TEST BANK for Krause and Mahan's Food and the Nutrition Care Process 16th Edition

TEST BANK for Krause and Mahan's Food and the Nutrition Care Process 16th Edition.

Chapter 01: Intake: Gastrointestinal Digestion, Absorption, and Excretion of Nutrients MULTIPLE CHOICE

1. Pepsinogen is converted to pepsin when it comes in contact with a. enterokinase. b. trypsinogen. c. hydrochloric acid. d. peptidases.

ANS: C

Pepsinogen is secreted in the stomach and converted to its active form by the acid environment of the stomach. Enterokinase is secreted by the brush border of the small intestine in response to the presence of chyme. Trypsinogen is secreted by the pancreas and activated by enterokinase. Various peptidases are secreted by the either brush border or the pancreas.

2. Which of the following is formed by bacterial synthesis in the colon? a. Vitamin K b. Vitamin D c. Vitamin B6 d. Niacin ANS: A

Colonic bacteria produce vitamin K, vitamin B12, thiamin, and riboflavin. Vitamin D may be metabolized by exposure of precursor vitamin D in the skin to ultraviolet light. The human body can synthesize niacin from the amino acid tryptophan. Vitamin B6 must be obtained from dietary sources such as meats, whole grains, vegetables, and nuts.

3. After surgical removal of a large portion of the small intestine, what functional

complication is most likely to develop? a. Changes in dietary habits b. Impaired digestion c. Loss of absorptive tissue d. Elimination of dietary residue ANS: C

The small intestine is the primary site of nutrient absorption because of its large absorption

surface area. Secretions from the liver, gallbladder, and pancreas can still contribute to digestion of intestinal contents. However, decreased absorption of nutrients and food components may result in more intestinal remains and residue. A patient may change dietary habits as a result of gastrointestinal discomfort experienced after intestinal resection, but this is not a functional complication.

4. The sight or smell of food produces vagal stimulation of the parietal cells of the gastric

mucosa, resulting in the increased production of what? a. Motilin b. Gastrin c. Cholecystokinin d. Secretin ANS: B

Parasympathetic innervation that causes secretion of gastrin and release of hydrochloric acid helps prepare the stomach for the potential of receiving food. After food chyme is passed into the small intestine from the stomach, secretin and cholecystokinin are secreted to stimulate pancreatic secretion of water and bicarbonate. They also signal gallbladder contractions and colonic motility, all resulting in reductions in stomach emptying and duodenal motility. Motilin is secreted from the duodenal mucosa during fasting to stimulate gastric emptying and intestinal motility.

5. If a patient experiences malabsorption of fat resulting from an impaired ability to produce

adequate bile salts for micelle formation, how may fat absorption be improved? a. By increasing short-chain fatty acids in the diet b. By increasing medium-chain fatty acids in the diet c. By increasing long-chain fatty acids in the diet d. By restricting dietary intake of cholesterol ANS: B

Medium-chain fatty acids of 8 to 12 carbons can be absorbed directly by mucosal cells without the presence of bile. The long-chain fatty acids require micelle formation for absorption. Short-chain fatty acids result from bacterial fermentation of malabsorbed carbohydrates and fibers. As bile is produced from cholesterol, dietary restriction of cholesterol is negligible in regard to improvements in fat absorption.

6. What is the function of secretin? a. Stimulation of gastric secretions and increased motility

b. Stimulation of gallbladder contraction and the release of bile c. Stimulation of the pancreas to secrete water and bicarbonate d. Stimulation of the parietal cells to secrete gastrin ANS: C

Secretin is the hormone that works in opposition to gastrin. Whereas gastrin stimulates stomach digestion activities, secretin decreases gastric output and promotes pancreatic secretions to neutralize the acidity of chyme. Cholecystokinin is also secreted when chyme enters the duodenum, and it is responsible for stimulating the gallbladder.

7. Which of the following is a list of enzymes released from the pancreas? a. Insulin, trypsin, and secretin b. Lactase, isomaltase, and dextrinase c. Protease, pepsin, and gastrin d. Trypsin, chymotrypsin, and carboxypeptidase ANS: D

Trypsin, chymotrypsin, and carboxypeptidase are three protein digestive enzymes secreted by the pancreas. Insulin is an endogenous hormone secreted by the pancreas. Secretin is a hormone secreted by the small intestine. Lactase and isomaltase (also known as dextrinase) are brush-border enzymes. Pepsin, which is a protease, and gastrin are hormones secreted by the stomach.

8. In what form is dietary fat absorbed from the lumen of the intestine? a. Chylomicron b. Micelle c. Triglyceride d. Lipoprotein ANS: B

Fats must be emulsified into micelles so that they may cross the unstirred water layer that borders the brush-border membranes. These micelles leave monoglycerides and fatty acids at the brush border, where they are reabsorbed and reassembled as triglycerides. The triglycerides are packaged with cholesterol, fat-soluble vitamins, and phospholipids into chylomicrons, which pass into the lymphatic circulation. When these reach the liver, the chylomicron components are repackaged into low-density lipoproteins.

9. Which of the following is true of probiotics? a. Probiotics are live microorganisms found in food.

b. Probiotics are nondigestible carbohydrates. c. Probiotics act primarily on bacteria in the proximal small intestine. d. Probiotics cannot be given as supplements because they readily die.

ANS: A

Probiotics are live microorganisms, which when administered in adequate amounts confer a health benefit on the host. They are found in fermented foods like yogurt and sauerkraut or as a nutritional supplement. Bacterial action is most intense in the distal small intestine and large intestine.

10. By which transport mechanism are most vitamins absorbed from the small intestine into

the blood? a. Passive diffusion b. Active diffusion c. Facilitative diffusion d. Passive osmosis ANS: A

Passive diffusion is limited by the number of channels available for nutrients to randomly pass through. Facilitated diffusion requires the presence of carrier proteins, which may be limited by the health and nutritional status of the person. Active transport requires energy, which also may be limited by the person’s health and nutritional status. Osmosis occurs in regard to concentration gradient and only involves the movement of water, not vitamins.

11. What are primarily absorbed by the large intestine? a. Water and fats b. Carbohydrates c. Proteins d. Water and electrolytes ANS: D

Water and electrolytes are usually the only absorbable remnants of dietary intake that reach the large intestine. Fats, carbohydrates, and proteins from the diet are absorbed throughout the small intestine.

12. What happens to cellulose and lignin as they go through the GI tract? a. They are converted into glucose before absorption. b. They are converted into glucose and absorbed by active transport. c. They are excreted in the feces unchanged. d. They are excreted in the feces as glucose.

