Chapter 16: Nutrition in Metabolic Stress: Burns, Trauma and Surgery My Nursing Test Banks

Chapter 16: Nutrition in Metabolic Stress: Burns, Trauma and Surgery

Grodner and Escott-Stump: Nutritional Foundations and Clinical Application: A Nursing Approach, 6th Edition

MULTIPLE CHOICE

1. If a 75-year-old woman needs hip replacement surgery but reports that she has lost 15 lb since her husband died 3 months ago because she has had very little appetite, the best approach would be to

a.

provide enteral feedings immediately after surgery.

b.

delay surgery until the patient returns to usual body weight.

c.

recommend using a multivitamin or multimineral supplement.

d.

ensure at least 2 weeks of good nutritional intake before surgery.

ANS: D

Loss of 15 lb in 3 months is probably associated with significant nutritional risk; at least 2 weeks of good nutritional intake should be encouraged before surgery to minimize risk of complications and improve healing. The patient is able to eat, and so enteral feedings are not needed, and it would be better to improve nutritional status before surgery rather than afterwards. Supplements may be helpful, but it is always better to obtain nutrients from food rather than supplements. Delaying surgery until the patient returns to usual body weight is not necessary so long as nutrient stores are replenished.

DIF:Cognitive Level: ApplyingREFage 350 | Page 353

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological integrity

2. If a patient is healing more slowly than expected after surgery, he or she may benefit from

a.

enteral feedings.

b.

supplemental zinc and vitamins A and C.

c.

supplemental iron and vitamins B12 and D.

d.

additional branched-chain amino acids.

ANS: B

Vitamins A and C and zinc play an important role in wound healing. Iron and vitamin B12 are important for maintaining optimal immune status, and vitamin D is important for healing broken bones. Branched-chain amino acids do not play a specific role in healing. Enteral feedings are not needed unless the patient is unable to maintain adequate oral intake.

DIF: Cognitive Level: Analyzing REF: Pages 348-349 | Pages 351-353

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological integrity

3. Of the following, the most stressful physical traumas would be

a.

a single bone fracture.

b.

a low-grade fever

c.

minor surgery.

d.

a large third-degree burn.

ANS: D

Serious burns result in significant increases in metabolic rate. Fractures, low-grade fevers, and minor surgery also increase metabolic rate, but to a lesser degree than do burns.

DIF: Cognitive Level: Analyzing REF: Page 350 | Pages 353-354 | Pages 356-358

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological integrity

4. If someone has been fasting for 36 hours, his or her body is meeting its glucose needs by breaking down

a.

glycogen.

b.

keto acids.

c.

amino acids.

d.

fatty acids.

ANS: C

Glycogen stores are depleted after 24 hours of starvation, so after 36 hours, the body would have to deaminate amino acids and produce glucose by gluconeogenesis. The body cannot make glucose from fatty acids. Keto acids are byproducts of incomplete fatty acid metabolism and also cannot be converted to glucose.

DIF:Cognitive Level: ApplyingREFages 349-350

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological integrity

5. If a malnourished patient has a poor appetite, the nurses first priority should be to recommend

a.

enteral feedings.

b.

increasing intake of fruits and vegetables.

c.

several small meals and snacks each day.

d.

limiting between-meal snacks to promote hunger.

ANS: C

The nurse should encourage malnourished patients to eat several small meals and snacks each day to promote adequate intake without fatigue. Enteral feedings may be necessary if the patient cannot achieve adequate intake, but it would not be the first strategy used. Increasing intake of fruits and vegetables would increase the volume of food eaten, which may cause satiety before the patient has ingested sufficient energy and protein. Limiting between-meal snacks is likely to decrease overall food intake.

DIF:Cognitive Level: ApplyingREFages 353-354

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological integrity

6. Once patients have completely recovered from gastric bypass surgery for treatment of obesity, an appropriate meal would be

a.

a large green salad with chopped turkey and vinaigrette dressing.

b.

a medium vanilla shake.

c.

half a small chicken breast and  cup of green beans.

d.

a cup of bean soup with vegetable sticks.

