Module 4 - Condition-Specific Nutrition Support (V.5)

Question 1

A patient with acute kidney injury (AKI) who requires parenteral nutrition support would most likely benefit from a solution containing which of the following?
A. Essential amino acids only
B. Essential amino acids with arginine only
C. Essential amino acids and nonessential amino acids
D. Essential amino acids and branched-chain amino acids

Answer 1

C. Essential amino acids and nonessential amino acids

Early clinical studies suggested that patients receiving a parenteral solution of essential amino acids (EAA) and dextrose could reduce need for dialysis. Subsequent studies comparing EAA to a mixture of EAA and nonessential amino acids showed no difference in the rate or frequency of recovery from AKI or survival. Formulations providing only EAA are not recommended. Branched-chain amino acids have demonstrated no advantage over standard amino acids in patients with AKI. Several nonessential amino acids, including tyrosine, arginine, and glutamine become conditionally essential in AKI.

Question 2

Which of the following types of fistulas will result in the greatest degree of nutritional loss?
A. Distal low output
B. Distal high output
C. Proximal low output
D. Proximal high output

Answer 2

D. Proximal high output

The higher the fistula occurs in the gastrointestinal tract, the greater the output and the higher the risk of metabolic derangements, as seen with proximal high output fistulas. Fluids and electrolytes will need to be managed and replaced carefully. Protein and calorie requirements may be elevated due to nutrient losses via fistula drainage and/or sepsis. Enteral nutrition may be possible in low output fistulas (< 500 mL/d) with distal enteral access and can be fed with a fiber containing formula. To minimize fistula output in distal ileal or colonic fistulas a fiber free or low fiber formula should be used and the site should be as high up as possible to increase the surface area for absorption

Question 3

Which of the following is a major contributing factor in the development of metabolic bone disease in patients with inflammatory bowel disease?
A. Corticosteroid use
B. Aluminum toxicity
C. Vitamin B12 deficiency
D. Oxalic acid deficiency

Answer 3

A. Corticosteroid use

Osteopenia and osteoporosis are metabolic bone disease complications associated with inflammatory bowel disease. Although it is controversial whether or not the primary contributor is corticosteroid therapy, a correlation has been shown between corticosteroid dose and degree of osteopenia. Supplementation of calcium and vitamin D reduces osteopenia in patients on long-term steroids.

Malnutrition, vitamin D deficiency, corticosteroid therapy, magnesium deficiency, and chronic inflammation, commonly found in patients with inflammatory bowel disease, are also associated with the development of metabolic bone disease.

Hypercalciuria, aluminum toxicity and magnesium deficiency may be associated with parenteral nutrition-associated metabolic bone disease and could be a factor for patients with inflammatory bowel disease who require long-term parenteral nutrition.

Aluminum toxicity and malabsorption are probably minor contributors to the problem in patients with inflammatory bowel disease.

Vitamin B12 and oxalic acid play no known role in metabolic bone disease.

Question 4

In patients with severe acute pancreatitis, the use of enteral nutrition via nasojejunal feeding tube rather than parenteral nutrition is associated with
A. an increased incidence of hyperglycemia.
B. a lower risk of developing infectious complications.
C. a greater incidence of negative nitrogen balance.
D. a decreased frequency of pancreatic stimulation.

Answer 4

B. a lower risk of developing infectious complications.

Severe acute pancreatitis has historically been considered an indication for parenteral nutrition in an effort to avoid enterally induced pancreatic stimulation; however, more recent research has demonstrated that enteral nutrition is well tolerated in severe acute pancreatitis. In a study of 38 patients with severe acute pancreatitis, enteral nutrition beyond the ligament of Treitz was compared with parenteral nutrition. Those who received enteral nutrition were less likely to develop infectious complications, maintained equal nitrogen balance and had a reduced incidence of hyperglycemia compared to those who received parenteral nutrition. The enteral feedings were well tolerated without adverse effects on the disease course. It is suggested that the enteral route be used preferentially, rather than parenteral nutrition, for the patient with severe acute pancreatitis. The 2013 American College of Gastroenterology Guidelines for Management of Acute Pancreatitis recommends administration of enteral nutrition as the preferred route of nutrition support to prevent infectious complications, unless EN is not available, tolerated or patient is not meeting nutritional requirements via EN alone.

Question 5

What is the glomerular filtration rate (GFR) of a patient with end-stage renal disease?
A. >90 mL/min/1.73 m2
B. 30-59 mL/min/1.73 m2
C. 15-29 mL/min/1.73 m2
D. <15 mL/min/1.73 m2

Answer 5

D. <15 mL/min/1.73 m2

Stage 1, Kidney damage with normal or high GFR: >90 mL/minute/1.73 m2.

Stage 2, Kidney damage with mild low GFR: 60-89 mL/minute/1.73 m2.

Stage 3, Moderate low GFR: 30-59 mL/minute/1.73 m2.