ANS: C

In humans, the secreted amylases cannot split the 1-2 and 1-4 linkages between the saccharides within the cellulose molecule. As a result, no individual glucose molecules are broken off.

13. Which is the process by which minerals are absorbed when they are bound to an acid,

organic acid, or amino acid? a. Cotransportation b. Carrier protein c. Competitive inhibition d. Chelation ANS: D

Chelation refers to the binding of a cation mineral to a ligand, not a whole protein.

Cotransporters carry two different minerals at a time, such as the case with sodium and phosphorus. An overlap of mineral transport mechanisms may lead to competitive absorption between minerals in the presence of other minerals, such as the case with iron or zinc supplementation, leading to a decrease in copper absorption.

14. How often do the cells lining the intestinal tract recycle? a. Every 2 to 3 days b. Every 3 to 5 days c. Every 5 to 7 days d. Every 10 to 14 days ANS: B

Intestinal mucosal cells have a life span of 3 to 5 days before they are sloughed off and recycled. They are fully functional only for the last 2 to 3 days as they migrate to the distal third of the villi.

15. What effect may be achieved by eating a diet high in prebiotic carbohydrates? a. Decreased SCFA production in the bowel b. Increased growth of Lactobacillus spp.

c. Decreased absorption of bile salts d. Increased absorption of cation minerals ANS: B

The use of prebiotic carbohydrates favors the growth of friendly bacteria such as lactobacilli and bifidobacteria. These bacteria ferment the prebiotic carbohydrates, promoting increased short-chain fatty acid production. These types of carbohydrates have not been demonstrated to have a bile-sequestering effect. Impairments in absorption of cation minerals tend to be in relation to phytates and oxalates that are present in plant foods.

16. How long does it take for small intestine contents to reach the ileocecal valve? a. 18 to 72 hours b. 3 to 8 hours c. 1 to 2 hours d. 2 to 3 hours ANS: B

Travel of contents through the small intestine takes 3 to 8 hours. A liquid meal empties from the stomach within 1 to 2 hours of eating. A solid meal takes 2 to 3 hours. Total transport from mouth to anus takes 18 to 72 hours on average.

Chapter 02: Intake: Energy Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. A particular food provides 100 kcal. How many kJ does this equal? a. 420 b. 480 c. 4200 d. 4800 ANS: A

One kilocalorie is equal to 4.184 kJ (100 kcal  4.2 kJ/kcal = 420 kJ).

2. Which of the following conditions is necessary to obtain an accurate measure of a patient’s

basal metabolic rate (BMR)? a. Test at the end of the day when the patient is ready to go to sleep. b. Test 2 to 3 hours after the last meal. c. Test in the morning after the patient has awakened. d. Test in environmental conditions equal to body temperature.

ANS: C

For an accurate measurement of BMR, the test should be performed when the body is using its minimum amount of energy, usually in the morning after waking, and at least 10 to 12 hours after the last meal so as to not include the thermic effect of food. Climates above 86F increase metabolism because of sweat gland activity.

3. If a patient’s body temperature were 104.6°F, what would the BMR be compared with

normal? a. 58% of normal b. 135% of normal c. 142% of normal d. 178% of normal ANS: C

An increase in body temperature increases the BMR by 7% for every degree Fahrenheit above the normal 98.6°F (104.6 – 98.6 = 6°F; 6°F  7% ÷ 1°F = 42%).

4. How does an elevation in body temperature with fever affect the metabolic rate? a. It does not change the metabolic rate. b. It increases the metabolic rate by 7% per degree Fahrenheit above normal. c. It increases the metabolic rate by 14% per degree Fahrenheit above normal. d. It decreases the metabolic rate by 7% per degree Fahrenheit above normal.

ANS: B

Fever causes an increase in body temperature. For every degree Fahrenheit above the normal 98.6°F, the BMR increases by 7%.

5. Which of the following does not increase the thermic effect of food (TEF)? a. Carbohydrates b. Fat c. Regular eating schedule d. Spicy foods ANS: B

Although dietary fat provides the highest concentration of energy, metabolism of fat is highly efficient, with only 4% of calories wasted. This partly explains the obesogenic aspect of dietary fat. The TEF after intake of carbohydrates and proteins tends to be higher than after fat intake. Following a regular eating schedule results in a higher TEF than irregular eating. The use of spice and mustard increases metabolism more than unspiced meals.

6. What is the clinical method for measuring human energy expenditure? a. Bomb calorimetry b. Indirect calorimetry c. Doubly labeled water d. Direct calorimetry ANS: B

Indirect calorimetry is commonly used in hospital settings. The piece of equipment is known as a metabolic cart or monitor. Other methods of measuring energy expenditure include doubly labeled water and direct calorimetry; however, these are not practical for clinical practice. Bomb calorimetry measures the energy available from food.

7. When is basal metabolism at its highest rate? a. During the digestion of a meal b. During periods of sleep

c. During periods of exercise d. During periods of rapid growth ANS: D

Because basal metabolism only accounts for the proportion of energy necessary for support of life functions, it does not include energy increase after eating (TEF) or during exercise (AT). During infancy, childhood, adolescence, and pregnancy, basal metabolism increases as FFM increases.

8. Which of the following best describes the contribution of physical activity to total energy

expenditure? a. It accounts for 10% of total energy expenditure. b. Its contribution to total energy expenditure increases with age. c. Its contribution to total energy expenditure is most consistent during childhood. d. It is the most variable component of total energy expenditure.

ANS: D

Activity thermogenesis is highly variable and dependent on body size and the efficiency of individual habits of motion. Whereas the thermic effect of food tends to be about 10% of TEE, AT can range from 100 kcal/day in sedentary people to 3000 kcal/day in highly active people. AT tends to decrease with age, and it tends to be variable during childhood.

9. What does indirect calorimetry measure? a. The amount of heat produced by the body at rest b. The energy potential of foods consumed c. Oxygen consumption and carbon dioxide excretion d. The resting metabolic rate ANS: C

Indirect calorimetry measures gas exchange that results from metabolism. The oxygen consumption and carbon dioxide excretion can be used to estimate a resting metabolic rate.

Direct calorimetry measures heat production, either from humans in a controlled environment, or from food, by incinerating the food and measuring the amount of heat released.

10. The respiratory quotient (RQ) is highest after consumption of a diet that is primarily

composed of what? a. Carbohydrate b. Protein

c. Fat d. Mixed macronutrients ANS: A

The RQ compares the carbon dioxide produced with the oxygen consumed when energy substrates are metabolized. The RQ for carbohydrate is 1. The RQs for protein, fat, and a mixed diet are, respectively, 0.82, 0.7, and 0.85.