ANS: C

After bariatric surgery, the total volume of food eaten at a meal should not exceed 1 cup, including no more than 2 oz of meat; the half chicken breast and green beans would meet these criteria. A large salad would provide low energy levels and is appropriate for weight loss but would be too great a volume of food after gastric bypass surgery. A medium vanilla shake would provide a high amount of energy and would be more than 1 cup in volume. Bean soup and vegetable sticks would be another healthy choice, but the overall volume of food would be too great.

DIF:Cognitive Level: ApplyingREFage 354

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological integrity

7. If a student group goes on hunger strike and drinks water but does not eat any food for 4 days, they are likely to

a.

feel colder than usual.

b.

have increased mental acuity.

c.

sleep for shorter periods of time.

d.

develop fluid overload.

ANS: A

The body conserves energy during starvation by decreasing metabolic rate, which would make the students feel colder than usual. Mental acuity would decrease as a result of decreased glucose supply. To conserve energy, they are likely to sleep more rather than less. With gradual loss of sodium, the students are more likely to experience fluid loss than overload; long-term lack of protein intake may result in edema or ascites, but this would not develop in a few days.

DIF:Cognitive Level: ApplyingREFages 349-350

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological integrity

8. A major difference between starvation and stress is that metabolic rate _____ during starvation and _____ during recovery from injury.

a.

increases; decreases

b.

decreases; increases

c.

is unaffected; increases

d.

decreases; is unaffected

ANS: B

Metabolic rate decreases during starvation because the body is trying to conserve energy. It increases during stress because the body uses energy to heal the injury.

DIF:Cognitive Level: UnderstandingREFages 349-351

TOP:Nursing Process: Assessment| Nursing Process: Planning

MSC:Client Needs: Physiological integrity

9. If a patient who has fallen down a flight of steps has a low body temperature, low blood pressure, and high blood glucose levels, he or she is probably

a.

in the initial injury (ebb) phase.

b.

in the recovery (flow) phase.

c.

developing a serious infection.

d.

developing multiple organ dysfunction syndrome (MODS).

ANS: A

Low body temperature (hypothermia), low blood pressure, and high blood glucose levels are characteristic of the initial injury phase. In the recovery phase, patients still have high blood glucose levels, but blood pressure normalizes and body temperature increases. Serious infections would also cause high blood glucose levels with an increase in body temperature and no effect on blood pressure. In MODS, body temperature is usually elevated; this is unlikely to result simply from a fall.

DIF: Cognitive Level: Applying REF: Page 350 | Pages 354-355

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological integrity

10. Four day after a major accident involving multiple broken bones, the patient would be expected to be in the _____ phase.

a.

critical

b.

stress

c.

ebb

d.

flow

ANS: D

After major stress, such as an accident causing multiple broken bones, patients are in the initial injury (ebb) phase (commonly known as shock) for 36 to 48 hours. By 4 days after the injury, they would be in the flow phase and would be highly hypermetabolic.

DIF:Cognitive Level: ApplyingREFage 350

TOP:Nursing Process: Assessment| Nursing Process: Planning

MSC:Client Needs: Physiological integrity

11. During starvation or fasting, the body adapts so that it can obtain as much energy as possible from

a.

glycogen.

b.

glucose.

c.

protein.

d.

fat.

ANS: D

During starvation, the body conserves protein and glycogen stores as much as possible, and all body tissues other than the brain, nerves, and red blood cells derive most of their energy from fat.

DIF:Cognitive Level: UnderstandingREFage 350

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological integrity

12. If a man who weighs 80 kg is recovering from surgery and has an average protein intake of 105 g/day, his protein intake is

a.

inadequate.

b.

deficient.

c.

appropriate.

d.

excessive.

ANS: C

During moderate stress, such as recovery from surgery, protein intake should be 1.0 to 1.5 g/kg body weight. For an 80-kg man, the recommended intake would therefore be 80 to 120 g/day. An intake of 105 g/day is within this range and is therefore likely to be adequate.

