Nd568final Sinn

ND
568: Medical Nutrition Therapy/ Clinical Nutrition Final Exam

Intern: Emily Sinn

1. Two liters of a 5% dextrose solution provide how many calories?
a. 340 kcals
b. Reasoning: In order to calculate the answer to this question I had to
consider the following information: 2 liters of solution is equal to
2,000 mL (or grams- see solution density below); 5% dextrose in that
solution can be identified at 5 g/100g (5%); 1 gm. dextrose = 3.4 kcals
and the density of the solution is likely to be 1 g/mL. From my
calculations below, 340 kcals would be provided from 5% dextrose
solution in 2 liters. Table 14-2 ‘Osmolality of Nutrients in PN
Solutions’ on page 315 provides sample calculations using the
nutrient Dextrose 5%.

3.4 kcal Dextrose x 5 g Dextrose x 2000 g Solution = 340 kcals
1 g Dextrose 100 g Solution

c. Citation: Mahan, L. K., Escott-Stump, S., & Raymond, J. L.
(2012). Krause's Food and the Nutrition Care Process (13th ed.). St.
Louis, Missouri: Elsevier Saunders.

2. When a starved patient begins to eat, they might expect:
a. An increased workload on the heart
b. Reasoning: From page 776 of Krause, “The failing heart is energy-
starved.” This statement leads me to believe that if an individual were
to experience a period of starvation, coming back from that would
affect the heart before causing constipation, lethargy or diarrhea.
When done properly, reintroducing food should not have such
negative effects on the GI tract or cause uncomfortable bowel
movements. With that in mind, a starved patient might expect an
increased workload on the heart when they begin to eat again.

3. Which is permitted on a diet, which excludes gluten?
a. Corn
b. Reasoning: According to table 45-5 on page 1036, ‘Comparison of
Foods Allowed in the Gluten-Free and Casein-Free Diet, Specific
Carbohydrate Diet, and Body Ecology Diet’, corn is listed as a food
allowed in unlimited amounts as a part of a Gluten- and Casein-Free
diet. The other answer choices rye, barley and wheat are all included
in the chart under ‘Gluten-containing grains’ that are not allowed as a
part of a gluten free diet. From this chart it is made clear that corn is
the only food listed that would be permitted on a diet that excludes
gluten.

4. Which of the following may result in hypoalbuminemia?
a. Providing only a 5% dextrose in water solution after stress
b. Reasoning: Box 14-3 on page 313 ‘Complications of Enteral Nutrition’
lists hypoalbuminemia as one of the several metabolic conditions
affected by enteral nutrition. Enteral nutrition includes Total
Parenteral Nutrition (TPN) and 5% dextrose in water solution would
be provided to the patient as a part of a TPN. This information leads
me to believe that a 5% dextrose solution in water could result in
hypoalbuminemia. By definition, hypoalbuminemia can be caused by
various conditions, including nephrotic syndrome, hepatic cirrhosis,
heart failure, and malnutrition; however, most cases of
hypoalbuminemia are caused by acute and chronic inflammatory
responses and serve as indicators for other conditions. From page
522, “amino acid supplements can lead to dehydration, hypercalciuria,
weight gain and stress on kidney or liver” with no indication that they
could also lead to hypoalbuminemia. A high protein diet with
inadequate water is incorrect because it would never be advised to
maintain dehydration in a patient. However, if a patient were stresses
increasing their protein intake would be appropriate. Giving a trauma
patient enteral feeding only is also incorrect as if that patient is able to
consume foods normally it would be unnecessary to approach them
with an enteral feed as the only option.
Peralta, R. (2017, September 13). Hypoalbuminemia. Retrieved
January 24, 2018, from
https://emedicine.medscape.com/article/166724-overview

5. An infant’s failure to thrive can be seen in:
a. Comparison with growth charts
b. Reasoning: Page 165 of Krause under ‘Interpretation of Height and
Weight’ states, “Children’s growth at every age can be monitored by
mapping data on growth curves, known as height-for-age, length-for-
age, weight-for-age, and weight-for-length curves…pediatric growth
charts and…height and weight are also useful for evaluating nutrition
status.” Although an infants’ behavior, weight and height and their
height could all be used as indicators for an infant’s failure to thrive, it
can be most useful to compare an individual to outside trends past
and present. Growth charts are superior as they have the ability to
compare data and paint a larger picture to determine an infant’s
current health status.

