Nutr Assess

Question 1

Copper deficiency is associated with

1. leukocytosis
2. macrocytic anemia
3. microcytic hypochromic anemia
4. erythrocytosis

Answer 1

3. microcytic hypochromic anemia
   Pts on long-term PN have developed anemia, leukopenia, neutropenia and skeletal abnormalities. Deficiencies of B12 or folate result in macrocytic anemia (large RBC). Deficiencies of iron or copper result in microcytic hypochromic anemia (small RBC that are pale in color due to decreased heme pigment). Copper is a metallocofactor for enzymes involved in iron absorption and transport, electron transport, connective tissue cross-linking, and is a component of ceruloplasmin.

Question 2

A pt receiving PN with a high ileostomy output is likely to require

1. increased sodium and increased fluid volume
2. decreased water and decreased sodium
3. increased sodium and decreased protein
4. decreased sodium and increased fluid volume

Answer 2

1. increased sodium and increased fluid volume
   Pts with ileostomy or small bowel fistula output are at risk for water and electrolyte losses. The Na content of ileostomy output can be as high as 120 mEq/L. Hyponatremia can result when fluid replacement does not contain adequate Na to correct for ileostomy losses.

Question 3

Which of the following is a characteristic of kwashiorkor malnutrition?

1. Splenomegaly
2. Hypoalbuminemia
3. Hypoglycemia
4. Cachexia

Answer 3

2. Hypoalbuminemia
   Kwashiorkor malnutrition is caused by insufficient protein intake during a prolonged period. The clinical features include hypoalbuminemia, edema, ascites, dermatitis, thin brittle hair, hepatomegaly and muscle wasting. In comparison, marasmus is caused by insufficient energy intake, and is characterized by extreme weight loss and cachexia.

Question 4

Which of the following conditions is most likely to result in malnutrition?

1. Cancer
2. PNA
3. Gastric ulcer
4. Multiple sclerosis

Answer 4

1. Cancer

This is probably the result of cancer cachexia, a wasting disease characterized by increased metabolism.

Question 5

Which of the following is the best indicator of risk for malnutrition?

1. Serial tricep skinfold remaining at the 20th percentile
2. Voluntary BMI change from 30 to 25 in 6 months
3. Involuntary wt loss of 10% UBW over 6 months
4. Albumin decrease from 4 to 3.5

Answer 5

3. Involuntary wt loss of 10% UBW over 6 mo

Question 6

Which of the following is the most appropriate indicator of malnutrition?

1. Involuntary weight loss of 5% of usual body weight over three months
2. Involuntary weight loss of 10% of usual body weight over six months
3. Weight less than 10% of ideal body weight
4. Weight less than 15% of ideal body weight

Answer 6

2. Involuntary wt loss of 10% of UBW over 6 months

Question 7

Which of the following is most characteristic of metabolism in both stress and starvation related malnutrition?

1. Ketosis
2. Hypoglycemia
3. Lipolysis
4. Hypermetabolism

Answer 7

3. Lipolysis
   Catabolism of endogenous substrate including fat stored in adipose tissue (lipolysis) is common in both forms of malnutrition. Hypoglycemia and ketosis are characteristic of starvation. Hypermetabolism and hyperglycemia are characteristic of stress-related malnutrition.

Question 8

Which of the following methods of nutrition assessment evaluate subcutaneous fat and muscle wasting at multiple body sites to determine nutritional status?

1. Nutritional risk index (NRI)
2. Prognostic nutrition index (PNI)
3. Subjective Global Assessment (SGA)
4. Prognostic inflammatory and nutritional index (PINI)

Answer 8

3. Subjective Global Assessment (SGA)
   The SGA evaluates nutritional status using five historical and four physical examination parameters. The historical information includes: weight history, dietary intake, gastrointestinal symptoms, functional status, and metabolic demand. The physical examination parameters include subjective measures of subcutaneous fat, muscle wasting, edema, and ascites at more than one body site.

