Self Assessment Pre-Test

Question 1

Question: 1 

Which of the following is the inpatient glycemic target for critically ill patients?

1: 80-110 mg/dL

2: 140-180 mg/dL

3: 180-210 mg/dL

4: 210-240 mg/dL

Answer 1

2: 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 in selected patients. Targets

Question 2

Question: 2 

Under conditions of sepsis and stress, which of the following metabolic alterations are most likely to occur?

1: Increased glucose production and increased glucose uptake

2: Increased glucose production and decreased glucose uptake

3: Decreased glucose production and decreased glucose uptake

4: Decreased glucose production and increased glucose uptake


Answer 2

2: 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 with nutrition support. It is recommended that glucose levels be adequately controlled to avoid polyuria and electrolyte disturbances.

Question 3

Question: 3 

Which of the following immunomodulating nutrients may be harmful in patients with severe sepsis?

1: Arginine

2: Glutamine

3: Nucleic acids

4: Omega-3 fatty acids


Answer 3

1: 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. Because of these effects, there is still much debate over the value of arginine in nutrition support for critically ill patients.

Question 4

Question: 4 

Which of the following best describes enteral glutamine supplementation in the critically ill patient not in multi organ failure?
1: Enteral glutamine is preferred over parenteral glutamine
2: Glutamine reduces systemic inflammation

3: Preferred glutamine dosage is 20-40grams/day

4: Glutamine has not been shown to reduce length of stay


Answer 4

4: Glutamine has not been shown to reduce length of stay

Question 5

Question: 5 

Which of the following are counter-regulatory hormones responsible for the hypercatabolism observed in critically ill trauma patients?

1: Glycogen, insulin, norepinephrine

2: Glucagon, epinephrine, cortisol

3: Glycerol, serotonin, thymoglobulin

4: Glycerin, leptin, adenosine

Answer 5

2: Glucagon, epinephrine, cortisol


The inflammation following a traumatic injury provokes a release of systemic catabolic hormones like epinephrine, glucagon, and cortisol from the hypothalamus. 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, homeostasis, and 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 6

Question: 6 

In patients with burns, providing caloric support above energy expenditure has been found to

1: decrease mortality.

2: improve wound healing.

3: decrease fat mass accumulation.

4: have no effect on lean body mass preservation.

Answer 6

4: have no effect on lean body mass preservation.
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 7

Question: 7

In pulmonary insufficiency, excessive calorie administration may cause increased blood pCO2 resulting in

1: metabolic acidosis.

2: metabolic alkalosis.

3: respiratory acidosis.

4: respiratory alkalosis.

Answer 7

3: respiratory acidosis.

The increased metabolism of glucose (oxidation and lipogenesis) increases CO2 production. This may result in increased blood pCO2 if pulmonary insufficiency is significant. According to the Henderson-Hasselbach equation, this will result in a decrease in pH. If compensatory retention and increase in bicarbonate ion do not occur, the pH may remain

Question 8

Question: 8 

Which of the following is NOT true of essential fatty acid deficiency (EFAD) in patients with cystic fibrosis (CF)?

1: Biochemical EFAD may be seen in both pancreatic sufficient and insufficient patients

2: Routine supplementation of omega-3 fatty acids is essential in the management of CF

3: Those patients with moderate to severe lung disease are at high risk for EFAD

4: Poor growth and pulmonary status correlate with biochemical markers of EFAD

Answer 8

2: Routine supplementation of omega-3 fatty acids is essential in the management of CF

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 9

Question: 9

Which of the following is the best choice for feeding a pancreatic insufficient infant with cystic fibrosis?

1: Protein hydrolysate formula with medium chain triglyceride (MCT)

2: Free amino acid formula with MCT

3: Human milk

4: Standard infant formula

Answer 9


3: Human milk

Human milk is the optimal choice over standard formula for any infant due to multiple beneficial components including immunologic properties, growth factors, and both pre- and probiotics. Human milk or standard infant formula with appropriate enzyme dosing is recommended. Protein hydrolysate or free amino acid formulas containing MCT are not indicated for infants with cystic fibrosis (CF) unless there is another medical reason such as bowel resection resulting in malabsorption or liver abnormalities.

