||stop the tube feeding, wait 1 hour, and recheck the residual.|
|b.||discontinue the feeding tube and tube feeding and call the physician for TPN orders.|
|c.||continue the tube feeding, if no other gastrointestinal symptoms exist, and reassess the patient with the next residual check.|
|d.||continue the tube feeding and place the patient in the left lateral decubitus position to facilitate gastric emptying.|
There is little evidence to support a correlation between gastric residual volumes and tolerance to feedings, gastric emptying, and potential aspiration. Except in selected high-risk patients, there is little evidence to support holding tube feedings in patients with gastric residual volumes less than 400 mL.
- A tracheostomy patient is experiencing regurgitation of tube feeding formula. The nurse’s first priority should be
|a.||checking to make sure the tracheostomy cuff is inflated during tube feedings.|
|b.||placing the patient in the right lateral decubitus position to promote gastric emptying.|
|c.||discussing the use of metoclopramide to facilitate gastric motility with the physician.|
|d.||placing the patient in prone position to improve draining from mouth.|
When regurgitation of formula is an issue, the following interventions can be used as appropriate: keep the cuff of the endotracheal or tracheostomy tube inflated during feedings to prevent aspiration; elevate the head to 30 to 45 degrees during feedings unless contraindicated; if head cannot be raised, position the patient in the right lateral position or prone position to improve drainage of vomitus from the mouth; and consider giving metoclopramide to improve gastric emptying.
- The patient’s feeding tube is occluded and cannot be flushed. The nurse knows that the best irrigant for feeding tube occlusion is
Although cranberry juice or cola beverages are sometimes used to reduce the incidence of tube occlusion, water is the preferred irrigant because it has been shown to be superior in maintaining tube patency.
- The nutritional alteration most frequently encountered in hospitalized patients is
|a.||respiratory quotient (RQ).|
The nutritional alteration most frequently encountered in the hospitalized patient is protein-calorie malnutrition. The respiratory quotient (RQ) is equal to the VCO2 divided by the VO2. Fat, protein, and carbohydrates each have a unique RQ; thus, RQ identifies which substrate is being preferentially metabolized and may provide target goals for calorie replacement. This process of manufacturing glucose from nonglucose precursors is called gluconeogenesis. Gluconeogenesis is carried out at all times, but it becomes especially important in maintaining a source of glucose in times of increased physiologic need and limited supply. Fat is used as a source of energy.
- Sodium and fluid restrictions ordered for the patient with heart failure are primarily aimed at reducing
|a.||use of medications.|
Myocardial infarction, nutrition interventions, and education are designed to reduce angina, cardiac workload, and the risk of dysrhythmia. Sodium restriction applies in the treatment of patients with heart failure because water follows sodium. Fluids should be restricted to 1500 to 2000 mL/day. Weight is an anthropometric measurement and is a long-term goal. Serum lipids is a biochemical data and is a long-term goal. Medications are used to control fluid levels in the body and prevention of angina and dysrhythmia.
- Which of the following signs would alert the nurse to possible nutritional alterations? (Select all that apply.)
|a.||Impaired wound healing|
ANS: A, B, D
Impaired wound healing, edema, and muscle wasting atrophy are indicative of impaired nutrition. Nail growth would indicate normal caloric intake. Diaphoresis refers to sweating and is indicated with exercising and infection.
- A patient was admitted with ESRD and on hemodialysis. Which of the following elements should be restricted? (Select all that apply.)
ANS: A, B, E
The kidneys are responsible for the balance of fluids, protein, and other nutrients. When the kidneys are functioning suboptimally, dietary intake of those substances must be restricted.
Chapter 07: Gerontological Alterations
- A 68-year-old patient has been admitted to the coronary care unit after an inferior myocardial infarction. Age-related changes in myocardial pumping ability may be evidenced by
|c.||decreased left ventricle afterload.|
|d.||increased cardiac output.|
Collagen is the principal noncontractile protein occupying the cardiac interstitium. Because myocardial collagen content increases with age, increased myocardial collagen content renders the myocardium less compliant and may be responsible for increased loading of blood vessels.
- Age-related pulmonary changes that may affect this patient include
|a.||increased tidal volumes.|
|b.||weakening of intercostal muscles and the diaphragm.|
|c.||improved cough reflex.|
|d.||decreased sensation of the glottis.|
Respiratory muscle function is affected by skeletal muscle and peripheral muscle strength. During aging, skeletal muscle progressively atrophies, and its energy metabolism decreases, which may partially explain the declining strength of the respiratory muscles.
- A 68-year-old patient has been admitted to the coronary care unit after an inferior myocardial infarction. Dopamine 3 mcg/kg/min has been ordered for this patient. What nursing implications should be considered when administering this drug to an older patient?
|a.||No changes are noted in older patients with this drug.|
|b.||Drug effect is enhanced by increased receptor site action.|
|c.||Increased breakdown by liver hepatocytes occurs, increasing dosage requirements.|
|d.||Drug metabolism and detoxification are slowed, increasing the risks of drug toxicity.|
Reduced drug-metabolizing capacity is caused by a decline in activity of the drug-metabolizing enzyme system, microsomal ethanol oxidizing system, and decrease in total liver blood flow. Medications that depend on the cytochrome P450 group of liver enzymes are most affected because age-associated changes cause as much as a 50% decline in enzymatic function.