6. How many calories are in 300 mL of a 5% dextrose solution?
a. 51
b. Reasoning: Similarly to question 1, in order to calculate the answer to
this question I had to consider the following information: the density
of this solution is likely to be 1 g/mL; 5% dextrose in that solution can
be identified at 5 g/100g (5%) and this solution in total is 300 mL; 1
gm. dextrose = 3.4 kcals. From my calculations below, 51 kcals would
be provided from 5% dextrose solution in 300 mL. Table 14-2
‘Osmolality of Nutrients in PN Solutions’ on page 315 provides sample
calculations using the nutrient Dextrose 5%.

3.4 kcal Dextrose x 5 g Dextrose x 300 mL = 51 kcals


7. Which test helps you determine if a diabetic has been following his diet?
a. Glycosylated hemoglobin
b. Reasoning: From page 681, ‘Screening and Diagnostic Criteria’ in
Krause recognizes, “The use of A1C for diagnosing diabetes was not
previously recommended. However, the A1C assay is not highly
standardized and a reliable measure of chronic glucose levels. The
A1C test reflects longer-term glucose concentrations and is assessed
from the results of glycosylated hemoglobin (A1C). When hemoglobin
and other proteins are exposed to glucose, the glucose becomes
attached to the protein …” With this information in mind, glycosylated
hemoglobin is the best answer to determine if a diabetic has been
following his diet.

8. You discover an incorrect diet order entered in the patient’s chart. You
should:
a. Discuss the order with the physician and make suggestions
b. Reasoning: From page 260 in Krause, “The “Care of the Patient”
section contains standards that apply specifically to medication use,
rehabilitation, anesthesia, operative and other invasive procedures,
and special treatments, as well as nutrition care standards…using an
interdisciplinary approach. Appropriate care requires caring for
screening of patients for nutrition needs, assessing and reassign
patient needs, developing and NCP, ordering and communicating the
diet order, preparing and distributing the diet order, monitoring the
process, and continually reassign and improving the NCP.” This
information leads me to believe that, in attempt to maintain a
collaborative effort, discussing the order with a physician would be
the best option. It would not be wise to chart the information if we,
Dietitians, see it as incorrect or fill the order solely because a
physician wrote the order. Furthermore, it would not be responsible
to change the order without collaborating with anyone from other
disciplines.

9. Which best applies to nutritional screening?
a. Should include nutritional parameters
b. Reasoning: From Krause’s textbook on page 592, “Nutritional
screening and careful evaluation of patients…guide the patients
overall plan of care.” In addition, from table 14-6 on page 320 is
‘Inpatient Parenteral Nutrition Monitoring’ and “lists several
parameters that should be monitored routinely.” The best and most
efficient way to screen a patient is to have as much information as
possible on the patient, which is why including all nutritional
parameters, best applies to nutritional screening.

10. When using anthropometric measurements, the most important factor is:
a. Competence of practitioner or calibration
b. Reasoning: From page 656 of Krause, “Objective parameters that are
helpful when monitored serially include anthropometric
measurements and dietary intake evaluation…this method uses a few
readily available parameters obtained by an experienced clinician.” I
found this to be the best response because the number of participants
done at one sitting does not affect the anthropometric measurements
of an individual or the ability to measure anthropometrics. Also,
patients are not required to be sitting to obtain a height or a weight.
There are several calibrations such as a Hoyer lift to weight patients
who may be wheelchair bound. Finally, these measurements do not
need to be conducted in the morning, even though an individuals
weight may vary slightly throughout the day their height would not
change. With all of this in mind, I chose the competence of the
practitioner or calibration as the most important factor when taking
anthropometric measurements.

11. Which is most characteristic of marasmus?
a. Serum albumin of 2.5 g/dL
b. Reasoning: According to Appendix 30 ‘Laboratory Values for
Nutritional Assessment and Monitoring–cont’d’ on page 1082,
albumin is preserved in the presence of starvation (definition of
marasmus) and the reference range is 3.5- 5 g/dL. Although this
reference range is slightly higher than that provided by the exam, I
was unable to find evidence that edema, severe fat and muscle
wasting or decreased lymphocytes were characteristics of marasmus.