Question 10

Question: 10 

What is the glomerular filtration rate (GFR) of a patient with end-stage renal disease? 
1: >90 mL/min/1.73 M2

2: 30-59 mL/min/1.73 M2

3: 15-29 mL/min/1.73 M2

4:

Answer 10

4: 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:

Question 11

Question: 11 

Increased mortality in maintenance hemodialysis patients has been associated with

1: low baseline body fat percentage and low muscle mass.
2: elevated albumin and decreased CRP values.

3: increased body mass index.

4: decreased serum cholesterol.

Answer 11

1: low baseline body fat percentage and low muscle mass.

Lower muscle mass reflects poor nutrition status and inflammation. Low fat mass reflects low body stores of energy and demonstrates poor coping with catabolic stress as caused by dialysis. A BMI between 30 Kg/m^2 and 34.9 Kg/m^2 as demonstrated by Dialysis Outcomes and Practice Patterns Study is considered protective in dialysis patients. A BMI of less than 25 Kg/m^2 is not considered beneficial for patients on HD.

Question 12

Question: 12 

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?

1: Refeeding syndrome

2: Tube feeding syndrome

3: Underfeeding

4: Overfeeding

Answer 12

2: Tube feeding syndrome
Adequate nutrition and balanced hydration is necessary for successful weaning from mechanical ventilation. 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 hypophosphatemia associated with refeeding syndrome can intensify respiratory dysfunction and diaphragmatic weakness, leading to difficulty in ventilator weaning. Tube feeding syndrome is the development of azotemia, hypernatremia and dehydration related to the use of high protein tube feedings and inadequate fluid provisions. Fluid overload and not fluid depletion is most often implicated in difficulty weaning from mechanical ventilation.

Question 13

Question: 13 

What is the recommended dietary protein intake in acutely ill adult patients receiving continuous renal replacement therapy (CRRT)?

1: 0.5-0.8 g/kg per day

2: 1.2-1.5 g/kg per day

3: 1.5-2 g/kg per day

4: 2.5-3 g/kg per day

Answer 13

3: 1.5-2 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. Consensus in the literature for daily protein delivery in patients undergoing CRRT is 1.5-2 g protein/kg per day. While doses as high as 2.5g 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 14

Question: 14 

What are the protein requirements for a stable patient receiving peritoneal dialysis (PD)?

1: 0.6-0.8 grams per kilogram per day

2: 1.2-1.3 grams per kilogram per day

3: 1.5-1.8 grams per kilogram per day

4: 2.0-2.2 grams per kilogram per day

Answer 14

2: 1.2-1.3 grams per kilogram per day

Protein losses through the peritoneum take place routinely while on PD. June 2000 K/DOQI guidelines recommend 1.2-1.3 gm protein/kg/day in clinically stable patients. Unless the patient has demonstrated stable protein status with 1.2 gms/kg/day, 1.3 gms/kg per day must be used

Question 15

Question: 15 

Which of the following is NOT a cause of malnutrition in a patient with liver disease?

1: Malabsorption

2: Decreased caloric intake

3: Abnormal fuel metabolism

4: Reduced energy expenditure

Answer 15

4: Reduced energy expenditure
Malnutrition in patients 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 is usually increased in liver disease especially in those patients with infections and ascites.

Question 16

Question: 16

Protein-energy malnutrition is most common in which of the following types of liver disease?

1: Viral hepatitis

2: Cirrhosis

3: Hepatic steatosis

4: Nonalcoholic steatohepatitis (NASH)

Answer 16

2: 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 in contrast to those with alcoholic liver disease/cirrhosis. Hepatic steatosis may occur as the first stage of hepatic insufficiency as the result of alcohol consumption. Patients with nonalcoholic steatohepatitis are usually obese and malnutrition is much less common.