Question 9

The Subjective Global Assessment used to evaluate the nutritional status of pts includes

1. dietary intake, delayed hypersensitivity skin testing, and wt hx
2. wt hx, dietary intake, and GI symptoms
3. laboratory indices, wt hx, and GI symptoms
4. arm anthropometry, dietary intake, and lab indices

Answer 9

2. wt hx, dietary intake, and GI symptoms
   The SGA has been applied successfully as a method of assessing nutritional status in a variety of pt populations. It integrates 5 historical (weight history, dietary intake, GI symptoms, functional status, metabolic demand) and four physical examination parameters (subcutaneous fat, muscle wasting, edema, ascites) to define nutritional status.

Question 10

Which of the following has been reported to be a significant independent predictor of morbidity and mortality in critically ill pts?

1. Albumin
2. Prealbumin
3. Transferrin
4. Retinol-binding protein

Answer 10

1. Albumin
   In a study including 1023 critically ill patients, albumin was a significant independent predictor of morbidity and mortality. ICU and hospital length of stay, ventilator days, risk of infection and mortality were significantly greater for patients with a serum albumin <2.6 g/dL.

Question 11

A previously well-nourished pt with persistent fever is admitted to the hospital. His lab tests reveal: albumin, 2.1 g/dL; C-reactive protein, 12 mg/L; serum calcium of 7.2 mg/dL. Which of the following is the most likely reason of the hypoalbuminemia?

1. Caloric intake is below recs
2. Protein intake below recs
3. Hypocalcemia
4. Inflammatory response

Answer 11

4. Inflammatory response

Albumin may decrease during inflammation and hypervolemia.

Question 12

Which of the following compromises the reliability of urinary urea nitrogen to calculate nitrogen balance?

1. Protein intake <0.5 g/kg/d
2. Creatinine clearance <50 mL/min
3. Diuresis >2.5 L
4. Fecal nitrogen > 1g

Answer 12

2. Creatinine clearance <50 mL/min
   Urine urea nitrogen is used primarily to monitor protein intake during nutrition support. Urine is usually collected for a 24-hour period in order to quantify the amount of urinary urea nitrogen. Compromised renal function, as indicated by a creatinine clearance <50 mL/min, low urine output, and muscle atrophy can alter urinary urea nitrogen, resulting in unreliable results.

Question 13

Which of the following has been shown to reduce plasma homocysteine concentrations?

1. Folic acid
2. Vit E
3. L-carnitine
4. Ascorbic acid

Answer 13

1. Folic acid
   Hyperhomocysteinemia has been linked to an increased risk for coronary artherosclerosis. Studies have shown that folic acid, vitamin B6, and vitamin B12 supplementation can reduce plasma homocysteine concentrations.

Question 14

Which of the following is the most appropriate fluid requirement for a healthy adult?

1. 15-20 mL fluid/kg/d
2. 20-25 mL fluid/kg/d
3. 30-35 mL fluid/kg/d
4. 40-45 mL fluid/kg/d

Answer 14

3. 30-35 mL fluid/kg/d

Question 15

Which of the following enzymes initiates the digestive process of carbohydrates in the mouth?

1. Lipase
2. Lactase
3. Maltase
4. Amylase

Answer 15

4. Amylase
   The salivary gland releases an enzyme called alpha amylase that initiates hydrolysis of carbohydrate when food enters the mouth. The degree of hydrolysis depends on the time that food is chewed and the nature of the food that enters the stomach. Lipase is an enzyme released from the pancreas that is important in the digestion of fat. Both lactase and maltase are located in the brush border cells of the small intestine and are important in intraluminal carbohydrate digestion.

Question 16

Iron is primarily absorbed in the

1. distal ileum
2. distal jejunum
3. proximal ileum
4. proximal jejunum

Answer 16

4. proximal jejunum
   Iron is absorbed primarily in the proximal jejunum in the ferrous state rather than the ferric state. The ferric form of iron is insoluble in aqueous solutions and, therefore, not absorbed. Gastric acid is very important in maintaining dietary iron in the ferrous state.

Question 17

Which of the following amino acids is most crucial in small intestinal structure and function?