12. After a gastrectomy, the diet order should indicate a decrease in:
a. Disaccharides
b. Reasoning: On page 846 in Krause in section titled ‘Radiation to the
Abdomen or Pelvis’, “Late effects can include lasting GI damage such
as malabsorption of disaccharides, fats, vitamins, minerals, and
electrolytes.” That statement allowed me to rule out protein or
calories as the correct answer. In addition, the University of
Pittsburgh’s Medical Center posted an article titled “Post-Gastrectomy
Diet” and lists foods that are not recommended, including sugars but
only mentions to limit fat or exclude high fat content foods. With that
in mind, I believe that disaccharides should be decreased in ones diet
after a gastrectomy.
Post-Gastrectomy Diet. (2013, June 10). Retrieved January 24, 2018,
from http://www.upmc.com/patients-
visitors/education/nutrition/pages/post-gastrectomy-diet.aspx

13. The main goal for a type 2 obese diabetic with persistent hyperglycemia is:
a. Control serum glucose levels
b. Reasoning: Page 158 of Krause in section titled ‘Blood Sugar
Regulation’ mentions, “When glucose levels are higher than normal
(hyperglycemia), the hormone insulin is secreted from the beta-cells
of the pancreas, glucose is taken up by the cells, and a normal blood
sugar level is restored… when this process goes awry, the stage is set
for the chronic conditions of insulin resistance, metabolic syndrome,
and, ultimately, T2DM.” Knowing that when left uncontrolled, serum
glucose levels can lead to diabetes, I chose controlling of serum
glucose levels to be the best answer as a main goal for a type 2 obese
diabetic patients.

14. Which can be included in a meal for someone with gluten- induced
enteropathy?
a. Potatoes with butter
b. Reasoning: From Box 9-11 on page 225 in our Krause textbook,
‘Examples of Potential Interactive Drug Excipients’ are listed. Of the
answer choices, the only option that listed a gluten free food was that
of potatoes with butter. The other answer choices, spaghetti, crackers
and oatmeal all contain gluten and would not be suitable for a patient
with gluten-induced enteropathy (celiac disease). Potatoes do not
contain gluten and therefore would be the best answer choice.

15. What is the appropriate diet for congestive heart failure?
a. Low sodium
b. Reasoning: From pages 769-770 in Krause, “For persons with
hypertension, the DASH diet is recommended. Both of these dietary
patterns emphasize lower-sodium foods and higher intake of
potassium. Total energy expenditure is higher in HF patients because
of the catabolic state; adequate protein and energy should be
provided… Recommendations for HF patients vary between 1200 and
2400 mg/day.” As evidenced by this information from the textbook, a
low sodium diet would be most appropriate for a patient with
congestive heart failure.

16. Why might a child with PKU have an increased incidence of dental caries?
a. The diet is high in carbohydrates, low in protein
b. Reasoning: Page 397 in Krause states, “…the types of food eaten
during television viewing can contribute to increased dental caries
resulting from the continued exposure of the teeth to dense
carbohydrate- and sugar-laden foods (Palmer, 2005).” On several
occasions the textbook makes reference to the direct relationship
between a high carbohydrate diet and the presence of dental caries.
Furthermore, according to the Mayo Clinic, “Without the enzyme
necessary to process phenylalanine, a dangerous buildup can develop
when a person with PKU eats foods that are high in protein.” These
statements led me to believe that a child with PKU might have an
increased incidence of dental caries if their diet is high in
carbohydrates and lower in protein.
Phenylketonuria (PKU). (2017, October 17). Retrieved January 24,
2018, from https://www.mayoclinic.org/diseases-
conditions/phenylketonuria/symptoms-causes/syc-20376302

17. A patient who had a real resection is placed on a tube feeding and begins to
have diarrhea. This may be due to:
a. Use of a hypertonic formula
b. Reasoning: By definition, a hypertonic formula is one that has an
osmolality greater than that of the body fluid. Page 605 of the Krause
textbook identifies dumping syndrome as, “a complex GI and
vasomotor response to the presence of larger-than-normal quantities
of hypertonic foods and liquids in the proximal small intestine.” If a
patient were to begin a tube feedings that would suggest there is an
issue with their stomach and its ability to digest foods. With that said,
if a hypertonic formula is put in place in large quantities it could cause
diarrhea.