Question 17

Question: 17 

Patients with chronic heart failure are typically on a loop diuretic. These patients are at risk for

1: hyperkalemia.

2: azotemia.

3: hypermagnesium.

4: hypoglycemia.

Answer 17

2: 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. Patients are not known to become hypoglycemic. Azotemia can occur related to volume depletion.

Question 18

Question: 18 

Hypoglycemia, requiring dextrose infusions to maintain euglycemia, is most likely to occur in which type of liver disease?

1: Hepatic steatosis

2: Well-compensated cirrhosis

3: Decompensated cirrhosis

4: Fulminant hepatic failure


Answer 18

4: Fulminant hepatic failure

Hypoglycemia is seen in the majority of 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.

Question 19

Question: 19 

In cirrhotic patients, which of the following should be implemented to assist in avoiding fasting-associated starvation during the night?

1: Late evening snack

2: Nocturnal tube feeding

3: Branched-chain amino acids supplement

4: Nocturnal parenteral nutrition

Answer 19

1: 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 20

Question: 20
Which of the following is an important indicator of protein-energy malnutrition in chronic liver disease?

1: Jaundice

2: Muscle wasting

3: Elevated liver function tests

4: Hepatic encephalopathy

Answer 20

2: 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 muscle circumference strength are used. Although these measurements can be affected by fluid retention, they are still useful to assess subcutaneous fat and muscle mass. Mid-arm muscle circumference and hand grip strength appear to be sensitive markers of body cell mass depletion. Hepatic encephalopathy, jaundice, and elevated liver function tests are not markers of malnutrition.

Question 21

Question: 21 

In patients with liver disease a low protein restriction may be recommended for patients with which of the following conditions?

1: Acute hepatic encephalopathy until cause is diagnosed and eliminated

2: Chronic alcoholic liver disease with cirrhosis

3: Hepatocellular carcinoma preparing for hepatectomy

4: Primary sclerosing cholangitis awaiting transplantation

Answer 21

1: Acute hepatic encephalopathy until cause is diagnosed and eliminated

Protein should not be restricted as a management strategy to reduce risk of developing hepatic encephalopathy. Protein requirements for the patient with hepatic failure should be determined in the same manner as for the general intensive care unit patient per the A.S.P.E.N. Guidelines: In patients with cirrhosis with acute encephalopathy a temporary protein restriction may be utilized until cause of the encephalopathy is diagnosed and eliminated. In hepatorenal syndrome a modest reduction in protein can be made on a temporary basis until renal function improves. Primary sclerosing cholangitis, alcoholic liver disease and hepatocellular carcinoma do not require protein restrictions.

Question 22

Question: 22 

The highest prevalence and severity of weight loss is found in patients with which of the following types of cancer?

1: Lung and colon

2: Breast and ovarian

3: Prostate and testicular

4: Pancreatic and gastric

Answer 22

4: 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 23

Question: 23 

Which of the following best describes the benefit of megestrol acetate in patients with cancer-associated cachexia?

1: Increase in lean muscle mass

2: Decreases the risk of thromboembolic events

3: Improves blood glucose control in diabetes mellitus

4: Improves appetite and ameliorates weight loss

Answer 23

4: 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 24

Question: 24 

The nutritional needs of a patient with a bone marrow transplant are best met with:

1: 20-25 kcal/kg daily with >= 1.5 g protein per kg body weight.

2: 20-25 kcal/kg daily with 80% of total calories from carbohydrate.

3: 30-35 kcal/kg daily with >= 1.5 g protein per kg body weight.

4: 30-35 kcal/kg daily with 80% of total calories from carbohydrate.

Answer 24

3: 30-35 kcal/kg daily with >= 1.5 g protein per kg body weight.

Energy needs will vary with the individual but usually, energy requirements are 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 25

Question: 25 

Supplementation with which of the following nutrients is routinely restricted during the early stages following hematopoietic stem cell transplantation (HSCT)?