- A 68-year-old patient has been admitted to the coronary care unit after an inferior myocardial infarction. When caring for this patient, the nurse will give increased attention to skin integrity because of the
|a.||thickening of the epidermal skin layer.|
|b.||loss of sebaceous glands.|
|c.||increased fragility from loss of protective subcutaneous layers.|
|d.||decreased melanocyte production.|
Ecchymotic areas may be seen because of decreased protective subcutaneous tissue layers, increased capillary fragility, and flattening of the capillary bed, predisposing older adults to developing ecchymoses. Medications and physiologic factors may result in an augmented bleeding tendency and appearance of ecchymotic areas; nevertheless, consideration should be given to the possibility of older adult abuse if ecchymosis is widespread or in unusual areas.
- An older patient is admitted to the hospital with an acute onset of mental changes and recent falls. The nurse knows that the most common cause of mental changes is
Some slight memory dysfunction is common with increasing age, but a significant decline may represent a change in individual need and may be a result of acute or chronic conditions. Acute mental status changes caused by infection, metabolic imbalances, or medications are usually reversible after identification and treatment.
- A nurse is teaching an older patient about the signs and symptoms of a myocardial infarction. Which statement by the patient would indicate that the teaching was effective?
|a.||“The pain in my chest may last a long time.”|
|b.||“I will feel like I have an elephant sitting on the center of my chest.”|
|c.||“The chest pain will be sharp and over the center of my chest.”|
|d.||“The pain may not be severe and may not be in my chest.”|
Myocardial infarction in older adults is often associated with ST-segment depression rather than ST elevation. Sensation of chest pain may be altered and may be less intense and of shorter duration. Other atypical symptoms may include dyspnea, confusion, and failure to thrive, which results in unrecognized signs and symptoms of cardiac problems and delays in diagnosis and treatment.
- An older patient is starting a new medication that is metabolized in the liver and excreted by the kidneys. Which is the best assessment to monitor the patient’s ability to tolerate the medication?
|a.||Liver function tests|
|b.||Drug side effects experienced by the patient|
|c.||Kidney function tests|
|d.||Therapeutic drug levels|
Adverse drug effects and medication interactions may be related to pharmacokinetics or the manner in which the body absorbs, distributes, metabolizes, and excretes a drug. The aging process is associated with changes in gastric acid secretion, which can alter ionization or solubility of a drug and hence its absorption. Medication distribution depends on body composition and on physiochemical drug properties. With advancing age, a patient’s fat content increases, lean body mass decreases, and total body water decreases, which can alter drug disposition.
- An older patient is receiving a nephrotoxic medication. Which of the following would be a priority for the nurse to monitor?
|d.||Level of consciousness|
Decrease in number and size of nephrons begins in the cortical regions and progresses toward the medullary portions of the kidney. This decrease in number of nephrons corresponds to a 20% decrease in weight of the kidneys between 40 and 80 years of age. Initially, this loss of nephrons does not appreciably alter renal function because of the large renal reserve and a simultaneous decrease in lean muscle mass.
- Which of the following can be a normal assessment finding for an older patient?
|b.||Decreased urine output|
|c.||Increased respiratory effort|
|d.||Difficulty problem solving|
The incidence of asymptomatic cardiac dysrhythmias increases in older patients. The most common dysrhythmia is the premature ventricular contraction. Other common types are atrial fibrillation, atrial flutter, and paroxysmal supraventricular tachycardia and atrioventricular conduction disturbances. All of the other findings are abnormal.
- Chemical changes in a drug that renders it active or inactive is known as
Metabolism is the chemical change in a drug that renders it active or inactive. Absorption is the receptor-coupled or diffusional uptake of drug into the tissue. Distribution is the theoretic space (tissue) or body compartment into which free form of a drug distributes. Excretion is the removal of a drug through an eliminating organ, often the kidneys; some drugs are excreted in bile or feces, in saliva, or through the lungs.
- Which of the following nonsteroidal anti-inflammatory drugs (NSAIDs) has the side effect of renal failure, HTN, heart failure, and GI bleed in the elderly population?
|c.||Aspirin greater than 325 mg|
Possible side effects of select NSAIDs include indomethacin: central nervous system (CNS) effects (highest of all NSAIDs); ketorolac: asymptomatic gastrointestinal conditions (ulcers); aspirin (>325 mg): asymptomatic gastrointestinal conditions (ulcers); and naproxen: gastrointestinal bleeding, renal failure, high blood pressure, and heart failure.
- An older patient is started on amitriptyline to control depression. The nurse knows to monitor for (Select all that apply)
|a.||impaired psychomotor function.|
|b.||irregular heart rate.|
ANS: A, B, C
Tricyclic antidepressants (amitriptyline and amitriptyline compounds) have strong anticholinergic effects; may lead to ataxia, impaired psychomotor function, syncope, falls; cardiac arrhythmias (QT interval changes); may produce polyuria or lead to urinary incontinence; may exacerbate chronic constipation