Stage 4, Severe low GFR: 15-29 mL/minute/1.73 m2.

Stage 5, Kidney failure: <15 (or dialysis) mL/minute/1.73 m2.

Question 6

In the first 1 - 3 months after a bone marrow transplant the nutritional needs of a patient are best met with
A. 20-25 kcal/kg daily with >= 1.5 g protein per kg body weight.
B. 20-25 kcal/kg daily with 80% of total calories from carbohydrate.
C. 30-35 kcal/kg daily with >= 1.5 g protein per kg body weight.
D. 30-35 kcal/kg daily with 80% of total calories from carbohydrate.

Answer 6

C. 30-35 kcal/kg daily with >= 1.5 g protein per kg body weight.

Energy needs will vary with the individual, but energy requirements are usually estimated at 1.5 x basal energy expenditure (BEE), or approximately 30 to 35 kcal per kilogram. Protein intake should be aimed at 1.5 g per kilogram during the first 1 to 3 months after transplantation.

Question 7

In pulmonary insufficiency, excessive calorie administration may cause increased blood pCO2 resulting in
A. metabolic acidosis.
B. metabolic alkalosis.
C. respiratory acidosis.
D. respiratory alkalosis.

Answer 7

C. respiratory acidosis.

Respiratory acidosis results from disorders producing alterations in ventilatory control, increased production of CO2, and respiratory muscle weakness. The increased CO2 production is greatest when overfeeding occurs (2 x BEE) due to an excess generation of CO2 relative to O2 consumption during carbohydrate metabolism.

Question 8

In patients with burns, providing caloric support above energy expenditure has been found to
A. significantly decrease hospital length of stay.
B. improve wound healing and graft success.
C. decrease fat accumulation and steatosis.
D. have no effect on preservation of lean body mass.

Answer 8

D. have no effect on preservation of lean body mass.

The metabolic stress that occurs in burn injury generates a hypercatabolic state that increases energy expenditure. Although patients with burns have increased needs, feeding in excess of energy expenditure may cause hyperglycemia, hepatic steatosis, and prolonged ventilator dependence. One study of critically ill burn patients showed that caloric delivery beyond 1.2 x measured resting energy expenditure did not conserve lean body mass but was associated with increased fat mass accumulation.

Question 9

Nutrition support for solid-organ transplant patients receiving cyclosporine may need to be modified due to the presence of
A. hyperkalemia.
B. hypoglycemia.
C. hypermagnesemia.
D. hypocholesterolemia.

Answer 9

A. hyperkalemia.

Cyclosporine, commonly used after solid organ transplantation for immune suppression, can frequently cause nutrient disorders such as hyperkalemia, hypomagnesemia, hyperglycemia, and hypercholesterolemia, and has a direct effect on the renin-angiotensin-aldosterone system contributing to altered potassium homeostasis. Cyclosporine also affects the renal tubular excretion of potassium. Patients taking cyclosporine should be educated on dietary potassium intake and should have serum potassium levels monitored on a regular basis.

Question 10

Human immunodeficiency virus (HIV) associated lipodystrophy syndrome is most commonly associated with which of the following classes of agents used to treat HIV infection
A. integrase strand transfer inhibitors (INSTIs).
B. non-nucleoside reverse transcriptase inhibitors (NNRTIs).
C. nucleoside reverse transcriptase inhibitors (NRTIs).
D. protease inhibitors (PIs).

Answer 10

C. nucleoside reverse transcriptase inhibitors (NRTIs).

HIV-associated lipodystrophy syndrome is manifested by subcutaneous adipose tissue loss with visceral adipose tissue sparing or accumulation. Subcutaneous tissue loss is often most evident in the face, buttocks, and lower extremities. Lipodystrophic patients may also be insulin resistant . Lipodystrophy has been strongly associated with first-generation nucleoside reverse transcriptase inhibitors.

Question 11

Which of the following are counter-regulatory hormones responsible for the hypercatabolism observed in critically ill trauma patients?
A. Glycogen, insulin, norepinephrine
B. Glucagon, epinephrine, cortisol
C. Glycerol, serotonin, thymoglobulin
D. Glycerin, leptin, adenosine

Answer 11

B. Glucagon, epinephrine, cortisol

The inflammation following a traumatic injury provokes a release of systemic catabolic hormones including epinephrine, glucagon, and cortisol. These hormones are responsible for glycogenolysis, gluconeogenesis, proteolysis, and free fatty acid release. The goal of this metabolic response by the patient is to maintain survival and homeostasis, and to promote recovery. Therapeutic intervention is geared toward blunting the inflammatory response without making the patient susceptible to immunosuppression. Timely resuscitation, including restoration of perfusion, oxygenation, and hemodynamic stability, is the top priority. The early initiation of nutrition is an important component of supportive therapy in the care of the trauma patient.