1: Sodium

2: Folate

3: Iron

4: Vitamin B12

Answer 25

3: Iron

Blood product support is usually required before, during and following HSCT with resultant iron overload. Iron overload may adversely affect overall survival post-HSCT increasing the likelihood of acute graft-versus-host disease, blood stream infection and sinusoidal obstruction syndrome of the liver.

Question 26

Question: 26 

Which of the following acute changes in serum chemistries would be expected in a patient who is experiencing tumor lysis syndrome(TLS)?

1: Hypercalcemia and hypomagnesemia

2: Hyperkalemia and hyperphosphatemia

3: Hypernatremia and hypermagnesemia

4: Hypoalbuminemia and hyperphosphatemia

Answer 26

2: 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 27

Question: 27 

Which of the following best describes the treatment of diarrhea in inflammatory bowel disease?

1: Cholestyramine is effective treatment for steatorrhea

2: Patients with diarrhea should be treated with prebiotics

3: Antidiarrheal agents once infectious etiology is ruled out

4: Pharmacological therapy is withheld until diarrhea exceeds 1 L/day

Answer 27

3: 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

Question: 28

A patient with Crohn’s disease that involves the distal ileum should be closely monitored for malabsorption of

1: iron.

2: calcium.

3: vitamin B12.

4: folic acid.

Answer 28

3: 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 29

Question: 29 

Which of the following is a major contributing factor in the development of metabolic bone disease in patients with inflammatory bowel disease?

1: Corticosteroids

2: Aluminum toxicity

3: Blood transfusions

4: Oxalic acid deficiency


Answer 29

1: Corticosteroids

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 and aluminum toxicity are 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 is probably a minor contributor to the problem in patients with inflammatory bowel disease. Oxalic acid plays no known role in metabolic bone disease.

Question 30

Question: 30

In patients with severe acute pancreatitis, the use of enteral nutrition via nasojejunal feeding tube rather than parenteral nutrition is associated with

1: an increased incidence of hyperglycemia.

2: a lower risk of developing infectious complications.

3: a greater incidence of negative nitrogen balance.

4: a decreased frequency of pancreatic stimulation.

Answer 30

2: 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 is not meeting nutritional requirements via EN alone.

Question 31

Question: 31 

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?

1: Thiamin

2: Vitamin B12

3: Folate

4: Riboflavin

Answer 31

1: 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 32

Question: 32

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 hypersecretions?

1: Cholestyramine

2: Loperamide

3: Histamine2 receptor antagonists

4: Proton pump inhibitors

Answer 32

4: Proton pump inhibitors
Both histamine2-receptor antagonists (H2-blockers) and proton pump inhibitors (PPIs) have been used to treat gastric hypersecretion; however, PPIs suppress significantly more acid than H2-blockers. Fifty centimeters of jejunum are necessary to absorb PPIs. Cholestyramine is used for diarrhea associated with excess fecal bile acids. Loperamide is used to slow intestinal transit.

Question 33

Question: 33 

Which of the following metabolic complications is most likely to occur in patients with short bowel syndrome with small bowel bacterial overgrowth?

1: D-lactic acidosis

2: D-lactic alkalosis

3: Metabolic alkalosis

4: Respiratory acidosis

Answer 33

1: D-lactic acidosis

Intestinal resection, especially involving removal of the ileocecal valve, predisposes patients to small bowel bacterial overgrowth (SBBO). SBBO results in deconjugation of bile salts and impaired micelle formation, resulting in fat malabsorption. Bacterial metabolism produces short-chain fatty acids (SCFAs). SCFAs may decrease luminal pH, denature intestinal enzymes and increase osmotic load. This results in rapid gut transit, maldigestion and malabsorption. D-lactic acid is produced by the fermentation of malabsorbed carbohydrate in the colon. Humans lack the enzyme needed to metabolize D-lactic acid. D-lactic acidosis should be suspected when there is unexplained metabolic acidosis in a patient with short bowel and an intact colon.