18. Which is restricted on a diet for hepatic encephalopathy?
a. Protein, sodium, fluid
b. Reasoning: Page 662, “The practice of protein restriction in patients
with low-grade hepatic encephalopathy is based on the premise that
protein intolerance causes hepatic encephalopathy.” In addition to
protein, as write by the American Liver Foundation, from their article
titled ‘Diet and Nutrition’, “Limit your intake of salty, sugary and fatty
foods.” Furthermore, from AASLD, “The standard therapy [for
Chronic Liver Diseases] includes a moderate sodium restriction (4.6-
6.9 salt/day)” and “fluid restriction should be considered when
sodium levels decrease less than 130 mEq/L”. Due to the direct
relationship between sodium levels and fluid balance in our bodies
both should be monitored in addition to a protein restriction for an
individual with hepatic encephalopathy.
c. Citation: Diet and Nutrition. (n.d.). Retrieved January 24, 2018, from
http://he123.liverfoundation.org/treatment-basics/importance-of-
adhering-to-your-treatment-plan/diet-and-nutrition/
Lalama, M. A., & Saloum, Y. (2016). Nutrition, fluid, and electrolytes in
chronic liver disease. Clinical Liver Disease, 7(1), 18-20. doi:
10.1002/cld.526
Mahan, L. K., Escott-Stump, S., & Raymond, J. L. (2012). Krause's Food
and the Nutrition Care Process (13th ed.). St. Louis, Missouri: Elsevier
Saunders.

19. How many non-protein calories are provided by 2 liters of a 7% Aminosyn
solution and 1 liter of 10% dextrose in water?
a. 340
b. Reasoning: Aminosyn is an amino acid solution and consists of
protein therefore; any calories provided from this solution would not
be applicable to this question. Moreover, the following information
was considered for me to calculate this question: 3.4 kcals/g Dextrose;
1 L = 1,000 mL; 10% dextrose in that solution can be identified as
10g/100g (10%) and this solution in total is 1 L. From my
calculations below, 340 kcals would be provided from 10% dextrose
solution in 1 L.
3.4 kcal Dextrose x 10 g Dextrose x 1,000 mL = 340 kcals


20. When should you provide nutrition counseling to an AIDS patient?
a. Immediately upon diagnosis
b. Reasoning: As mentioned on pages 863-864, “Proper nutrition may
help maintain lean body mass, reduce the severity of HIV-related
symptoms, improve quality of life, and enhance adherence… MNT is
integral to successfully manage HIV…All individuals with HIV
infection should have access to a RD or other qualified nutrition
professional. Patients should undergo a baseline nutrition
assessment once they are diagnosed with HIV.” Verbatim, nutrition
counseling should be provided immediately upon HIV diagnosis.

21. What best measures excess calorie reserves?
a. Triceps skinfold
b. Reasoning: Written on page 162 under ‘Subcutaneous Fat in Skinfold
Thickness’ reads, “The skinfold sites identified as most reflective of
body fatness are over the triceps and the biceps, below the scapula,
above the iliac crest, and on the upper thigh. The triceps skin-fold
(TSF) and subscapular measurements are the most useful because the
most complete standards and methods of evaluation are available for
these sites.” With that in mind, weight, Creatinine and arm
circumference are not the best choices when measuring excess calorie
reserves.

22. Which of the following is equivalent to a very lean meat exchange?
a. Cottage cheese
b. Reasoning: As evidenced by Table 30-3 ‘Copper Content of
Commonly Used Foods’ on page 649 of the textbook:

Cottage cheese has been listed as an example of lean meat unlike the
other answer options.

23. A post-surgical patient with prolonged ileus should be treated with:
a. Parenteral nutrition
b. Reasoning: By definition, an ileus refers to the intolerance of oral
intake. With that in mind, a tube feed would need to be administered
and if this individual is having issues digesting and tolerating food
they would require their nutrients through a vein. From pages 655
and 789 respectively in the Krause text, “Parenteral Nutrition (PN) is
indicated if a patient will be taking nothing orally for at least 5 days”…
“Parenteral nutrition is best used for short-term support in patients
with clearly evident needs such as those recuperating from
gastrointestinal surgery.” Being said, a high fiber diet would not be
appropriate as this patient is unable to digest foods via their mouth
and enteral nutrition is not the answer because their gut is also not
functioning properly.