11. Studies have shown that which factor(s) is(are) the primary determinant of an individual’s

resting energy expenditure (RMR)? a. The amount of lean body mass b. The amount of adipose tissue c. A person’s age, gender, and health status d. The individual’s body weight ANS: A

The lean body mass, or fat-free mass, accounts for about 80% of the variance in RMR. Although the body weight and composition are affected by a person’s age, gender, and health status, the amount of metabolically active tissue that exists within the overall lean body mass contributes to the overall metabolic rate.

12. Which of these best describes the change in the metabolic rate during pregnancy? a. It decreases as a result of a decrease in maternal physical activity. b. It increases as a result of fetal growth. c. It increases as a result of fetal growth and maternal cardiac output. d. It decreases as a result of an increase in maternal adipose tissue.

ANS: C

Hormonal changes that occur during pregnancy support the changes in the maternal body to support the growth of the fetus. These changes include the growth of metabolically active tissue in the uterus, placenta, and fetus. Additionally, blood volume is increased, and cardiac workload increases. Because the metabolic rate is dependent on metabolically active tissues, as these increase and the heart’s work increases, the overall metabolic rate increases.

13. A dish has 60 g of carbohydrate, 35 g of protein, and 25 g of fat. How many total

kilocalories are in the dish? a. 480 kcal b. 555 kcal c. 605 kcal d. 655 kcal ANS: C

One gram of carbohydrate provides 4 kcal. One gram of protein provides 4 kcal. One gram of fat provides 9 kcal. Therefore, (60  4) + (35  4) + (25  9) = 240 kcal + 140 kcal + 225 kcal = 605 kcal.

14. How many kilocalories are in 4 oz of 40-proof schnapps? a. 28 kcal b. 64 kcal c. 128 kcal d. 240 kcal ANS: C

The kilocalorie equivalent of an alcoholic drink is equal to the volume of drink times the proof  0.8 kcal/proof/fl oz. 4  40  0.8 = 128 kcal.

15. How is the determination of the physical activity level (PAL) categories beyond sedentary

different from the sedentary category? a. They are based on metabolic equivalents. b. They are based on the pace of walking. c. They are based on the total time spent doing physical activity. d. They are based on types of physical activity.

ANS: B

Beyond the sedentary category, the PAL category is determined according to the energy expended by a person walking a set pace of 3 to 4 mph. Low-active, active, and highly active PALs are equivalent to walking 2, 7, and 17 miles per day, respectively, at 3 to 4 mph. Metabolic equivalents (METs) are another means by which to determine energy expenditure during physical activity, but they are not used in the EER estimation.

Determination of physical activity energy expenditure using METs does consider the type, or intensity, of physical activity and total time spent doing physical activity.

16. In research regarding the measurement of activity-related energy expenditure, what

method correlated with and validated triaxial monitors of human movement? a. Doubly labeled water b. Indirect calorimetry c. Heart rate monitor d. Physical activity questionnaire ANS: A

As doubly labeled water has become the research method of choice in regard to measurements of total energy expenditure as well as the individual components of energy expenditure, comparisons of other techniques are made to it. Indirect calorimetry can be used for activity energy expenditure but not in free-living situations. The heart rate monitor has not been found to be reliable in measurement of physical activity in individuals. Physical activity questionnaires would be used as a less expensive alternative to movement monitors and are not used for validation of other techniques.

17. A respiratory quotient of 0.64 would most likely occur in which of these patients? a. A pregnant woman b. A patient with diabetic ketoacidosis c. A trauma patient in the ICU d. Someone who had just eaten a high-fat meal ANS: B

The respiratory quotient provides information on the type of fuel the body is burning for energy. A mixed fuel meal yields a respiratory quotient of 0.82. Burning fat exclusively is 0.7. Burning ketones results in a respiratory quotient less than or equal to 0.65.

18. A cocktail containing 10 g of alcohol and 20 g of carbohydrate would provide how many

calories? a. 150 b. 170 c. 120 d. 220 ANS: A

Alcohol contains 7 kcal/g. 10 g  7 kcal/g = 70 kcal. Carbohydrates provide 4 kcal/g. 20 g  4 kcal/g = 80 kcal. 70 + 80 = 150 kcal.

Chapter 03: Clinical: Water, Electrolytes, and Acid–Base Balance Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Eating which of the following would most likely increase dietary potassium intake? a. Fruits and vegetables b. Saltwater fish c. Grains d. Cereals ANS: A

Fruits and vegetables tend to be the richest sources of dietary potassium with a number of them providing more than 300 mg per serving. Seafood, grains, and cereals do not contribute nearly the same amount of potassium available in fruits and vegetables.

2. When vasopressin is excessively secreted in the blood, which of the following effects

occurs? a. Low serum potassium because water is retained. b. Low serum sodium because water is retained. c. High serum potassium because water is excreted. d. High serum sodium because water is excreted.

ANS: B

Vasopressin, also known as antidiuretic hormone, stimulates renal reabsorption of water.

In syndrome of inappropriate diuretic hormone, excessive secretion of vasopressin retains water and results in hyponatremia and low urine output. Aldosterone is the hormone that stimulates renal sodium retention, and when present, the kidneys excrete potassium in exchange for the sodium, which then attracts the retention of water.

3. Which effect is of greatest concern in water intoxication? a. Increased fluid volume of the brain cells b. Hypertension c. Decreased circulating blood volume d. Increased urinary output ANS: A

When water intake exceeds the body’s ability to excrete it, such as with impairment in

kidney function, intracellular fluid volume increases. The increase in the fluid volume of brain cells results in swelling which contributes to headaches, nausea, blindness, vomiting, and convulsions. Hypertension, decreased circulating blood volume, and changes in urinary output tend to be associated with or the cause of hypovolemia.

4. For the average woman,

ml/day would meet fluid needs.

a. 1500 b. 1700 c. 2700 d. 3500 ANS: C

A daily allowance of water from all sources, including beverages and foods, is about 2700 ml/day for women and 3700 ml/day for men. The general recommendation for water intake is approximately 35 ml/kg of usual body weight in adults.

5. How does body water, as a percentage of body weight, change based on stage of the life

cycle and lifestyle? a. Decreases significantly with age and is higher in athletes than nonathletes. b. Decreases significantly with age and is lower in athletes than nonathletes. c. Increases significantly with age and is higher in athletes than nonathletes. d. Increases significantly with age and is lower in athletes than nonathletes.