Question 34

Question: 34 

Patients with short bowel syndrome would benefit most from octreotide injections in the presence of

1: an intact colon.

2: short bowel secondary to mesenteric ischemia.

3: short bowel secondary to inflammatory bowel disease.

4: refractory diarrhea not controlled with standard antidiarrheal agents.

Answer 34


4: refractory diarrhea not controlled with standard antidiarrheal agents.
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 35

Question: 35 

Which of the following diets should be recommended to patients with a short bowel and colon in continuity?

1: High fat

2: High oxalate

3: High simple carbohydrate

4: High complex carbohydrate

Answer 35

4: High complex carbohydrate
A diet high in complex carbohydrates (50% to 60%) and low in fat (20% to 30%) has been shown to reduce fecal calorie loss and to increase overall energy absorption in short bowel syndrome (SBS) patients with at least a portion of their colon present. This diet also reduces steatorrhea and decreases oxalate absorption. To decrease risk of oxalate nephropathy, SBS patients who have a colon 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. In addition, some starches will be converted to SCFA by colonic bacterial fermentation and used as energy. Concentrated sugars should be avoided because they generate a high osmotic load and potentiate stool output.

Question 36

Question: 36 

Nephrolithiasis, caused by calcium oxalate stones, can occur in patients with short bowel syndrome (SBS) who

1: have no remaining colon.

2: do not maintain adequate hydration.

3: have no remaining ileum.

4: take 500 mg calcium 2-3 times per day.

Answer 36

2: do not maintain adequate hydration.
Nephrolithiasis from calcium oxalate stones is multifactorial but is primarily due to accelerated oxalate 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, leaving oxalate free to pass into the colon to be absorbed and then filtered by the kidney. In the kidney, oxalate binds to calcium, resulting in oxalate nephropathy. Volume depletion increases the risk of nephrolithiasis. 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 in the lumen to bind oxalate.

Question 37

Question: 37 

Which of the following types of fistulas will result in the greatest degree of nutritional loss?

1: Distal low output

2: Distal high output

3: Proximal low output

4: Proximal high output

Answer 37

4: 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 (

Question 38

Question: 38 

Malnourished women with hyperemesis gravidarum who require specialized nutrition support are likely to require supplementation of

1: chloride.

2: thiamin.

3: vitamin E.

4: manganese.

Answer 38

2: thiamin.

Due to poor intake, 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 the initiation of dextrose-containing fluids in patients with hyperemesis gravidarum.

Question 39

Question: 39 

Which of the following best describes the use of enteral nutrition support in hyperemesis gravidarum (HEG)?

1: Postpyloric placement of feeding tubes requires radiation exposure, which is an unacceptable risk during pregnancy

2: Concentrated, hypertonic enteral formulas are indicated to maximize delivery of nutrients needed during pregnancy in a smaller volume

3: Successful use has been reported and a trial of enteral nutrition prior to initiation of parenteral nutrition is appropriate

4: Prospective, randomized clinical trials have demonstrated the superiority of enteral nutrition over parenteral nutrition in regard to infectious complications and successful delivery of goal protein and calories

Answer 39

3: Successful use has been reported and a trial of enteral nutrition prior to initiation of parenteral nutrition is appropriate

The severe nutritional deprivation caused by hyperemesis is preferably treated with enteral feeds, but there is also a risk for aspiration if the patient cannot tolerate the feeds and continues to vomit. Patients have also been known to refuse feeding tube placement due to physical discomfort, and aesthetics. Although enteral nutrition support is not entirely without the potential for complications, it is recommended initially over the parenteral route to avoid some of the more severe complications associated with PN. Some complications of parenteral nutrition in pregnancy include: pneumothorax, puncture of nearby artery, air embolism, infections (due to immunologic suppression), thrombosis (due to hypercoagulable state) sepsis, cardiac issues due to electrolyte imbalances, gall bladder dysmotility, and intrahepatic cholestasis. The use of parenteral nutrition as the mode of treatment has also been known to require closer monitoring and incur a higher cost.