Question 12

A critically ill hyperglycemic patient receiving continuous enteral nutrition with a history of insulin dependent diabetes should ideally be placed on
A. prandial subcutaneous insulin.
B. oral glucose-lowering agents given via the feeding tube.
C. continuous IV insulin infusion.
D. correction (sliding scale) subcutaneous insulin.

Answer 12

C. continuous IV insulin infusion.

Insulin should be used to treat diabetes during enteral nutrition. In the critical care setting, continuous intravenous insulin infusion has been shown to be the best method for achieving glycemic targets and allows for off cycles during the 24-hour period when enteral feeding is held or discontinued.

Question 13

Which of the following immunomodulating nutrients may be harmful in patients with sepsis/septic shock?
A. Arginine
B. Selenium
C. Nucleic acids
D. Omega-3 fatty acids

Answer 13

A. Arginine

Arginine is a major substrate for nitric oxide production. Under normal conditions, small quantities of nitric oxide have a beneficial effect on immune function and tissue oxygenation. Thus, arginine is considered an “immune-enhancing” agent. However, nitric oxide can also be detrimental by leading to coagulation abnormalities and altered hemodynamic status. In this case, arginine could be considered harmful for patients with sepsis/septic shock. Because of these effects, there is still much debate over the value of arginine in nutrition support for critically ill patients.

Question 14

Patients with short bowel syndrome would benefit most from octreotide injections in the presence of
A. recent bowel resection with loss of ileocecal valve
B. short bowel secondary to mesenteric ischemia.
C. short bowel secondary to inflammatory bowel disease.
D. refractory diarrhea not controlled with diet and medication.

Answer 14

D. refractory diarrhea not controlled with diet and medication.

Octreotide reduces the production of a variety of GI secretions and slows jejunal transit. However, its effects are often short lasting and have not been shown to improve absorption or lead to the elimination of the need for parenteral nutrition. Due to an increased risk for cholelithiasis, expense and the potential for octreotide to inhibit bowel adaptation, use of octreotide should be reserved for patients with large volume stool losses in whom fluid and electrolyte management is problematic and should be avoided in the early adaptation stage.

Question 15

Which of the following best describes enteral glutamine supplementation in the critically ill patient in multi organ failure?
A. Enteral glutamine decreases mortality
B. Enteral glutamine decreases ventilator days
C. Enteral glutamine decreases hospital length of stay
D. Enteral glutamine decreases nosocomial infections

Answer 15

D. Enteral glutamine decreases nosocomial infections

A recent meta-analysis investigated the impact of glutamine-supplemented nutrition on the outcomes of critically ill patients and found that glutamine supplementation did not decrease mortality and length of hospital stay in critically ill patients. However, glutamine supplementation did reduce nosocomial infections among critically ill patients.

Question 16

Which of the following is true of essential fatty acid deficiency (EFAD) in patients with cystic fibrosis (CF)?
A. Routine supplementation of omega-3 fatty acids is essential in the management of CF
B. EFAD usually does not manifest in CF patients until the second decade.
C. CF patients without pancreatic insufficiency rarely develop EFAD
D. EFA profiles have been shown to improve in CF patients after lung transplantation

Answer 16

D. EFA profiles have been shown to improve in CF patients after lung transplantation

Disruption in the exocrine function of the pancreas leads to malabsorption of fat, protein, and fat-soluble vitamins in CF patients. Essential fatty acid deficiency may contribute to inflammatory pathways contributing to the pulmonary and gastrointestinal symptoms associated with CF. The overt signs of EFAD (scaly dermatitis, alopecia, thrombocytopenia, and growth failure) are uncommon in patients with CF. EFAD correlates with poor growth and pulmonary status. EFA status is usually evaluated by measuring the triene: tetraene ratio. Although supplementation with omega 3 fatty acids are sometimes used in the management of CF, results from clinical trials have shown mixed results and further trials are needed to determine the efficacy of routine EFA supplementation in the management of CF.

Question 17

What is the most appropriate feeding strategy for a morbidly obese trauma patient?
A. High protein, hypocaloric feeding
B. High protein, hypercaloric feeding
C. Low protein, hypocaloric feeding
D. Low protein, hypercaloric feeding

Answer 17

A. High protein, hypocaloric feeding

Data on nutrition support in obese patients support the hypocaloric, high protein feeding strategy. High-protein hypocaloric feeding is thought to maintain nitrogen balance and lean body mass while facilitating the mobilization of adipose tissue for fuel utilization. Hypercaloric feeding would likely result in hyperglycemia and difficulty weaning from the ventilator.

Question 18

ERAS (Enhanced Recovery After Surgery) is a care program that has been shown to improve outcomes after major surgery. The key mechanism behind the ERAS effectiveness is:
A. comprehensive preoperative nutrition counseling.
B. decrease the stress of surgery and support recovery.
C. decreased NPO duration and optimized nutrition before/after surgery.
D. the multi-professional and multidisciplinary approach.