24. When assessing nutritional status, which would be the most beneficial?
a. Diet intake info, clinical data, laboratory data
b. Reasoning: On page 983 section titled ‘Nutrition Assessment and
Growth’ there are 3 main title headers that include: Dietary Intake,
Laboratory Indices in addition to Table 43-15 that includes specific
lab values to monitor. Not to suggest that a 24 hour recall, weight
history, diet order, socioeconomic status or cultural habits are not
important however, the most information to assess and assist a
patient can be found from their diet intake, clinical data and labs.
Citation: Mahan, L. K., Escott-Stump, S., & Raymond, J. L.

25. Open tube feedings should be disposed of after:
a. 24 hours
b. Reasoning: According to the Cleveland Clinic’s manual titled ‘Tube-
Feeding Instructions For Home’ from section titled ‘Preparation for
Giving Your Tube Feeding’ states, “ Throw away any formula that has
been opened for more than 24 hours.” With that statement in mind,
the open tube feedings should be disposed of after 24 hours.
Citation: Mahan, L. K., Escott-Stump, S., & Raymond, J. L.
Tube-Feeding Instructions For Home. (n.d.). Retrieved January 23,
2018, from
https://my.clevelandclinic.org/ccf/media/files/Digestive_Disease/ce
nter-human-nutrition/home-enteral-nutrition-booklet.pdf

26. What is a guide for calculating water needs with tube feedings?
a. 1 cc water/ 1.0 calories
b. Reasoning: From slide 5 of the presentation published by Abbott
Nutrition ‘Best Practice for Managing Tube Feeding’, a listed
intervention is 1 mL water/Cal fed/day. Moreover, during my clinical
rotations both LTC and Acute have used 1 mL/kcal as a reference
point when calculating patient’s needs.
c. Citation: Campbell, S. M. (n.d.). Best Practices for Managing Tube
Feeding. Retrieved January 23, 2018, from
https://static.abbottnutrition.com/cms-prod/abbottnutrition-
2016.com/img/M4619.005%20Tube%20Feeding%20manual_tcm12
26-57873.pdf
27. A long-term care patient has normal intestinal function but cannot eat. What
tube feeding should you provide?
a. Isotonic lactose-free formula
b. Reasoning: From page 632 in Krause, “Patients with strictures or
partial bowel obstruction benefit from a reduction in dietary fiber or
limited food particle size. Small, frequent feedings may be tolerated
better than large meals. Small amounts of isotonic, liquid oral
supplements may be valuable in restoring intake without provoking
symptoms.” After reviewing this statement I believe the best tube feed
option would be an isotonic lactose-free formula to deliver nutrients
into this patients body without disturbing any other symptoms.

28. If you have lactose intolerance, which food could you most likely handle?
a. Yogurt
b. Reasoning: Table 29-3 on page 622 in the Krause textbook titled
‘Lactose Content of Common Foods’ lists several products in addition
to their serving size and the amount of lactose content. In 1 cup of
yogurt there are between 5-10 grams of lactose. Along with this
information, there is an asterix that reads “*Note: Although yogurt
does contain lactose, cultured yogurt is generally well tolerated by
those with lactose intolerance.” See photo below:


29. The normal range for hemoglobin A1C is:
a. 4-6%
b. Reasoning: Page 681 of the Krause textbook mentions,
“Measurements of A1C therefore reflect a weighted average of plasma
glucose concentration over the preceding weeks. In non-diabetic
persons A1C values are 4% - 6%; these values correspond to mean
blood glucose levels of approximately 70 – 126 mg/dL.” With that
said, 4-6% is the normal range for hemoglobin A1C.

30. Patients with decubitus ulcers will likely demonstrate low:
a. Serum albumin
b. Reasoning: As written on page 448 in the Krause textbook, “Several
factors contribute to the formation of pressure ulcers…notably
malnutrition (inadequate protein) and under nutrition (inadequate
energy intake) set the stage for its development and can delay wound
healing.” Without appropriate nutrition ulcers can be more likely to
form and we use increased protein needs, 1.2-1.5 g/kg to help the
healing process.