1. Alanine
2. Leucine
3. Aspartate
4. Glutamine

Answer 17

4. Glutamine
   While all amino acids are important in metabolism, glutamine is a key fuel for the small intestine. Glutamine is essential for small intestinal structure and function. It could be useful to supplement glutamine to patients who are suffering trauma or receiving parenteral nutrition.

Question 18

In persons with phenylketonuria, tyrosine becomes an essential amino acid due to

1. an increase in the tyrosine hydroxylase enzyme
2. a deficiency in the phenylalanine enzyme
3. an increase in the phenylalanine hydroxylase enzyme
4. a decrease in the tyrosine hydroxylase enzyme

Answer 18

2. a decrease in the phenylalanine hydroxylase enzyme
   Phenylalanine hydroxylase is the enzyme involved in the conversion of phenylalanine to tyrosine. If there is a defect in this enzyme, a deficiency of tyrosine occurs. This is the reason tyrosine is included in phenylketonuria (PKU) formulas.

Question 19

Which of the following is an aromatic amino acid?

1. Valine
2. Leucine
3. Tyrosine
4. Isoleucine

Answer 19

3. Tyrosine
   Valine, leucine, and isoleucine are branched-chain amino acids. The aromatic amino acids include phenylalanine, tyrosine, tryptophan, and methionine. Altered amino acid metabolism is a hallmark of liver disease characterized by low levels of circulating branched-chain amino acids and elevated levels of circulating aromatic amino acids.

Question 20

Which of the following are examples of conditionally indispensible amino acids?

1. Leucine and isoleucine
2. Phenylalanine and valine
3. Glutamine and arginine
4. Histidine and tryptophan

Answer 20

3. Glutamine and arginine
   Conditionally indispensable amino acids are synthesized from other amino acids under normal conditions but require a dietary source in order to meet increased needs caused by metabolic stress. For example, Arginine becomes conditionally indispensable for wound healing. Conditionally indispensable amino acids include: Arginine, Cysteine, Glutamine, Glycine, Proline and Tyrosine.

Question 21

An NPO post-operative patient has been on 2-in-1 parenteral nutrition (PN) for three weeks. He develops a diffuse scaly dermatitis, hair loss, anemia and thrombocytopenia. Which of the following is the probable cause?

1. He has not been receiving IVFE for 3 weeks
2. He has been receiving trace elments 3 times/week d/t a national shortage
3. He is receiving 20 kcal/kg/d from PN because of hyperglycemia
4. He has PN related cholestasis and is experiencing fat malabsorption

Answer 21

1. He has not been receiving IVFE for 3 weeks
   Provision of fat free PN for three weeks has resulted in essential fatty acid deficiency. Signs of EFAD include scaly dermatitis, alopecia, thrombocytopenia, anemia and impaired wound healing. Provision of 2-4% of total calories as fat should be sufficient to prevent essential fatty acid deficiency.

Question 22

Which of the following IVF most closely resembles jejunal and ileal electrolyte content?

1. Lactated ringer
2. 0.9% sodium chloride
3. 0.45% sodium chloride
4. D5 0.45% sodium chloride

Answer 22

1. Lactated ringer

Question 23

Which of the following clinical situations would best describe a critically ill patient with syndrome of inappropriate antidiuretic hormone (SIADH)?

1. Appears euvolemic but is total body water overloaded because there is inappropriate concentration of the urine
2. Appears hypervolemic and is total body water overloaded because there is inappropriate dilution of the urine
3. Appears hypovolemic but is total body water overloaded because there is inappropriate fluid resorption in the kidneys
4. Appears euvolemic but is total body water overloaded because there is inadequate production and release of anti-diruetic hormone from the adrenal glands

Answer 23

1. Appears euvolemic but is total body water overloaded because there is inappropriate concentration of the urine
   Hyponatremia associated with SIADH is common in the critically ill patient. The role of antidiuretic hormone is to control water loss via the kidneys depending on individual hydration status. When excessive antidiuretic hormone is produced, water is conserved rather than excreted and the urine becomes concentrated. Spot urine sodium levels and urine osmolality will both be elevated. The clinical picture associated with SIADH is euvolemia with total body water overload due to an inappropriate concentration of the urine.