Answer 18

B. decrease the stress of surgery and support recovery.

ERAS is an elaborate pre- and postoperative care program. Objectives are to avoid starvation, decrease the stress of surgery (which induces insulin resistance) and limit postoperative IVF while optimizing pain control and GI function and mobilization. The nutrition components are to avoid pre-op fasting by providing CHO nutrition/fluid and withholding routine bowel prep. Patients receive less IVF and experience fewer post-op complications. ERAS was originally designed for elective colon resection surgeries.

Question 19

A 24-year-old, 10 week pregnant woman presented with persistent nausea and vomiting for the past 6 weeks associated with a 10% weight loss. Her symptoms were refractory to a 48 hour trial of anti-emetics and IV fluids. Given mother’s nutritional status, decision was made to initiate nutrition support. What vitamin should be supplemented in this patient before providing nutrition support?
A. Vitamin B12
B. Thiamin
C. Vitamin E
D. Vitamin C

Answer 19

B. Thiamin

Due to poor intake, increased losses and increased demand for glucose metabolism in pregnancy, decreased thiamin levels are frequently seen in patients with hyperemesis gravidarum, increasing the risk for Wernicke’s encephalopathy, a potentially fatal neurologic syndrome. Thiamin supplementation should be considered with initiation of dextrose-containing fluids in patients with hyperemesis gravidarum.

Question 20

A 24-year-old woman is in the 10th week of her pregnancy. She has persistent nausea and vomiting for the past 6 weeks that has been associated with a 10% weight loss. Her nausea and vomiting is refractory to a 48 hour trial of anti-emetics and IV fluids. The decision to provide nutritional support is made to minimize further deterioration of the mother’s nutritional status and possible negative effects on the fetus. What is the most appropriate initial nutrition therapy to implement?
A. EN with isotonic formula via Nasogastric tube
B. EN with isotonic formula via Gastrostomy tube
C. EN with polymeric formula via Nasogastric tube
D. EN with polymeric formula via Gastrostomy tube

Answer 20

C. EN with polymeric formula via Nasogastric tube

Hyperemesis gravidarum is severe, intractable nausea and vomiting complicated by dehydration, electrolyte imbalance, nutrition deficiencies and weight loss. However, this is not a permanent problem. Nasoenteric tubes generally remain in place for 6 – 8 weeks and is an appropriate feeding tube for short term EN. The process for selecting an enteral formula for the pregnant patient requiring EN is similar to the process for nonpregnant patients. Polymeric formula is appropriate for patients with adequate digestive and absorptive process. Because constipation is often a problem in pregnancy (25 – 45 % of pregnant women experience with complication), a fiber – containing formula should be considered.

Question 21

Which of the following is an important indicator of protein-energy malnutrition in chronic liver disease?
A. Jaundice
B. Muscle wasting
C. Hypoalbuminenia
D. Hepatic encephalopathy

Answer 21

B. Muscle wasting

Muscle wasting and subcutaneous fat loss are important clinical indicators of protein-energy malnutrition. As part of the physical examination, anthropometric measurements, such as triceps skin fold and mid-arm circumference can be used. Although these measurements may be affected by fluid retention, they can be useful to assess subcutaneous fat and muscle mass. Mid-arm circumference and hand grip strength appear to be sensitive markers of body cell mass depletion. Hepatic encephalopathy, jaundice, and hypoalbuminenia are not markers of malnutrition.

Question 22

Which of the following diets should be recommended to patients with short bowel syndrome (ileal resection) and colon in continuity?
A. High fat
B. High oxalate
C. High simple carbohydrate
D. High complex carbohydrate

Answer 22

D. High complex carbohydrate

A diet high in complex carbohydrates (50% to 60%) and low in fat (20% to 30%) has been shown to increase overall energy absorption and SCFA production as well as reduce steatorrhea and fecal wet weight in short bowel syndrome (SBS) patients with at least a portion of their colon present. This diet helps to reduce magnesium and calcium losses and decreases oxalate absorption.

Normally oxalate binds to calcium and is excreted in the stool, but in fat malabsorption calcium binds to free fatty acids leaving oxalate free to be absorbed. To decrease risk of oxalate nephrolithiasis, SBS patients who have a colon in continuity should restrict dietary oxalate intake and consume high calcium foods or calcium citrate supplements. Regardless of bowel anatomy, the provision of complex carbohydrates in the diet of SBS patients is preferred because they reduce the osmotic load and may exert a positive effect on the adaptation process. In the intestine, starch is broken down more slowly than simple sugars, thus improving tolerance. Concentrated sugars should be avoided because they generate a high osmotic load and potentiate stool output.

Question 23

Which of the following is NOT a cause of protein-energy malnutrition in a patient with liver disease?
A. Malabsorption
B. Decreased caloric intake
C. Abnormal fuel metabolism
D. Reduced energy expenditure

Answer 23

D. Reduced energy expenditure

Protein-energy malnutrition with liver disease is multifactorial. Reduced caloric intake from anorexia and early satiety, fat malabsorption from altered bile acid circulation, and increased protein and fat oxidation are the main etiologies. Energy expenditure may be increased in those patients with infections and ascites.