ANS: A

At birth, an infant’s body weight is about 75% to 85% water compared with a lean adult, who is 60% to 70% by body weight. As muscle mass decreases with age, total body water also decreases. Also, compared with the lean adult, an obese adult may be 45% to 55% water by body weight. This is because the weight is displaced by adipose tissue, which contains very little water.

6. Where in the body is interstitial fluid located? a. Within body cells and the lymphatic system b. Within body cells c. Between and around body cells d. In the blood and the lymphatic system ANS: C

The interstitial space is the space between and around the body cells, and it contains the interstitial fluid. Fluid within body cells is known as intracellular fluid. Fluid within the

blood and lymphatic system is considered to be extracellular fluid.

7. Statement is true concerning thirst? a. It is regulated by the hypothalamus. b. It is related to a decrease in serum osmolality. c. The elderly have an increased sense of thirst. d. Thirst receptors are located in the thyroid gland.

ANS: A

Thirst is regulated by the hypothalamus in response to increased serum osmolality. The elderly have a diminished sense of thirst. There are no thirst receptors in the thyroid gland.

8. The kidneys compensate for a loss of body water by excreting a. additional fluids and electrolytes. b. additional electrolytes. c. more concentrated urine. d. more dilute urine.

ANS: C

When water loss occurs, antidiuretic hormone secretion promotes renal reabsorption of water as a means of conserving water in the body. As a result, the urine that is excreted will be more concentrated with metabolites and electrolytes. This can be evidenced by a darker urine that has a higher than normal specific gravity.

9. The recommended fluid intake based on caloric intake is a. 2 ml/kcal for adults and 3 ml/kcal for infants. b. 0.5 ml/kcal for adults and infants. c. 2 ml/kcal for adults and 1 ml/kcal for infants. d. 1 ml/kcal for adults and 1.5 ml/kcal for infants.

ANS: D

Fluid intake of 1 ml/kcal for adults and 1.5 ml/kcal for infants provides about 35 ml/kg in adults and 150 ml/kg in infants. These levels help to maintain fluid balance within humans.

10. For a normal healthy adult, fluid balance is achieved when the amount of water taken in is a. half the amount that is lost. b. about equal to the amount lost. c. twice the amount lost. d. unrelated to the amount of water lost.

ANS: B

Water balance is achieved when the water taken into the body through food and beverage sources and water produced through metabolic processes are equal to the amount of water lost through urine, feces, sweat, and respiration. Excessive water intake or losses result in water imbalance.

11. Refeeding syndrome can result in a. hypophosphatemia. b. hypomagnesemia. c. death. d. All of the above.

ANS: D

Refeeding syndrome occurs when a starved patient is fed and there is rapid utilization of phosphorus for phosphorylation of glucose. ATP production also requires magnesium. As the body begins making ATP, serum magnesium and phosphorus drop. If not treated this can be a life-threatening condition.

12. Which of the following results from ingesting a large amount of sodium? a. Hypotension b. Muscular cramps c. Increased urinary calcium excretion d. Increased urinary potassium excretion ANS: C

Persistent excessive sodium intake has been associated with the development of hypertension and increased calcium excretion. Hypotension does not occur as result of increased sodium intake. Muscle cramping is more associated with imbalances in calcium and magnesium intake. Increased urinary output of potassium is a common side effect of the use of loop diuretics for the control of hypertension and fluid volume.

13. Which organ(s) maintain acid-base balance by the regulation of hydrogen ions? a. Lungs b. Liver

c. Kidneys d. Adrenal glands ANS: C

Hydrogen ion excretion and retention is controlled through the kidneys. The kidneys also contribute to acid-base regulation through the excretion and retention of bicarbonate. The lungs are the other organs involved in acid-base regulation, and they do so by controlling the expiration of carbon dioxide. The liver and adrenal glands do not function in acid-base regulation, although their metabolic activities may contribute to acid or base production.

14. What is the primary means by which hydrogen ions are generated in the body? a. Normal tissue metabolism b. Ingestion of highly acidic foods c. Oxidation-reduction reactions d. Reabsorption of bicarbonate ANS: A

Hydrogen ion and acid formation results from normal metabolism. All foods, not just acidic ones, may result in the production of organic acids. Carbon dioxide is a common volatile acid that results from oxidation of carbohydrates, fats, and proteins. Bicarbonate is considered to be a base, and control of its concentration, along with carbon dioxide concentrations, is a primary focus of acid-base regulation.

15. Which of the following is a characteristic of metabolic acidosis? a. Accumulation of bicarbonate b. Decreased ventilation and retention of carbon dioxide c. Accumulation of acids from abnormal metabolism d. Excessive loss of carbon dioxide from the lungs ANS: C

Metabolic acidosis is simply named for the production of acids through metabolic processes. Diabetic ketoacidosis and lactic acidosis are two conditions that lead to metabolic acidosis. Metabolic alkalosis results from an accumulation of bicarbonate.

Respiratory acidosis results from retention of carbon dioxide, but respiratory alkalosis is associated with excessive carbon dioxide respiration.

16. Sodium is increased the most by the intake of a. fresh vegetables. b. frozen vegetables.

c. fresh meats. d. luncheon meats.

ANS: D

One ounce of luncheon meat could provide 400 mg of sodium. Fresh meat provides 30 mg of sodium per ounce if no salt, flavored salt, or flavor enhancers are used. Fresh vegetables provide very little sodium, and processing 1 cup of frozen vegetables without salt will provide about 10 mg of sodium.

17. In the extracellular space, what is the primary buffer system? a. Phosphate b. Bicarbonate and carbonic acid c. Hydrogen d. Protein ANS: B

Bicarbonate and carbonic acid buffer the production of hydrogen ions and carbon dioxide that results from cellular metabolism, and this occurs primarily in the extracellular space.

The phosphate buffering system and protein buffering are activities that more commonly occur in the intracellular space.

18. Which acid-base imbalance can result from diuretics use, vomiting, and loss of chloride? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic alkalosis d. Metabolic acidosis ANS: C

Metabolic alkalosis results from a loss of acid, such as HCl through gastric suctioning, and loss of extracellular fluid, such as would occur in diuretic use or vomiting. Respiratory alkalosis occurs when excessive respiration occurs, such as heavy breathing after exercise or in anxiety. Respiratory acidosis happens when there is damage to the lungs or respiration that does not allow for the exchange of carbon dioxide with oxygen. Metabolic acidosis results from medical conditions that lead to a buildup of metabolic acids in the body.