Question 24

In a patient with nonhealing wounds suspected of having a vitamin A deficiency, supplementation of vitamin A (25,000 IU/day) should usually be given for a MAXIMUM of

1. 2 days
2. 10 days
3. 45 days
4. 60 days

Answer 24

2. 10 days
   Vitamin A has multiple functions in wound healing including cellular differentiation, enhancement of epithelialization and collagen synthesis. However, it can be toxic at high doses and, therefore, supplementation should be limited to no more than 10 days.

Question 25

A pt with alcoholism is admitted with SBO and is started on PN providing 400gm dextrose. If, after 3 days, the pt develops Wernicke’s encephalopathy it is most likely d/t a deficiency of

1. pyridoxine
2. thiamine
3. folic acid
4. vit C

Answer 25

2. thiamine

Question 26

Lactic acidosis can be a result of which vitamin deficiency?

1. Folic acid
2. Vit E
3. Thiamine
4. Vit C

Answer 26

3. Thiamine
   Thiamine is necessary for the metabolism of glucose, specifically, the conversion of pyruvate to acetyl CoA. In the absence of thiamine, pyruvate is converted to lactic acid.

Question 27

In addition to aggressive refeeding, which of the following places a pt at high risk for hypophosphatemia?

1. DKA, chronic alcoholism
2. Parkinson disease, tumor lysis syndrome
3. Pancreatitis, Fanconi syndrome
4. ARF, SIADH

Answer 27

1. DKA, chronic alcoholism
   Patients particularly at risk for hypophosphatemia include malnourished patients who are aggressively renourished, patients with diabetic ketoacidosis, and chronic alcoholism. Aggressive refeeding increases insulin production. Insulin is an anabolic hormone which drives potassium and phosphorus into the cell resulting in serum depletion.

Question 28

The risk of metastatic calcification of calcium phosphate in soft tissues increases when the product of phosphorus and calcium in the serum (serum phosphorus x serum total calcium) exceeds

1. 25
2. 35
3. 45
4. 55

Answer 28

4. 55
   A primary complication of hyperphosphatemia, besides hypocalcemia, is metastatic calcification in soft tissues, blood vessels, and organ parenchyma. The risk of metastatic calcification of calcium phosphate in soft tissues increases when the product of phosphorus and calcium in the serum (serum Phos x serum total Ca) is as low as 55.

Question 29

Zinc deficiency caused by malnutrition is most likely to result in

1. diarrhea
2. carotenemia
3. coagulopathy disorder
4. increased absorption of nutrients

Answer 29

1. diarrhea
   Zinc helps regenerate gut epithelium and increase levels of brush border enzymes. Protein energy malnutrition compromises zinc status by activating cyclic guanine monophosphate (cGMP) synthesis which inhibits sodium and chloride absorption and stimulates chloride secretion, causing diarrhea. Zinc losses are increased due to the diarrhea, further exacerbating absorption of nutrients in the gut.

Question 30

Copper toxicity is associated with

1. liver disease
2. kidney disease requiring HD
3. aggressive zinc supplementation
4. lung disease

Answer 30

1. liver disease
   Copper toxicity can cause severe nausea, diarrhea, and vomiting. More serious manifestations with acute or more chronic toxic ingestion or Wilson’s disease include coma, hepatic necrosis, liver failure, renal failure, vascular collapse, and death. Since about 80% of copper is excreted in the bile, patients who have liver disease should be monitored and supplementation reduced or eliminated. Hemodialysis increases copper losses. Zinc supplementation can impair copper absorption.

Question 31

Hepatic encephalopathy is most likely to be improved by which of the following trace elements?

1. Selenium
2. Copper
3. Zinc
4. Chromium

Answer 31

3. Zinc
   Zinc deficiency is very common in liver disease. Data suggest that supplementation with oral zinc is associated with improvement in amino acid metabolism and encephalopathy.

Question 32

Which of the following best describes the utility of aluminum in parenteral solutions?

1. Potentiates the action of insulin
2. Has no known biologic function
3. Decreases the incidence of bone fractures
4. Is necessary for normal erythropoiesis

Answer 32

2. Has no known biologic function

Question 33

Which of the following can result in an invalid indirect calorimetry measurement?