DIF: Cognitive Level: Applying REF: Page 351 TOP: Nursing Process: Planning

MSC:Client Needs: Physiological integrity

13. If a 40-year-old, woman weighing 60 kg breaks both ankles while hiking and is hospitalized, her fluid needs would be _____ mL.

a.

1800 to 2100

b.

2100 to 2400

c.

2400 to 2700

d.

2700 to 3000

ANS: B

Fluid needs during hypermetabolic stress for adults younger than 55 years are 35 to 40 mL/kg. For a 60-kg woman, this amounts to 2100 to 2400 mL (35 60 mL to 40 60 mL).

DIF: Cognitive Level: Applying REF: Page 351 TOP: Nursing Process: Planning

MSC:Client Needs: Physiological integrity

14. The amino acid that plays an important role in the gastrointestinal tract during stress is

a.

arginine.

b.

glutamine.

c.

methionine.

d.

phenylalanine.

ANS: B

During stress, glutamine is mobilized in large quantities from skeletal muscle and the lungs to be used directly as a fuel source by intestinal cells. Glutamine also plays a significant role in maintaining intestinal immune function and enhancing wound repair by supporting lymphocyte and macrophage proliferation, hepatic gluconeogenesis, and fibroblast function. Arginine has a role in maintaining immune function in the gastrointestinal tract but is not as critical in stress as glutamine. Methionine and phenylalanine do not have specific roles during stress.

DIF:Cognitive Level: RememberingREFage 349 | Page 353

TOP: Nursing Process: Planning MSC: Client Needs: Physiological integrity

15. When refeeding a malnourished patient, it is especially important to monitor blood levels of

a.

phosphorus.

b.

iron.

c.

zinc.

d.

vitamin C.

ANS: A

Overfeeding of a malnourished patient can result in dangerous hypophosphatemia as phosphorus enters the cells from the blood. Iron is important for immune function and zinc and vitamin C levels are important for healing, but these levels are not so critical during refeeding.

DIF:Cognitive Level: UnderstandingREFage 359

TOP:Nursing Process: Assessment| Nursing Process: Implementation

MSC:Client Needs: Physiological integrity

16. During the initial injury (ebb) phase, the main nutritional priority is

a.

normalizing blood glucose levels.

b.

normalizing fluid status.

c.

providing adequate protein.

d.

avoiding overfeeding.

ANS: B

During the initial injury phase, the main priority is fluid resuscitation. At this time, the body is unable to metabolize exogenous protein and energy. Avoidance of overfeeding is important but is not the primary initial concern.

DIF: Cognitive Level: Applying REF: Page 350 TOP: Nursing Process: Planning

MSC:Client Needs: Physiological integrity

17. The best way to determine energy needs of stressed patients is to use

a.

indirect calorimetry.

b.

the Ireton-Jones formula.

c.

the Dietary Reference Intakes.

d.

patient hunger and appetite cues.

ANS: A

Energy needs of stressed patients are highly individual; the most accurate way to measure them is using indirect calorimetry. Formulas such as Ireton-Jones are used when indirect calorimetry is not available, but their results are less accurate. The Dietary Reference Intakes provide estimates of energy needs for health populations but do not account for individual differences or for stress. Stressed patients often have very poor appetites despite high energy needs.

DIF: Cognitive Level: Understanding REF: Pages 351-352 | Page 356

TOP:Nursing Process: Assessment| Nursing Process: Planning

MSC:Client Needs: Physiological integrity

18. If a malnourished patient undergoes an emergency appendectomy and develops pneumonia during the recovery, he or she probably

a.

has a history of smoking.

b.

used protein from the intercostal muscles for energy.

c.

had bronchitis before undergoing surgery.

d.

needs evaluation for dysphagia.

ANS: B

Malnourished stressed patients may use protein from their intercostal muscles for energy; weakening of chest muscles increases the likelihood of pneumonia. It is unfair to assume a history of smoking in a patient who develops pneumonia. Pneumonia is sometimes caused by dysphagia or may develop from bronchitis, but in a stressed malnourished patient, this is not the most likely explanation.