Question 24

Which of the following is the inpatient glycemic target for critically ill patients?
A. 80-110 mg/dL
B. 140-180 mg/dL
C. 181-210 mg/dL
D. 211-240 mg/dL

Answer 24

B. 140-180 mg/dL

For the critically ill patient, blood glucose levels should be maintained between 140-180mg/dL. Lower glucose targets may be appropriate for selected patients, but targets <110mg/dL are not recommended.

Question 25

Patients with chronic heart failure are typically on a loop diuretic. These patients are at risk for
A. hyperkalemia.
B. azotemia.
C. hypermagnesemia.
D. hypoglycemia.

Answer 25

B. azotemia.

Loop diuretics are known to cause electrolyte abnormalities as a result of increased urine output. Specific disturbances include excess potassium and magnesium excretion which can result in hypokalemia and hypomagnesemia. Loop diuretics are not associated with hypoglycemia. Azotemia can occur related to volume depletion.

Question 26

Which of the following metabolic complications may occur in patients with short bowel syndrome and small bowel intestinal bacterial overgrowth?
A. Metabolic acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Respiratory acidosis

Answer 26

A. Metabolic acidosis

Intestinal resection involving removal of the terminal ileum and/or the ileocecal valve with the colon in continuity predisposes patients to small intestinal bacterial overgrowth (SIBO). Rarely, patients with short bowel syndrome (SBS) can develop D-lactic acidosis and variable presentations of encephalopathy from colonic proliferation of D-lactic acid producing bacteria. This cycle is exacerbated as D-lactate producing bacteria thrive in an acidic environment which is common in SBS as a result of many factors, including metabolism of unabsorbed carbohydrate that leads to production of lactate and decreases the pH. Respiratory and metabolic alkalosis are characterized by an increase in pH related to alterations in respiration (e.g. hyperventilation) and metabolism (e.g. excess vomiting), respectively. Respiratory acidosis is characterized by a decrease in pH secondary to hypoventilation and reduced clearance of CO2.

Question 27

Which of the following best describes the treatment of diarrhea in inflammatory bowel disease?
A. Cholestyramine is effective treatment for steatorrhea
B. Patients with diarrhea should be treated with prebiotics
C. Start antidiarrheal agents once infectious etiology is ruled out
D. Withhold pharmacological therapy until diarrhea exceeds 1 L/day

Answer 27

C. Start antidiarrheal agents once infectious etiology is ruled out

Antidiarrheals should not be given to patients with inflammatory bowel disease until the possibility of an infectious etiology of the diarrhea has been ruled out. Otherwise, there is a risk of developing toxic megacolon that can result in mortality and morbidity. Cholestyramine, used to treat bile salt malabsorption, can be used with antidiarrheal agents for patients who have undergone extensive bowel resection. There are no definite guidelines on when treatment for diarrhea should begin. However, stool output greater than 500 mL/day for 2 consecutive days should be evaluated with intervention started to reduce the risk of volume depletion and electrolyte deficiencies. There is currently a growing interest in the role of prebiotics and probiotics in the management of patients with inflammatory bowel disease. However, there are no evidence-based recommendations for using prebiotics and probiotics as standard therapy with diarrhea.

Question 28

The highest prevalence and severity of weight loss is found in patients with which of the following types of cancer?
A. Lung and colon
B. Breast and ovarian
C. Prostate and testicular
D. Pancreatic and gastric

Answer 28

D. Pancreatic and gastric

A large multicenter cooperative study of patients with 12 types of cancer found that over half of cancer patients present with weight loss at the time of diagnosis. The lowest prevalence of weight loss was found in patients with sarcomas, breast, and hematologic cancers. Patients with prostate, colon, and lung cancers had an intermediate prevalence of weight loss. The highest prevalence of weight loss came from patients with pancreatic and gastric cancers.

Question 29

Which of the following best describes the benefit of megestrol acetate in patients with cancer-associated cachexia?
A. Increase in lean muscle mass
B. Decreases the risk of thromboembolic events
C. Improves blood glucose control in diabetes mellitus
D. Improves appetite and ameliorates weight loss

Answer 29

D. Improves appetite and ameliorates weight loss

Megestrol acetate is a synthetic progestational agent that promotes weight gain and helps to stimulate appetite. Progestagens induce the release of Neuropeptide Y from the hypothalamus and downregulate the synthesis and release of proinflammatory cytokines. The change in weight is thought to be largely due to increased adipose tissue and edema. Megestrol acetate can exacerbate underlying diabetes mellitus, and rarely leads to adrenal suppression. It may also be associated with a small increase in the risk of deep venous thrombosis.

Question 30

A patient with Crohn’s disease that involves the distal ileum should be closely monitored for malabsorption of
A. iron.
B. calcium.
C. vitamin B12.
D. folic acid.