19. What is the primary disturbance when respiratory alkalosis occurs? a. Increased bicarbonate b. Increased partial pressure of carbon dioxide

c. Decreased bicarbonate d. Decreased partial pressure of carbon dioxide ANS: D

Because respiratory alkalosis is associated with the excessive elimination of carbon dioxide, the primary disturbance is a decrease in the partial pressure of carbon dioxide in the blood. Respiratory acidosis would result in an increased partial pressure of carbon dioxide. Metabolic alkalosis would be reflected by an increase in bicarbonate, and metabolic acidosis would be evident with a decrease in bicarbonate.

20. How would the body compensate for metabolic acidosis? a. Increased kidney excretion of bicarbonate b. Increased ventilation of carbon dioxide c. Decreased kidney excretion of bicarbonate d. Decreased ventilation of carbon dioxide ANS: B

When excessive metabolic production of acids occurs, the body compensates by stimulating increased expiration of carbon dioxide to reduce acid concentrations in the body. Whereas increased kidney excretion of bicarbonate would be the compensation mechanism for dealing with respiratory alkalosis, decreased excretion of bicarbonate would compensate for respiratory acidosis. In metabolic alkalosis, the lungs would compensate by reducing expiration of carbon dioxide.

Chapter 04: Intake: Assessment of Food- and Nutrition-Related History Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. The purpose of nutritional screening is to a. identify patients at nutritional risk. b. determine a patient’s nutritional problem. c. categorize patients as high or moderate risk. d. assess the patient’s nutritional status.

ANS: A

Nutrition screening is a quick means of identifying whether or not a person may be at risk for a nutritional problem. Usually, only a few well-selected parameters related to nutrition are evaluated to determine this risk. If screening does identify a potential risk, then a more complete nutrition assessment should be performed. The assessment will identify any specific nutrition problems the patient may have. Generally, screening is not used to classify degree of risk—either the patient is at nutritional risk or not.

2. A food diary or calorie count should be recorded for

hours.

a. 48 b. 72 c. 24 d. 36 ANS: B

With the availability of complete intake records, 72 hours is usually enough to reflect an individual’s average intake. With incomplete records, the data collection may need to be extended beyond 72 hours. In a hospital setting, between the patient’s health status and the foods and menus offered, intake will vary from meal to meal and from day to day. By tracking the intake across 3 days, the assessment can account for this variation.

3. What is a limitation of using the 24-hour recall and the food frequency? a. The patient’s level of literacy b. The time required to collect data c. The lack of tools for conducting these d. Reliance on the patient’s memory

ANS: D

Both the food frequency and the 24-hour food recall depend on the patient’s memory of past intake. This can be of particular difficulty when trying to evaluate the diet history of an elderly person or a child. To their benefit, both of these methods require little time or materials to administer, and they do not require the patient to write down and maintain his or her own record of intake.

4. Which of the following is not true of nutrition screening? a. Should be able to be done quickly b. Should include weight history c. Should be done by dietitians d. Should be setting specific ANS: C

Tools and parameters should be established by dietitians but screening may be performed by other health care professionals. The parameters should be easily accessible and the process should be quick. The screening tool used should be specific to the setting.

5. The Nutrition Care Process Food- and Nutrition-Related History includes a. dietary practices. b. medications. c. attitudes related to food. d. All of the above.

ANS: D

All aspects of a patient’s life that affect intake of nutrients are included in the nutrition history, including dietary patterns, medication use, and attitudes and beliefs related to food and self-care.

6. In the patient’s

history, you would most likely find out about the patient’s cultural

views related to health care. a. medical b. social c. medication d. dietary ANS: B

Aspects of culture, which include religious and cultural beliefs and practices, are identified while obtaining a patient’s social history. Culture affects who a person turns to for health

care and how a person feels about different types of health care. Culture is also an included aspect of the diet history, but this would be focused on dietary habits and preferences dictated by culture as opposed to health care.

7. The MNA short form has been validated for use in what population? a. Critically ill elderly b. Surgical populations c. Subacute and ambulatory elderly d. Children ANS: C

The MNA short form is a rapid and reliable screening tool for ambulatory and subacute elderly populations. MUST is used for medical and surgical populations.

TRUE/FALSE

1. Smartphones are now a legitimate method to record food intake.

ANS: T

Information about actual intake is collected through direct observation or an inventory of foods eaten based on observation of what remains on the individual’s tray or plate after a meal. In many cases photographs taken by smartphones are useful in documenting amount of food consumed.

Chapter 05: Clinical: Biochemical, Physical, and Functional Assessment Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Laboratory tests for nutrients a. are not useful if you have only a single test result. b. are always best done on whole blood. c. may indicate deficiency before clinical or anthropometric data does. d. are currently not well controlled.

ANS: C

Laboratory-based nutrition testing, used to estimate nutrient concentration in biologic fluids and tissues, is critical for assessment of both clinical and subclinical nutrient deficiencies. Most of these states can be assessed in the laboratory so that nutritional intervention can occur before a clinical or anthropometric change or a frank deficiency occurs. Single test results may be useful for screening or to confirm an assessment based on changing clinical, anthropometric, and dietary status. The best biologic medium to test depends on the specific nutrient. Laboratory assessment is stringently controlled. It involves comparing control samples with predetermined substance or chemical constituent concentrations with every patient specimen.

2. Which of the following is not associated with a decrease in prealbumin levels? a. Starvation b. Inflammation c. Protein-wasting disease of the gastrointestinal tract d. Zinc deficiency ANS: A

Prealbumin levels may appear normal when a patient has uncomplicated or severe malnutrition due to starvation without inflammation. Prealbumin levels decrease in response to inflammation, protein-wasting diseases of the intestines and kidney, and in malignancy. As zinc is necessary in the synthesis of prealbumin, zinc deficiency will result in decreased levels.

3. Which nutrient-related disorder is likely to result in a stool test being ordered? a. Diabetes

b. Anemia c. Night blindness d. Cheilosis ANS: B

The fecal occult blood test is routinely ordered for adults older than age 50 years and younger adults with unexplained anemia. The presence of blood may indicate bleeding in the gastrointestinal tract that is causing the anemia.

4. Which of the following occurs during acute illness or trauma? a. Negative acute-phase reactants increase. b. Positive acute-phase reactants decrease. c. Negative acute-phase reactants decrease. d. Both positive and negative acute-phase reactants increase.

ANS: C

Negative acute-phase proteins are those that are negatively affected by trauma, meaning that their levels and production decrease in response to the trauma. These include albumin, transferrin, prealbumin, and retinol-binding protein. Positive acute-phase reactants are those that increase in levels and production in response to trauma.