1. Enterocutaneous fistula
2. Chest tube leak
3. Hemodynamic stability
4. Inspired oxygen (FiO2) less than 60%

Answer 33

2. Chest tube leak
   Clinical factors can affect the validity of indirect calorimetry measurements in critical illness. For instance, if the patient requires inspired oxygen (FiO2) > 60%, the indirect calorimetry study should not be performed since the results may be inaccurate. The presence of an air leak can produce invalid results, as possible with a chest tube or bronchopleural fistula and within an endotracheal tube cuff. Furthermore, hemodialysis can alter measurements because of the potential loss of CO2 through the dialysis coil.

Question 34

In assessing the caloric goal for patients receiving nutrition support, the measured resting energy expenditure determined from indirect calorimetry should be

1. reduced by 10% if respiratory quotient exceeds 1.0.
2. increased by a stress factor of 1.2-1.5 for sepsis or trauma.
3. adjusted by a thermogenesis factor for enterally fed patients.
4. used as the caloric target without addition of stress or activity factors

Answer 34

4. used as the caloric target without addition of stress or activity factors
   REE measured under steady state conditions closely approximates true 24-hr energy expenditure. No stress or activity factors are needed and could result in overfeeding.

Question 35

A respiratory quotient (RQ) of .95 most likely suggests

1. primarily fat oxidation
2. mixed substrate utilization
3. underfeeding
4. overfeeding

Answer 35

2. mixed substrate utilization
   RQ = CO2 produced/O2 consumed. An RQ <0.7 or >1.0 may result from unusual metabolic factors (hypoventilation or hyperventilation). Overfeeding or underfeeding may result in an RQ outside the 0.7-1.0 range, however this is not always the case. Traditional interpretation of RQ is as follows: RQ of 0.7 is primarily fat oxidation, 0.82 is primarily protein oxidation, 0.85-0.95 suggests mixed substrate utilization, and 1.0 is carbohydrate oxidation.

Question 36

Which of the following predictive equations has demonstrated the greatest accuracy in estimating actual resting metabolic rate in obese and nonobese adults?

1. Owen using adjusted body weight
2. Harris-Benedict using actual body weight
3. Harris-Benedict using adjusted body weight
4. Mifflin-St. Jeor using actual body weight

Answer 36

4. Mifflin-St. Jeor using actual body weight

Question 37

Cheilosis is a physical symptom associated with a deficiency of

1. Vit D
2. Folic acid
3. Riboflavin
4. Vit C

Answer 37

3. Riboflavin
   Cheilosis, cracking of the corners of the mouth, is observed with a deficiency of riboflavin, niacin, iron, and pyridoxine.

Question 38

Malnutrition is most common in which of the following forms of inflammatory bowel disease?

1. Crohn’s disease
2. Ulcerative colitis
3. Microscopic colitis
4. Collagenous colitis

Answer 38

1. Crohn’s disease

Question 39

An end stage liver disease patient with refractory ascites is awaiting liver transplantation and is intolerant to tube feeding. His serum sodium is 128 mEq/L. Which of the following would be most appropriate to recommend?

1. No parenteral nutrition
2. Restrict fluid, restrict sodium , provide 0.5 g/kg per day protein
3. Restrict fluid, restrict sodium, provide 1.5 g/kg per day protein
4. Restrict fluid, supplement sodium, provide 1.0 g/kg per day protein

Answer 39

3. Restrict fluid, restrict sodium, provide 1.5 g/kg per day protein

Question 40

Arginine supplementation should be used most cautiously in which of the following patients?

1. Trauma patients
2. Surgical patients
3. Septic shock patients
4. Immunocompromised patients

Answer 40

3. Septic shock pts
   Arginine, which increases the production of nitric oxide, has been shown to have positive effects on recovery from trauma and surgery through its effect on blood flow, immune function, wound healing, and organ failure. In conditions of pronounced vasodilation, as in septic shock, the production of nitric oxide would be expected to exacerbate hemodynamic instability.

Question 41

What is the approximate normal length of small intestine in adults?