Answer 30

C. vitamin B12.

Crohn’s disease can appear anywhere from the mouth to the most distal bowel. As a result, patients with Crohn’s disease can become deficient in a whole host of nutrients. Iron and calcium are absorbed in the duodenum. Folic acid is absorbed in the proximal jejunum. Vitamin B12 is absorbed in the distal ileum.

Question 31

Which of the following has NOT been shown to delay weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease who are receiving enteral nutrition?
A. Refeeding syndrome
B. Trophic feeding
C. Underfeeding
D. Overfeeding

Answer 31

B. Trophic feeding

Both overfeeding and underfeeding have been associated with prolonged ventilator dependence.

Refeeding syndrome is characterized by a serum depletion of phosphorus, magnesium, and potassium as a result of aggressively refeeding malnourished patients. The hypophosphotemia can intensify respiratory dysfunction, diaphragmatic weakness and decreased cellular energy production leading to difficulty in ventilator weaning.

Both strategies, trophic or full nutrition by EN have similar outcomes during the first week of hospitalization. Trophic feeds (the amount of substrate to provide gut stimulation) are typically 10mL to 20mL EN per hour. The large study published in 2012 (EDEN) compared full EN and trophic feeds during the first week of critical illness and found no differences in ventilator days, 60 day mortality or infectious complications.

Question 32

Treatment for patients with overt hepatic encephalopathy who have impairments in cognitive and neuromuscular function include all EXCEPT
A. supplementing zinc, B1, B6, and B12.
B. treating with lactulose or other FDA approved medication.
C. providing a meal pattern of 3 meals and 3 snacks.
D. providing low protein diet.

Answer 32

D. providing low protein diet.

The long standing tradition of protein restrictions for patients with advanced liver disease has no solid scientific basis and recent studies do not support this approach. Protein requirements should be determined in the same manner as for the general ICU patient. Since patients with advanced liver disease enter into starvation mode with decreased glucose oxidation and increased protein and fat catabolism, a diet should be divided into three meals and three snacks with one snack provided at bedtime. Primary sclerosing cholangitis, alcoholic liver disease and hepatocellular carcinoma do not require protein restrictions. Patients with advanced liver disease are frequently deficient in vitamins B1, B6, B12 and folate. Another common deficiency is zinc. These deficiencies develop due to poor intake and decreased absorption.

Question 33

A patient with chronic heart failure on high-dose furosemide is started on enteral nutrition for an inability to consume adequate oral nutrition. Despite a slow advancement to goal feeding rate, he suffers from electrolyte imbalance and peripheral neuritis. Deficiency of which vitamin should be suspected in the cause of his symptoms?
A. Thiamin
B. Vitamin B12
C. Folate
D. Riboflavin

Answer 33

A. Thiamin

Furosemide and digoxin may decrease thiamin uptake by cardiac cells in patients with heart failure. Thiamin deficiency in the form of wet beriberi is characterized by an enlarged heart, nonspecific electrolyte alterations, profound vasodilation, and peripheral neuritis. Symptoms of heart failure secondary to wet beriberi have been shown to improve fairly rapidly in response to thiamin supplementation in tablet or injection form.

Question 34

Protein-energy malnutrition is most common in which of the following types of liver disease?
A. Viral hepatitis
B. Cirrhosis
C. Hepatic steatosis
D. Nonalcoholic steatohepatitis (NASH)

Answer 34

B. Cirrhosis

Protein-energy malnutrition is prevalent in all forms of cirrhosis; severe muscle wasting may be clinically apparent. Patients with compensated viral diseases, such as hepatitis B and C, usually are not severely malnourished compared to those with alcoholic liver disease/cirrhosis. Hepatic steatosis may occur as the first stage of hepatic insufficiency as the result of alcohol consumption. Malnutrition is much less common in patients with nonalcholic steatohepatitis.

Question 35

Under conditions of sepsis and stress, which of the following metabolic alterations are most likely to occur?
A. Increased glucose production and increased glucose uptake
B. Increased glucose production and decreased glucose uptake
C. Decreased glucose production and decreased glucose uptake
D. Decreased glucose production and increased glucose uptake

Answer 35

B. Increased glucose production and decreased glucose uptake

The metabolic response to sepsis and stress is characterized by an increase in glucose production and a decrease in glucose uptake. Stress hormones induce insulin resistance and hyperglycemia is commonly observed in stressed patients. It is recommended that glucose levels be adequately controlled to avoid polyuria, electrolyte disturbances, and infectious complications.

Question 36

Calcium oxalate nephrolithiasis can occur in patients with short bowel syndrome (SBS) with an intact colon who
A. eat a diet with 20-30% of daily energy goal as fat.
B. do not maintain adequate hydration.
C. have < 100 cm terminal ileum resected.
D. take 500 mg calcium 2-3 times per day.