5. Which of the following is a positive acute-phase reactant? a. Interleukin-1 b. Albumin c. Transthyretin d. C-reactive protein ANS: D

Positive acute-phase reactants include C-reactive protein, alpha-1-antichymotrypsin, alpha-1-antitrypsin, fibrinogen, ferritin, and complement components C3 and C4, just to name a few. Interleukin-1 is one of the cytokines triggered by trauma that reorients hepatic synthesis of plasma proteins. Albumin and transthyretin (prealbumin) are both negative acute-phase proteins.

6. During trauma, what happens to negative acute-phase reactant levels? a. Blood levels decrease because of decreased synthesis. b. Blood levels increase because of transport into the vascular space. c. Blood levels are not altered because of the catabolism of proteins.

d. Blood levels are similar to what they would be during simple starvation.

ANS: A

During the acute phase of trauma, the negative acute-phase reactant levels decrease in the blood. Part of this is because of decreased synthesis resulting from a downregulation of gene expression and translation. In the case of albumin, other aspects of the reduction include increased catabolism and transport to extravascular spaces. This is different from what happens to albumin during starvation because in that case, plasma albumin levels are maintained by a shift from the extravascular space.

7. Which of the following is true about bioelectric impedance analysis? a. It measures lean body tissue. b. It is noninvasive and portable. c. It is not accurate in a dehydrated individual. d. All of the above.

ANS: D

Bioelectrical impedance analysis (BIA) is a body composition analysis technique based on the principle that, relative to water, lean tissue has a higher electrical conductivity and lower impedance than fatty tissue because of its electrolyte content. BIA has been found to be a reliable measurement of body composition (fat-free mass and fat mass). The equipment needed is portable, and the method has been shown to be safe and noninvasive.

For accurate results the patient should be well hydrated; have not exercised in the previous 4 to 6 hours; and have not consumed alcohol, caffeine, or diuretics in the previous 24 hours. If the person is dehydrated, a higher percentage of body fat than really exists is measured.

8. Which indicator of protein status has the longest half-life? a. Albumin b. Prealbumin c. Retinol-binding protein d. Transferrin ANS: A

Albumin has a half-life of about 3 weeks. Prealbumin has a half-life of 2 days.

Retinol-binding protein has a half-life of about 12 hours. Transferrin has a half-life of 8 days.

9. Which of the following has been used as a measure of somatic protein status?

a. C-reactive protein b. Retinol-binding protein c. Urinary methylmalonic acid d. Urinary creatinine ANS: D

Urinary excretion of creatinine is related to the skeletal muscle or somatic protein; however, as the value can be affected by the intake of muscle meats, use of this measure is more limited to research. C-reactive protein is used as an indicator of inflammation.

Retinol-binding protein may be used as an indicator of starvation-related malnutrition but it does decrease with inflammation. Urinary methylmalonic acid is a sensitive indicator of vitamin B12 deficiency.

10. Which of the following manifestations will occur in iron deficiency anemia? a. Microcytic anemia b. Macrocytic anemia c. High reticulocyte count d. High MCV ANS: A

Microcytic anemia is mostly associated with iron deficiency. Macrocytic anemia, which would be reflected by a high MCV value, is usually caused by either folate or vitamin B12 deficiency. Reticulocytes are large, nucleated, immature red blood cells that are released in small numbers with mature red blood cells. The presence of these may indicate erythropoiesis in response to blood loss, hemolysis, or iron, folate, or vitamin B12 therapies.

11. Which of the following is a measure of iron storage? a. TIBC b. Serum ferritin c. Transferrin d. Hemoglobin ANS: B

Ferritin is the storage protein that sequesters the iron gathered in the liver, spleen, and marrow. Total-iron binding capacity is a direct measure of all proteins available to bind iron dependent on the number of free iron-binding sites on transferrin. Transferrin is the primary blood transport protein of iron. Hemoglobin is the oxygen-carrying protein in red blood cells and uses iron as a functional component.

12. Which of the following deficiencies could cause macrocytic anemia? a. Vitamin B12 b. Vitamin B6 c. Homocysteine d. Iron ANS: A

Vitamin B12 and folate deficiencies both may promote the development of macrocytic anemia because they are involved in DNA synthesis, and loss of either results in the impaired production of red blood cells. Homocysteine is a product of methionine metabolism. Levels of homocysteine increase when vitamin B12 and folate are deficient because these are necessary for its conversion back to methionine. Vitamin B6 affects homocysteine by converting it to cysteine. However, neither of these promote anemia. Iron is associated with microcytic anemia.

13. Which of the following would be included in a complete blood count? a. Total cholesterol b. Mean cell volume c. Glucose d. Albumin ANS: B

A CBC panel focuses on the analysis and descriptions of the red blood cells, including hemoglobin, hematocrit, and mean cell volume (the size of the red blood cells). Glucose, total cholesterol, and albumin are values on a common serum chemistry or blood panel.

14. Which laboratory value would be added in a comprehensive metabolic pane, CMP

(compared with a Basic Metabolic Panel, BMP)? a. Albumin b. Glucose c. Blood urea nitrogen d. White blood cells

ANS: A

The Centers for Medicare and Medicaid Services established that for the BMP, the following tests are reimbursable: glucose, calcium, potassium, carbon dioxide, chloride, blood urea nitrogen, and creatinine. For the CMP, the following are added: albumin, total protein, alkaline phosphate, alanine aminotransferase, aspartate aminotransferase, and bilirubin. WBC would appear on a CBC, which may include a differential identifying the levels of the different types.

15. Which of the following is not a laboratory measure of hydration status? a. Serum sodium b. Blood urea nitrogen c. Serum glucose d. Urine specific gravity ANS: C

Although high serum glucose levels in people with diabetes mellitus have a dehydrating effect, by itself, it is not a measure of hydration. Glucose, sodium, and blood urea nitrogen (BUN) are all factors in the calculation of serum osmolality. Serum osmolality, serum sodium, BUN, and urine specific gravity are all laboratory values that may be used to assess hydration status.

16. Which of the following is a measure of glucose control? a. Highly sensitive C-reactive protein b. Hemoglobin A1C c. Homocysteine d. Apolipoprotein B ANS: B

The percentage of glycosylated hemoglobin (hemoglobin A1C) in the blood is directly related to the average blood glucose levels for the preceding 2 to 3 months. Homocysteine and hs-CRP are two inflammatory markers, higher levels of which are associated with increased risk of cardiovascular disease. Apolipoprotein B is the part of the protein present in low-density lipoprotein, and it is also associated with increased risk of atherogenesis, possibly through its susceptibility to oxidation by ROS and lipid peroxides.