31. Mr. Jones has CHF but no CAD or increased CHD risk. His diet should be:
a. 2 gram Na
b. Reasoning: Page 771 in the Krause textbook includes a diagram titled
‘Pathophysiology and Care Management Algorithm: Heart Failure’.
Nutrition Management for HF includes: “Diet low in saturated fat,
trans fat, cholesterol, restricted sodium diet - <2 gm./day, increased
use of whole grains, fruits, vegetables; limit fluid to 2 L per day,
Magnesium supplementation, Thiamin supplementation…” From that
list the one management tool that matched my answer choices was
that of a low (<2 gm.) sodium diet for individuals with CHF.

32. A tube fed patient develops diarrhea. What is the most likely cause?
a. Medications
b. Reasoning: As evidenced by the following information regarding
Medical Nutrition Therapy for Pulmonary Disease on page 786,
“Nutrition assessment and therapy must take into account routinely
prescribed medications…Pulmonary patients experience side effects
such as dry mouth and throat, nausea, early satiety, vomiting,
diarrhea, increased serum glucose levels, sodium retention,
hypokalemia, hand tremors, headache, and dizziness.” Among many
side effects, medications have the ability to cause diarrhea in a patient
receiving a tube feed.

33. According to the Diabetic Exchange Lists, when substituting 2 % milk for
non-fat milk, you must omit how many fat exchanges?
a. 1
b. Reasoning: According to the Diabetic Exchange List, “The whole-milk
group has much more fat per serving than the skim and low-fat
groups. Whole milk has more than 3 ¼% butterfat.” When
substituting 2 % milk for non-fat milk only 1 fat exchange must be
omitted.

c. Citation: The Diabetic Exchange List. (n.d.). Retrieved January 23,
2018, from
http://glycemic.com/DiabeticExchange/The%20Diabetic%20Exchan
ge%20List.pdf

34. A TPN regimen that contains 1 L of D50W and 1 L of 7% Aminosyn provides
how many non-protein calories?
a. 1700
b. Reasoning: As previously mentioned as rationale for question 19,
Aminosyn is an amino acid solution and consists of protein therefore;
any calories provided from this solution would not be applicable to
this question. 1 L of D50W consists of 50% Dextrose and 50% water
(500 mL/each). My calculations below show that a TPN regimen
would provide 1,700 non-protein calories:

3.4 kcal Dextrose x 500 mL Dextrose x 1,000 mL = 1,700 kcals
1 g Dextrose 1000 mL Dextrose


35. The best way to provide nutrition counseling for a patient who has anorexia
nervosa would be to:
a. Remain flexible to help the patient set realistic goals
b. Reasoning: By definition on page 1053, “Nutrition Counseling: A
supportive process, characterized by a collaborative counselor-
patient relationship, to set priorities, establish goals, and create
individualized action plans that acknowledge and foster responsibility
for self-care to treat an existing condition and promote health.” Also
mentioned on page 691 a part of section ‘Nutrition Intervention’,
“Nutrition counseling involves behavior and attitude change through
the use of strategies that promote behavior changes and motivation
and intention to change.” From the definitions of nutrition counseling,
it is evident that the best answer choice is to remain flexible to help
the patient set realistic goals as opposed to increasing their food
intake and counseling which may be unwanted, emphasizing health
benefits associated with weight gain as I’m sure they have heard it all
before, and maintaining a “no-nonsense attitude” would only hinder
the professionals ability to connect with the patient.

36. Your patient is on Coumadin. Which foods would you make sure to
consistently include in their diet?
a. Spinach, collard greens
b. Reasoning: From Appendix 31 on page 1101 ‘Nutritional Implications
of Selected Drugs’ lists Coumadin as an anticoagulant and mentions,
“consistent intake of dietary supplements (i.e., in vitamins) must be
consistent to achieve desired state of anticoagulation”. Both spinach
and collard greens are a good source of Vitamins A, C and B-6. With
that information in mind I would make sure to include spinach and
collard greens in the diet of an individual on Coumadin.