Question 40

Question: 40 

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?

1: Peripheral parenteral nutrition

2: High calorie diet with a calorie count

3: Structured meal plan with supplemental enteral feedings

4: Ad lib diet with 72 hour calorie count

Answer 40

3: Structured meal plan with supplemental enteral feedings

It is generally accepted that eating disorder patients require medical stabilization and nutrition rehabilitation. Several reviews have indicated that in the United States, oral refeeding is the preferred modality for nutritional 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 advancement of enteral feedings for patients with anorexia nervosa due to the high risk of developing refeeding syndrome. In some cases, TF have been shown to significantly increase both weight and show improvement in BMI compared to oral refeeding therapy alone.

Question 41

Question: 41 

Persistent hyperglycemia in patients with type 2 diabetes can result in the development of

1: cholestasis.

2: glucolipotoxicity.

3: hepatic steatosis.

4: macrocytic anemia.

Answer 41

2: glucolipotoxicity.

Chronically elevated glucose levels in patients with type 2 diabetes adversely affect insulin secretion. Glucotoxicity and glucolipotoxicity are closely interrelated in the sense that glucolipotoxicity does not exist without chronic hyperglycemia and chronically elevated fatty acid levels do not harm beta-cell function as long as blood glucose levels are normal. Macrocytic anemia is caused by the deficiency of folic acid and/or vitamin B12.

Question 42

Question: 42 

Human immunodeficiency virus (HIV) associated lipodystrophy syndrome is

1: visceral adipose tissue loss.

2: not observed in patients on highly active antiretroviral therapy (HAART).

3: selective subcutaneous adipose tissue loss.

4: seen mostly in patients younger than 40 years old.

Answer 42

3: selective subcutaneous adipose tissue loss.

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 43

Question: 43 

What is the most appropriate feeding strategy for a morbidly obese trauma patient?

1: High protein, hypocaloric feeding

2: High protein, hypercaloric feeding

3: Low protein, hypocaloric feeding

4: Low protein, hypercaloric feeding

Answer 43

1: 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. A low protein feeding is inappropriate for trauma patients.

Question 44

Question: 44 

Zinc supplementation should be provided to patients with wounds

1: of any and all types.

2: who are suspected to have a zinc deficiency.

3: who are elderly.

4: who have below normal zinc levels.

Answer 44

2: who are suspected to have a zinc deficiency.

Zinc is an essential trace mineral necessary for the synthesis of granulation tissue and reepithelialization and also exerts an antinflammatory and antimicrobial effect. Zinc deficiencies are commonly seen in patients with diarrhea, malabsorption, or in hypermetabolic states (stressed, sepsis, burns, venous ulcers, or seriously injured). Serum zinc levels are used to assess zinc status, however serum zinc levels fall in the presence of inflammation, as albumin is the primary transporter of zinc, and interpretation of serum zinc levels are difficult. Therefore, patients with wounds of any and all types do not necessarily require zinc supplementation but only those with a suspected zinc deficiency.

Question 45

Question: 45 

Nutrition support for solid-organ transplant patients receiving cyclosporine may need to be modified due to the presence of

1: hyperkalemia.

2: hypoglycemia.

3: hypermagnesemia.

4: hypocholesterolemia.

Answer 45

1: 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 46

Question: 46 

A patient with acute kidney injury (AKI) who requires parenteral nutrition support would most likely benefit from a solution containing which of the following?

1: Essential amino acids only

2: Essential amino acids with arginine only

3: Essential amino acids and nonessential amino acids

4: Essential amino acids and branched-chain amino acids

Answer 46

3: 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 47

Question: 47 

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 was 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?

1: Thiamin

2: Zinc

3: Folate

4: Copper

Answer 47

4: Copper
Deficiencies of thiamin, zinc, 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, leucopenia, neutropenia and symptoms of peripheral neuropathy.