17. In urinalysis tests, which of the following is expected to appear at some level in normal

people? a. Glucose

b. Ketones c. Blood d. Protein ANS: D

Small amounts of protein, from 2 to 8 mg/dL, are expected in normal urine. Larger amounts are associated with damage to the kidneys. Results for glucose, ketones, and blood in the urine are expected to be negative.

18. Which of the following is a criterion for diagnosing malnutrition in adults? a. Excess adiposity b. Intention weight loss c. Energy intake less than estimated needs d. Hypoalbuminemia ANS: C

Criteria to diagnose malnutrition in adults include unintentional weight loss, energy intake below estimated needs, functional capacity, muscle wasting, fat loss, and fluid accumulation. Two criteria must be met to diagnose malnutrition. Each criterion is quantified as either severe or nonsevere for acute, chronic, and environmental malnutrition. Presence of adiposity and intentional weight loss are not included. No laboratory data is required.

Chapter 06: Clinical: Nutritional Genomics Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Approximately how many nucleotides make up human DNA? a. 1 million b. 2 billion c. 3 billion d. 8 billion ANS: C

When mapping of the human genome was completed in 2003, human DNA was determined to consist of 3 billion nucleotides.

2. What is the term that describes the natural variations in a gene that create no adverse

effects on the individual and appear frequently within the population? a. Autosomal dominant b. Homozygous c. Polymorphism d. Heterozygous ANS: C

Polymorphism refers to one of multiple variations of a gene’s sequences, which explains why human beings are distinctly different from one another. Autosomal dominant refers to genetic inheritance when an allele on an autosome presents a phenotype, whether a single copy of the allele (heterozygous) or two copies of the allele (homozygous) are present.

3. What is the effect of a silent mutation on DNA? a. It is harmful to the host. b. It accumulates additional mutations more quickly than unaffected DNA. c. It improves certain functions of the DNA. d. It has no effect on the DNA. ANS: D

A silent mutation is a gene variant that has no effect on DNA function. The term “mutation” tends to refer to a genetic difference that results in a harmful effect. “Gene variant” refers to a genetic difference that may result in a difference, but this difference is

not necessarily harmful.

4. What is the term that describes a gene that is present but is not readily measurable? a. Pedigree b. Reduced penetrance c. Dominance d. Linkage ANS: B

Reduced penetrance refers to when a person has the genotype that is not readily measurable. This concept is usually applied to the genetic inheritance of disease, such as when the pedigree of a disease is tracked through a family history. Dominance refers to the phenotypic expression of a single allele, whether it is associated with an autosome or a sex-linked chromosome. Linkage refers to how genes are sequenced with others in the DNA strand.

5. Which type of disorders is the most common of the Mendelian inherited disorders? a. Autosomal recessive diseases b. Autosomal dominant diseases c. X-linked dominant diseases d. X-linked recessive diseases ANS: A

Autosomal recessive diseases are the most common as two copies of an abnormal autosomal allele are necessary for the phenotype to be expressed. Both autosomal and X-linked dominant diseases only need one abnormal allele for expression to occur. An X-linked recessive condition could only occur in a woman if she inherits two copies of the recessive trait. Because males only have one X chromosome, if the recessive trait is present, it will be expressed.

6. Which of the following is a syndrome caused by extra chromosomes? a. William syndrome b. Down syndrome c. Angelman syndrome d. Prader-Willi syndrome ANS: B

Down syndrome is also known as trisomy 21 because an extra chromosome 21 is present.

William syndrome is a condition resulting from a missing chromosome 7. Angelman and

Prader-Willi syndromes both involve missing chromosome 15.

7. What syndrome results from inheriting two copies of a deletion in chromosome 15 from

the father? a. William syndrome b. Down syndrome c. Angelman syndrome d. Klinefelter syndrome ANS: C

The difference between Angelman syndrome and Prader-Willi syndrome is the source of the inherited abnormal alleles. When both are inherited from the father, the result is Angelman syndrome. When both are inherited from the mother, then Prader-Willi syndrome is the result. William syndrome results from a deletion of chromosome 7. Down syndrome results from the presence of an extra chromosome 21. Klinefelter syndrome results from an extra X chromosome.

8. Phenylketonuria is what type of genetic disorder? a. Autosomal dominant b. Autosomal recessive c. X-linked dominant d. X-linked recessive ANS: B

PKU, tyrosinemia, maple syrup urine disease, and other metabolic disorders known as inborn errors of metabolism result from autosomal recessive disorders. Examples of nutrition-related conditions that are autosomal dominant disorders include Albright hereditary osteodystrophy and familial hypercholesterolemia. One nutrition-related X-linked dominant disorder is fragile X syndrome. Diabetes insipidus and adrenoleukodystrophy are examples of X-linked recessive disorders with nutritional implications.

9. The purpose of the Genetic Information Nondiscrimination Act (GINA) is to a. protect against discrimination. b. ban insurers from denying coverage based on genetic information. c. prevent employers from firing individuals based on genetic testing results. d. All of the above.

ANS: D

Many legislators and legal experts believe the Americans with Disabilities Act sufficiently protects against discrimination, but as an added measure of protection, the GINA was passed by Congress and went into effect on November 21, 2009. GINA defines genetic testing and genetic information, bans discrimination based on genetic information, and penalizes those who violate the provisions of this law. Consumers and health care professionals can feel comfortable in adopting this new service.

10. In regard to nutritional assessment, which of the following will nutrition professionals

need to be able to read to identify a patient’s potential susceptibility to diseases? a. Phenotype b. Genotype c. Karyotype d. Genomic imprint ANS: B

Whereas the genotype refers to the patient’s unique genetic makeup, the phenotype is the measurable expression of a gene. The genotype can provide the information that the patient may be susceptible to a particular disease, depending on the influence of specific food components and other environmental factors. If the disease of concern became present, this would be the phenotype expressed. A karyotype is a visual display of chromosomes. Genomic imprinting refers to the process by which a phenotype is influenced by whether a gene variant was inherited from the mother or the father.

11. Within a strand of DNA, which of the following nucleotide base pairing is possible? a. Adenine-guanine b. Cytosine-thymine c. Adenine-uracil d. Cytosine-guanine ANS: D

In DNA, only two potential base pairings are possible: adenine with thymine and cytosine with guanine. In RNA, uracil may take the place of thymine to be paired with adenine.