Answer 36

B. do not maintain adequate hydration.

Nephrolithiasis from calcium oxalate stones in SBS patients is multifactorial but primarily due to increased availability of oxalate for absorption in the colon. Normally, dietary oxalate binds to calcium and is excreted in the stool. However, in the setting of steatorrhea, calcium binds to fatty acids, allowing excess and unbound oxalate to be absorbed from the colon and filtered by the kidneys. Oxalate stone formation is facilitated in the kidneys of SBS patients by excess oxalates, dehydration, metabolic acidosis and hypomagnesemia. Maintaining adequate hydration to support a urine output > 1200 mL/day is the most important intervention to prevent this complication. Oral calcium supplements of 800 to 1200 mg/day, in divided doses not exceeding 500 mg, are used in an effort to compete with fatty acids to bind oxalate in the colon. Limiting dietary fat intake to 20-30% of ingested macronutrients minimizes steatorrhea, oxalate absorption as well as loss of calcium and magnesium. SBS patients with less than 100cm of terminal ileum resected are at lower risk of bile salt malabsorption and steatorrhea.

Question 37

A 14-year-old with a 4-month history of intentional weight loss of 15% of her usual weight and a BMI less than the 5th percentile is diagnosed with anorexia nervosa. She is admitted to the hospital for medical stabilization and is unwilling to consume enough food to meet her nutritional needs. A 24-hour calorie count reveals that the patient is consuming a very restricted diet averaging 850 calories daily. Which of the following is the most appropriate nutrition intervention at this time?
A. Peripheral parenteral nutrition
B. High calorie diet with a calorie count
C. Structured meal plan with supplemental enteral feedings
D. Total parenteral nutrition

Answer 37

C. Structured meal plan with supplemental enteral feedings

Several reviews have indicated that in the United States, oral refeeding is the preferred modality for nutrition rehabilitation. Enteral feeds, however, have been helpful for patients who are unable to eat, or have been unwilling to eat. Electrolytes, including potassium, magnesium and phosphorus, should be checked at baseline and routinely with initiation and structured advancement of enteral feedings for patients with anorexia nervosa due to the high risk of developing refeeding syndrome.

Question 38

A 51-year-old female who is 10 years post gastric bypass surgery for obesity presented with numbness and tingling in her distal lower extremities that had progressively worsened. She had been on an oral multivitamin supplement. She was significantly anemic and neutropenic. Her vitamin B12 level was normal as were her serum iron, ferritin, and transferrin levels. What nutritional deficiency is the most likely cause of all of these symptoms?
A. Thiamin
B. Zinc
C. Folate
D. Copper

Answer 38

D. Copper

Deficiencies of thiamin, zinc, folate, vitamin B12, iron and copper have all been described after gastric bypass surgery.

Vitamin B12 deficiency can cause anemia and peripheral neuropathy;

iron and folate deficiencies can cause anemia but not peripheral neuropathy.

Thiamin deficiency can cause neuropathy but not anemia.

Zinc deficiency can present with skin rashes, hair loss and loss of taste.

Copper deficiency is rare, but presents with anemia, leukopenia, neutropenia, and symptoms of peripheral neuropathy.

Question 39

What are the protein requirements for a stable patient receiving peritoneal dialysis (PD)?
A. 0.6-0.8 grams per kilogram per day
B. 1.2-1.3 grams per kilogram per day
C. 1.5-1.8 grams per kilogram per day
D. 2.0-2.2 grams per kilogram per day

Answer 39

B. 1.2-1.3 grams per kilogram per day

Protein losses through the peritoneum take place routinely while on PD. KDOQI guidelines recommend 1.2-1.3 gm protein/kg/day in clinically stable patients.

Question 40

Increased mortality in maintenance HD patients has been associated with
A. low baseline body fat percentage and low muscle mass.
B. elevated albumin and decreased CRP values.
C. increased BMI.
D. increased serum cholesterol.

Answer 40

A. low baseline body fat percentage and low muscle mass.

Low muscle mass reflects poor nutritional status and can reflect inflammation. Low fat mass reflects low body stores of energy. Elevated CRP levels are increased with HD and cause greater weight loss, decreased albumin and decreased appetite. A BMI of 30-34.9 is considered protective in HD patients. A BMI less than 23 and hypoalbuminemia (< 3.2g/dL) were strong predictors of mortality in HD patients. Serum cholesterol level is inversely correlated with the risk for death. It has been noted that serum cholesterol concentration is elevated in the long-term dialysis survivors.

Question 41

Zinc supplementation should be considered for patients:
A. with chronic wounds.
B. with unexplained skin rashes and alopecia.
C. who are elderly.
D. who have below normal zinc levels.

Answer 41

B. with unexplained skin rashes and alopecia.

Zinc is an essential trace element necessary for cell replication and growth. It is a cofactor for collagen and protein synthesis and proliferation of inflammatory cells and epithelial cells.

Zinc deficiencies occur secondary to gastrointestinal surgery, and diseases that impair intestinal absorption and or diseases that increase zinc losses which may include celiac disease, cystic fibrosis, inflammatory bowel disease and Crohn’s disease.