37. Chemically defined formulas are used for:
a. Short bowel syndrome
b. Reasoning: According to the article ‘Elemental and Semi-Elemental
Formulas: Are They Superior to Polymeric Formulas?’, “Patient with
short bowel syndrome (SBS) tend to be considered ideal candidates
for elemental and semi-elemental formulas because of the
malabsorption associated with SBS and the theoretical benefit of more
efficient absorption’. The other options (post chemotherapy
treatment, hyper metabolism and Galactosemia) do not have the same
effect on GI structure or function as SBS would. This information led
me to conclude that chemically defined formulas are best used for
short bowel syndrome.
c. Citation: Parrish, C. R. (2005, December). Elemental and Semi-
Elemental Formulas: Are They Superior to Polymeric Formulas?
Retrieved January 25, 2018, from
https://med.virginia.edu/ginutrition/wp-
content/uploads/sites/199/2015/11/MakolaArticle-Dec-05.pdf

38. A teenager was brought to the hospital with CVA and dysphagia. The
dietitian should immediately:
a. Do a swallow test
b. Reasoning: Page 929 of the Krause text acknowledges, “Dysphagia
often leads to malnutrition because of inadequate intake…A
swallowing evaluation by a speech-language pathologist (SLP) is
important in assessing and treating swallowing disorders.” In
addition, ordering a nasogastric feeding without testing the patient
first would be irresponsible because at this point we have no idea how
well the patient can even swallow. Next, ordering a dysphagia diet or
a CVA diet and disregarding the dysphagia without any further testing
or assessment of the patient does not allow us to provide the best
care. By ordering a swallow test from the SLP we are initiating a
collaborative effort among health professionals in addition to taking
steps to better assess the patients needs.

39. A Crohn’s patient who was previously well nourished has a fever and ileus 7
days PO (postoperative). Which feeding method should you recommend?
a. Peripheral IV infusion
b. Reasoning: Page 638 of the Krause textbook incudes the following
information regarding feeding methods in patients with altered GI
function, “In some cases, overfeeding in an attempt to compensate for
malabsorption results in further malabsorption, not only of ingested
foods and liquids but also of the significant amounts of GI fluids
secreted in response to food ingestion. Patients with an extremely
short bowel may depend on parenteral solutions for at least part of
their nutrient and fluid supply.” Due to this patient’s ileus, inability for
their intestine to contract normally and move waste out of the body
led me to believe that a peripheral IV infusion would be the best
feeding method to recommend.

40. Intervention by a Dietitian conducting nutrition assessment is best
determined by:
a. Results of nutrition screening
b. Reasoning: The Nutrition Care Process is made up of Nutrition
Assessment & Re-assessment, Nutrition Diagnosis, Nutrition
Intervention and Nutrition Monitoring & Evaluation. Before any of
these steps can happen, as outlined on page 254 of the Krause
textbook is the “Screening & Referral System: identify risk factors, use
appropriate tools and methods and involve interdisciplinary
collaboration.” From this diagram it is evident that before nutrition
assessment can be conducted a nutrition screening must be
completed.

41. How many grams of protein would you receive on a 1500-calorie diet, which
is 20% protein?
a. 300
b. Reasoning: Typically 20-30% of our calories come from protein. In
order to calculate this information I completed the following
calculation:

1500 kcals x 0.20 percent protein = 300 kcals from protein


42. How many calories are in 1.5 L of a 25% dextrose solution?
a. 1275
b. Reasoning: As previously mentioned as rationale, the following
information was considered in order to complete my calculations: 1 g
Dextrose = 3.4 kcals; 1.5 L solution = 1,500 mL. My calculations below
show that 1.5 L of a 25% dextrose solution would contain 1,275
calories.

0.25 percent Dextrose x 1500 mL solution = 375 g Dextrose

3.4 kcal x 375 g Dextrose x 1500 g Solution = 1275 kcals


43. Which anthropometric measurements are useful in assessing adults?
a. Triceps skinfold, arm muscle circumference, height, weight
b. Reasoning: From page 880 in the Krause textbook, “It is important to
monitor these changes by taking anthropometric measurements.
Monitoring trends with body weight is important; however, doing so
will not likely identify body shape changes. Generally, there is a shift
in body composition even though weight remains stable. Taking
waist, hip, arm, mid-upper arm, and thigh circumference
measurements and triceps, subscapular suprailac, abdominal, and
thigh skinfold measurements are useful in monitoring exact locations
of either fat hypertrophy or atrophy.” Regarding the other answer
choices, a head circumference would almost be irrelevant to assess an
individual’s anthropometrics and a serum albumin test is also not
considered to be an anthropometric measurement. With all of this
information in mind I thought the triceps skinfold, arm muscle
circumference, height and weight are the most useful tools when
assessing adults.