DIF:Cognitive Level: AnalyzingREFages 350-351

TOP:Nursing Process: Assessment| Nursing Process: Planning

MSC:Client Needs: Physiological integrity

19. If a severely burned patient has been unable to eat more than a few bites each day for a week, he or she should be fed by means of

a.

enteral feedings into the stomach.

b.

enteral feedings into the jejunum.

c.

central parenteral nutrition.

d.

peripheral parenteral nutrition.

ANS: A

If a stressed patient is unable to maintain adequate oral intake for more than 5 to 10 days, he or she should be fed via an enteral feeding tube into the stomach. Jejunal feedings would be used only if the patient has a high risk for aspiration. Enteral feedings are preferred over parenteral feedings because they promote normal nutrient metabolism and maintain integrity of the gut.

DIF:Cognitive Level: ApplyingREFage 352 | Page 356

TOP: Nursing Process: Planning MSC: Client Needs: Physiological integrity

20. In a critically ill patient receiving parenteral nutrition, a blood glucose level of 145 mg/dL is considered

a.

too low.

b.

acceptable.

c.

slightly elevated.

d.

seriously elevated.

ANS: B

For critically ill patients receiving parenteral nutrition, the goal is to maintain blood glucose levels between 140 and 180 mg/dL. Therefore, a blood glucose level of 150 mg/dL is acceptable.

DIF:Cognitive Level: ApplyingREFage 359

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological integrity

21. If a patient has significant fluid losses from perspiration and wound dressings that cannot be measured easily, the best way to monitor fluid balance is to

a.

measure serum sodium levels.

b.

weigh the patient daily.

c.

use formulas to calculate losses.

d.

check urine concentration.

ANS: B

The best way to monitor fluid balance is to weigh the patient daily. Hormones are secreted to keep serum sodium level within a narrow range regardless of hydration status. Formulas are not available to calculate fluid losses. Urine concentration does not provide a definitive measurement of fluid status.

DIF: Cognitive Level: Analyzing REF: Page 353 TOP: Nursing Process: Evaluation

MSC:Client Needs: Physiological integrity

22. After surgery, once bowel sounds return, the most appropriate first meal should be

a.

clear liquids.

b.

soft and low in fiber.

c.

chosen by the physician.

d.

chosen by the patient.

ANS: D

Once bowel sounds return after surgery, patients may gradually introduce foods as they choose. Patients used to be given liquids initially, but there is no reason to justify this practice. Patients are more likely to achieve adequate oral intake if they are allowed to make their own food choices.

DIF: Cognitive Level: Applying REF: Page 354 TOP: Nursing Process: Planning

MSC:Client Needs: Physiological integrity

23. If a patient undergoes resection of 6 inches of the colon, they are likely to have the best outcome if they

a.

gave the bowel complete rest for 7 to 14 days.

b.

begin oral or enteral feedings the day after surgery.

c.

follow a soft, low-fiber diet.

d.

follow a high-fiber diet to promote laxation.

ANS: B

After gastrointestinal surgery, patients recover best if they begin oral or enteral feedings the first day after surgery. Complete bowel rest is likely to result in loss of integrity of the intestinal mucosa. The amount of fiber in the diet is less important than delivery of nutrients to promote healing and maintain immune function.

DIF:Cognitive Level: ApplyingREFage 354

TOP:Nursing Process: Planning| Nursing Process: Implementation

MSC:Client Needs: Physiological integrity

24. Presurgical nutritional status would be most important for a(n)

a.

middle-aged man undergoing open heart surgery to replace a heart valve.

b.

young woman undergoing a mastectomy for treatment of breast cancer.

c.

older adult undergoing cholecystectomy.

d.

child undergoing tonsillectomy.

ANS: A

Patients with high risk for malnutrition who undergo high-risk procedures, such as open heart surgery, prostatectomy, and hip replacement, have significantly longer hospital stays and higher mortality rates than do well-nourished patients. Outcomes of mastectomy, cholecystectomy, and tonsillectomy would also be affected by nutritional status, but to a lesser degree.