Chronic diarrhea and exudate from large wounds may also lead to zinc losses. However, research has not proved that general use of zinc is effective for patients with chronic wounds.

Serum zinc levels are used to assess zinc status, however, serum zinc levels fall in the presence of inflammation and are dependent on albumin for transport. Therefore, interpretation of plasma zinc levels should be interpreted cautiously in the presence of hypoalbuminemia and inflammation.

Clinical signs and symptoms of zinc deficiency include: rash, alopecia, impaired night vision, alterations in taste and smell, impaired immune function, anorexia and diarrhea. Zinc deficiencies are not associated with age.

Question 42

Which of the following acute changes in the serum chemistry profile would be expected in a patient who is experiencing tumor lysis syndrome(TLS)?
A. Hypercalcemia and hypomagnesemia
B. Hyperkalemia and hyperphosphatemia
C. Hypernatremia and hypermagnesemia
D. Hypocalcemia and hyperphosphatemia

Answer 42

B. Hyperkalemia and hyperphosphatemia

Tumor lysis syndrome (TLS) is caused by massive tumor cell lysis with the release of large amounts of potassium (hyperkalemia), phosphate (hyperphosphatemia), and nucleic acids into the systemic circulation. Catabolism of the nucleic acids to uric acid leads to hyperuricemia. TLS most often occurs after the initiation of cytotoxic therapy.

Question 43

What is the recommended maximum dietary protein intake in critically ill adult patients receiving continuous renal replacement therapy (CRRT)?
A. 1.0 g/kg per day
B. 1.5 g/kg per day
C. 2.0 g/kg per day
D. 2.5 g/kg per day

Answer 43

D. 2.5 g/kg per day

The delivery of adequate protein to acutely ill patients requiring dialysis is critical secondary to hypercatabolism, obligatory use of protein as a preferred fuel source during the stress response, and the likelihood of significant protein losses in CRRT effluent. In general, centrally-infused protein losses into CRRT effluent range from 10-17% and should be taken into consideration when determining protein requirements. While doses as high as 2.5 g protein/kg per day have been advocated to promote positive nitrogen balance, disadvantages of high-protein delivery may include the exacerbation of uremia, increased demand on hepatic and renal function, and increased costs.

Question 44

In cirrhotic patients, which of the following should be implemented to assist in avoiding fasting-associated starvation during the night?
A. Late evening snack
B. Nocturnal tube feeding
C. Branched-chain amino acids supplement
D. Nocturnal parenteral nutrition

Answer 44

A. Late evening snack

Cirrhotic patients have depleted glycogen stores and utilize more fat as fuel during periods of prolonged starvation. This accelerated starvation phenomenon can be seen in an overnight fast of 12 to 18 hours. A late evening snack may help prevent fasting-associated starvation. Provided the patient is able to consume adequate oral intake, tube feeding and branched-chain amino acids would have no role. Parenteral nutrition is not indicated with a functional gut.

Question 45

Gastric hypersecretions following significant small bowel resection can become problematic. Which of the following medications have shown to be the most successful in suppressing gastric hypersecretion?
A. Cholestyramine
B. Loperamide
C. Histamine2 receptor antagonists
D. Proton pump inhibitors

Answer 45

D. Proton pump inhibitors

Both histamine2-receptor antagonists (H2-blockers) and proton pump inhibitors (PPIs) have been used to treat gastric hypersecretion; however, PPIs are more effective at suppressing acid than H2-blockers. As PPIs are absorbed in the small bowel, higher than standard initial doses for oral administration may be required in SBS patients.

Alternatively, oral dissolving tablets may be beneficial. Delayed release forms should be avoided in SBS patients.

Cholestyramine is used for diarrhea associated with excess fecal bile acids.

Loperamide is used to slow intestinal transit.

Question 46

Supplementation with which of the following nutrients is routinely restricted during the early stages following hematopoietic stem cell transplantation (HSCT)?
A. calcium
B. Folate
C. Iron
D. Vitamin B12

Answer 46

C. Iron

Blood product support, hyper-transfusion, is usually required before, during and after HSCT, thus leading to iron overload. Iron overload may adversely affect the outcome of the transplant by increasing the likelihood of acute graft-versus-host disease, blood and fungal infections, and sinusoidal obstruction syndrome of the liver.

Question 47

Hypoglycemia, requiring dextrose infusions to maintain euglycemia, is most likely to occur in which type of liver disease?
A. Hepatic steatosis
B. Viral hepatitis
C. Decompensated cirrhosis
D. Fulminant hepatic failure

Answer 47

D. Fulminant hepatic failure

Hypoglycemia is commonly seen in patients with fulminant hepatic failure and may result from impaired glycogenolysis, glycogenesis, gluconeogenesis and hyperinsulinemia requiring aggressive glucose administration. Patients are usually in a hypercatabolic state with an increase in energy expenditure and can become rapidly malnourished.