44. Good advice for a patient with a hiatal hernia is to:
a. Don’t eat before bed
b. Reasoning: As evidenced by Box 28-1 ‘Nutrition Care Guidelines for
Reducing Gastro esophageal Reflux and Esophagitis’ that lists several
habits to adopt when dealing with GI distress including a condition
like a hiatal hernia. Number 2 reads, “Avoid eating at least 3 to 4
hours before lying down.” In addition, none of the answer choices
were included in this list, which led me to believe the best advice for a
patient with a hiatal hernia is to not eat before bed/laying down.

45. Nutritional therapy for hepatitis includes:
a. High protein, high carbohydrates, moderate fat, high calories
b. Reasoning: From the article titled ‘Viral Hepatitis’ published by the
U.S. Department of Veterans Affairs, a diet most appropriate for an
individual with hepatitis would include an adequate combination of
all macronutrients.
c. Citation: Viral Hepatitis. (2006, July 25). Retrieved January 24, 2018,
from https://www.hepatitis.va.gov/patient/daily/diet/single-
page.asp

46. An insulin-dependent diabetic living along calls you with symptoms of
nausea, vomiting and anorexia. What do you recommend?
a. Continue with insulin and drink anything he can
b. Reasoning: Regardless of the symptoms I would not suspect making
the recommendation to discontinue insulin at any point. In addition,
the nausea, vomiting and anorexia could prevent an individual from
wanting to eat or being able to eat. With this in mind, the only answer
option left is to continue with the insulin and drink anything he can.
From Dr. Bernstein’s book “Diabetes Solution” explains ways to
control diabetes with varying symptoms including the importance of
fluid replacement. With that said, continuation of the insulin and
increasing fluid consumption would be my recommendation.
c. Citation: Bernstein, R. K. (2015, February 06). Vomiting, Nausea, and
Diarrhea - Adjusting Your Diabetes Medication. Retrieved January 24,
2018, from http://www.diabetes-book.com/adjusting-diabetes-
medication/

47. Which of the following is part of the nutritional therapy for Type 1 Diabetes
in a lean person?
a. Time meals
b. Reasoning: From page 677 of the textbook is a diagram titled
‘Pathophysiology and Care Management Algorithm: Type 1 Diabetes
Mellitus’. Within this diagram is an explanation for Medical Nutrition
Therapy, “Integrate insulin regimen into preferred eating and physical
activity schedule; consistency in timing and amount of carbohydrate
eaten if on fixed insulin doses…adjust premeal insulin dose based on
insulin-to-carbohydrate ratios…energy intake to prevent weight gain
in adults…adequate energy and nutrient intake to promote growth
and development in children…cardio protective nutrition
interventions.” Only one of the answer choices to this question was
also reflected by the diagram and is that of timing meals as a part of
nutritional therapy for T1DM.

48. The ketogenic diet is used to help treat:
a. Seizures
b. Reasoning: From Table 41-1, ‘Nutritional Considerations for
neurologic Conditions’ on page 925 of Krause, epilepsy is listed with a
corresponding relevant nutrition therapy of a ketogenic diet. From
this chart, I believe the best answer to this question is that the
ketogenic diet is used to help treat seizures.

49. A 60 kg female receives 2700 calories on TPN. The calorie to nitrogen ration
is 150:1. How many grams of nitrogen is she getting?
a. 18
b. Reasoning: If the calorie to nitrogen ratio is 150:1 that means for
every 150 kcals this woman is receiving through her TPN, she is also
receiving 1 g of nitrogen. I completed the following calculation to
determine she is getting 18 grams of nitrogen per ever 2700 calories.

2700 kcals x 1 g nitrogen = 18 g nitrogen
150 kcals


50. Which of the following best reflects protein status?
a. Serum albumin
b. Reasoning: As listed in Appendix 30. ‘Laboratory Values of
Nutritional Assessment and Monitoring – cont’d’ on page 1087 are
Clinical Chemistry Panels for Protein Status and among the proteins is
Albumin. “Easily and quickly measured calorimetrically…Decreased
levels can occur following short-term protein and energy deficiency or
protein exudates such as in severe burns;

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568: Medical Nutrition Therapy/ Clinical Nutrition Final Exam

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