DIF:Cognitive Level: ApplyingREFage 354

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological integrity

25. The factor that contributes most to development of MODS is

a.

blood glucose level.

b.

inflammatory response.

c.

fever.

d.

malnutrition.

ANS: B

MODS generally results from an uncontrolled inflammatory response. Blood glucose level may be elevated and fever is likely to be present, but these are symptoms rather than causes. Malnutrition exacerbates but does not cause MODS.

DIF:Cognitive Level: UnderstandingREFage 354 | Page 356

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological integrity

26. The best indicator that it is safe for a patient to begin to resume oral intake after surgery is

a.

presence of bowel sounds.

b.

return of appetite.

c.

ability to sit upright.

d.

normal blood glucose level.

ANS: A

After surgery, patients may resume oral intake when they have bowel sounds because this indicates that the gastrointestinal tract is working. Appetite may not return for several days, but patients still need nutrients, and so they need to eat anyway. Patients should not eat lying down because of the risk of aspiration, but they do not need to be able to sit completely upright to eat. Blood glucose level is not an indicator of whether the patient is ready to resume oral intake.

DIF: Cognitive Level: Applying REF: Page 354 TOP: Nursing Process: Planning

MSC:Client Needs: Physiological integrity

27. The staff member best equipped to determine the nutrient needs of patients with severe burns is the

a.

physician.

b.

registered nurse.

c.

pharmacist.

d.

registered dietitian.

ANS: D

Registered dietitians have the training necessary to best determine the nutrient needs of patients according to their age, weight, gender, area and degree of burn, and nutritional status. The nurse makes important contributions to monitoring outcomes and identifying potential concerns, and the physician determines treatment. The pharmacist would be involved if the patient receives parenteral nutrition or if there are concerns about drug-nutrient interactions.

DIF: Cognitive Level: Applying REF: Page 359 TOP: Nursing Process: Planning

MSC: Client Needs: Health promotion and maintenance

28. If a patient is seriously burned and the muscle tissue is visible, the patient has a _____ burn.

a.

first-degree

b.

second-degree

c.

third-degree

d.

nonthermal

ANS: C

A burn that destroys the entire epidermis, dermis, and underlying subcutaneous tissue so that muscle tissue visible is a third-degree burn. First-degree burns involve only the epidermis. Second-degree burns involve the epidermis and dermis. Nonthermal injuries are caused by electricity, chemicals, or radiation and may be first-, second-, or third-degree burns.

DIF:Cognitive Level: ApplyingREFages 356-357

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological integrity

29. If a patient experiences a third-degree burn over 30% of the body surface area, the first priority would be

a.

provision of adequate protein.

b.

prevention of nausea and vomiting.

c.

replacement of fluids and electrolytes.

d.

provision of adequate energy.

ANS: C

During the first 24 to 48 hours after a major burn, nutrition care focuses on replacement of fluids and electrolytes. Provision of adequate protein and energy is important over the long term, but it is not the first priority in this early treatment period. Burned patients do not usually experience nausea and vomiting.

DIF:Cognitive Level: ApplyingREFage 356

TOP:Nursing Process: Planning| Nursing Process: Implementation

MSC:Client Needs: Physiological integrity

30. The factor that would have the greatest influence on the energy needs of a burned patient is the

a.

patients activity level.

b.

patients emotional stress level.

c.

percentage of total body surface area burned.

d.

type of burn (thermal, chemical, electrical, or radioactive).

ANS: C

Energy needs of burned patients are influenced by size of the burn. Patients are not usually active after major burns, and so activity does not affect energy needs. Emotional stress does not affect energy needs. Energy needs are not affected by the cause of the burn.

DIF:Cognitive Level: ApplyingREFages 356-358

TOP:Nursing Process: Assessment| Nursing Process: Planning

MSC:Client Needs: Physiological integrity

Leave a Reply