1. 100 cm
2. 150 cm
3. 200 cm
4. 600 cm

Answer 41

4. 600 cm
   The normal small intestine is approximately 600 cm in length. The colon is approximately 150 cm. Patients with less than 150-200 cm of small bowel without a colon may have significant fluid and nutrient losses, i.e. short bowel syndrome.

Question 42

What is the primary fuel of the colonocytes?

1. Medium chain fatty acids
2. Glucose
3. Glutamine
4. Short chain fatty acids

Answer 42

4. Short chain fatty acids
   The short chain fatty acids include acetate, propionate, and butyrate. The colon can convert (by fermentation) complex carbohydrate to short chain fatty acids. The short chain fatty acids stimulate water and sodium absorption in the colon and provide a source of calories as well.

Question 43

Dietary fat is predominately absorbed in what part of the intestine?

1. Ileum and colon
2. Stomach and duodenum
3. Distal jejunum and ileum
4. Duodenum and proximal jejunum

Answer 43

4. Duodenum and proximal jejunum
   Absorption of fat in the normal person occurs predominantly in the duodenum and proximal jejunum. Conjugated bile acids released into the proximal intestine forms polymolecular aggregates called mixed micelles, which aid in the solubilization and absorption of dietary fat.

Question 44

Gastrectomy pts are at risk for a deficiency of which vitamin?

1. B12
2. Folic acid
3. Thiamine
4. B6

Answer 44

1. B12
   Parietal cells in the stomach are responsible for producing intrinsic factor, which under normal circumstances binds with Vitamin B12 and aids in the absorption of B12 in the small bowel. When the stomach is resected, there is no longer adequate intrinsic factor to bind with B12

Question 45

Which of the following anatomic structures is LEAST important to the function of a massively resected gastrointestinal tract?

1. Colon
2. Ileum
3. Jejunum
4. Ileocecal valve

Answer 45

3. Jejunum
   The ileum has specific absorption functions that cannot be performed in any other area of the GI tract. The ileocecal valve and colon play an important role in transit time and electrolyte balance. The jejunum cannot adapt to perform the functions of a resected ileum or colon, whereas the illeum or colon can assume function of a resected jejunum over time.

Question 46

Which of the following is associated with adaptation to starvation?

1. Hyperthermia
2. Reduced muscle mass
3. Lipogenesis
4. Increased cardiac capacity

Answer 46

2. Reduced muscle mass
   During starvation, successful adaptation reduces energy and protein requirements as long as the ratio of energy to protein is not too low. The physiologic costs of adaptation are lowered metabolic rate, reduced muscle mass, muscular weakness, functional disability, mild hypothermia, and reduced cardiac and respiratory capacity.

Question 47

What is the fluid requirement for pts during critical illness and sepsis?

1. 15-20 mL/kg/d
2. 30-40 mL/kg/d
3. 45-55 mL/kg/d
4. 60-70 mL/kg/d

Answer 47

2. 30-40 mL/kg/d

Question 48

Valproic acid (Depakene) has been shown to induce a deficiency in which of the following nutrients?

1. Copper
2. Carnitine
3. Fatty acids
4. Essential amino acids

Answer 48

2. Carnitine
   Depakene, an antiepileptic drug, has been shown to induce carnitine deficiency. The mechanism of this effect is not fully explained. Impaired renal handling may be involved. Carnitine is involved in the metabolism of fatty acids.

Question 49

Methotrexate acts by interfering with the normal intracellular metabolism of which of the following nutrients?

1. Thiamine
2. Folate
3. Carnitine
4. Vit D

Answer 49

2. Folate
   Methotrexate is a chemotherapeutic drug. Folate analogues, such as methotrexate, are structurally similar to folate but are able to bind with and inhibit the action of various enzymes.

Question 50

What vitamin absorption is most likely to be impaired with the use of proton pump inhibitor therapy?

1. Vit A
2. Vit C
3. Vit B6
4. Vit B12

Answer 50

4. Vit B12
   Proton pump inhibitors decrease gastric acidity and may thus interfere with the absorption of protein-bound dietary vitamin B12.