12. In protein synthesis, what subcomponent of DNA directs the inclusion of a specific amino

acid within the protein? a. The gene b. The intron c. The codon d. The exon ANS: C

Whereas a gene is the sequence of nucleotides that codes for a whole particular protein, a codon within the gene is a three-nucleotide sequence that specifies the individual amino acid included with the protein. The exon is the sequence of nucleotides that corresponds to the sequence of amino acids within the protein. The exon is made up of codons. An intron is a sequence of nucleotides that does not code for amino acids, and these are interspersed between exons.

13. During protein synthesis, when are introns removed? a. Transcription b. Posttranscriptional processing c. Translation d. Posttranslational processing ANS: B

After transcription results in mRNA production, the mRNA must undergo preparation for translation processes within the endoplasmic reticulum. Among these posttranscriptional processes are the removal of introns, the capping of the 5-prime end, and the addition of a polyadenosine tail to the 3-prime end of the mRNA. After the protein is produced during translation, posttranslational processing involves the change in the protein to its active form.

14. In genomics, “SNP” refers to a. the sequencing of nucleotides to make proteins. b. a method of extracting a gene from a DNA strand. c. a variation in a DNA sequence caused by one nucleotide. d. sex-linked nucleotide penetrance.

ANS: C

An SNP is a single nucleotide polymorphism, which results from the inclusion or deletion of a single nucleotide, thus affecting promoting a variation in DNA. An SNP can affect the

sequencing of proteins by transcribing for a different amino acid in the protein sequence.

Sex-linked penetrance of a disease within a population is more associated with chromosomal differences as opposed to individual nucleotides. Restriction endonucleases are the enzymes used to cut DNA to extract a nucleotide sequence.

15. Which of the following may promote a change in a DNA molecule affecting gene

expression without changing the nucleotide sequence? a. Genomic imprinting b. Mutation c. SNP d. Gene variant ANS: A

Genomic imprinting refers to the process by which a change in the DNA results in a phenotype influenced by whether a gene variant was inherited from the mother or the father. Mutations or gene variants are changes in the nucleotide sequence. A single nucleotide polymorphism results in a change in the nucleotide sequence, but by only one nucleotide.

16. Which area of study focuses on the identification and understanding of the function of the

end products of the genes within the human genome? a. Nutrigenomics b. Proteomics c. Metabolomics d. Genomics ANS: B

Proteomics focuses on studying the proteins produced by genes. Metabolomics focuses on the study of cellular metabolites that may be useful in the monitoring of disease progression. Nutrigenomics studies the influence of nutrient and other food factors on the expression of genes. Genomics is the all-encompassing study of genes and proteins and their relation to disease, including the influences of environmental factors.

17. The 677CT variant of the MTHFR gene may increase the risk of a. copper toxicity. b. vitamin A toxicity. c. zinc deficiency. d. folic acid deficiency.

ANS: D

The 677CT variant of the MTHFR gene results in decreased conversion of dietary folate or folic acid to 5-methyl folate and can result in folic acid deficiency.

18. Nutritional components of food affect genetic expression by acting as ligands for

peroxisome proliferator-activated receptors (PPARG). Which disease may not be positively affected by this nutrigenomic relationship? a. Type 2 diabetes mellitus b. Cancer c. Obesity d. Atherosclerosis ANS: B

PPARG transcription factors function in lipid and lipoprotein metabolism, glucose homeostasis, adipocyte proliferation, and foam cell formation. Omega-3 and omega-6 fatty acids serve as ligands for PPARs, and as a result, potential beneficial effects could result in reduced expression of type 2 diabetes mellitus, atherosclerosis, and obesity. Research connecting nutrigenomics to cancer presently is investigating relationships to detoxification factors.

19. Among which types of inheritance have no nutrition-related disorders been identified? a. Autosomal recessive b. X-linked dominant c. Y-linked d. X-linked recessive ANS: C

Y-linked disorders are associated with males, but no specific nutrition-related disorders have been associated with Y-linked inheritance. Nutrition-related autosomal recessive disorders include inborn errors of metabolism. An X-linked dominant nutrition-related disorder is fragile X syndrome, a type of mental disorder susceptible to folic acid deficiency. X-linked recessive nutrition-related disorders include nephrogenic diabetes insipidus and adrenoleukodystrophy.

Chapter 07: Inflammation and the Pathophysiology of Chronic Disease Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Allostasis is a. a test for inflammation. b. a root cause of obesity. c. lysosomal degradation. d. a condition of metabolic stability with adjustments for environmental influences.

ANS: D

Allostasis is a condition of metabolic stability with adjustments for environmental influences and stresses. It will be established even under inflammatory conditions. This can lead to inflammation but allostasis is not a test for inflammation.

2. Nutrient Triage Theory refers to a. the nutrient partner principle. b. nutrients being preferentially used for functions important for survival during poor

dietary supply. c. nutrients being preferentially used to fuel inflammation. d. nutrients being preferentially used to resolve long-latency nutrient insufficiencies.

ANS: B

The concept of Nutrient Triage Theory states that during poor dietary supply, nutrients are preferentially utilized for functions that are important for survival. The nutrient partner principle refers to the symbiosis between two nutrients such as calcium and vitamin D. Long-latency nutrient insufficiencies result from chronic poor intake and contribute over a period of time to the development of chronic disease.

3. Chronic inflammation is associated with

.

a. a progressive shift in the type of cells present at the site of inflammation b. production of cytokines c. loss of the body’s ability to recognize “self” d. All of the above ANS: D

Prolonged inflammation known as chronic inflammation leads to a progressive shift in the

type of cells present at the site of inflammation and is characterized by simultaneous destruction and healing of tissue. The immune system’s response to physiologic and metabolic stress is to produce proinflammatory molecules such as cytokines. The immune system’s function is to keep the body healthy by responding appropriately with an inflammatory response and then returning the body to an alert system of defense. But when the natural defense system is damaged in multiple areas, such as the gastrointestinal barrier, lining of the lungs, ears, nose, throat, and skin, there can be a loss of ability of the body to recognize “self” from “nonself.”

4. Increased intestinal permeability is associated with

.

a. blocking of large molecules to prevent passage into the internal microenvironment b. an allogenic state c. decreased antigenic load d. more severe food sensitivity or allergy ANS: D

The loss of the integrity of the gut barrier leads to intestinal permeability. It is sometimes known as “leaky gut.” This condition provides access of larger molecules into the internal microenvironment. A situation occurs where antigens, often from food, become more significant and allostasis is no longer present.

5. Essential fatty acids and polyunsaturated fatty acids are converted to what? a. Insulin b. Cytokines and adipokines c. Prostaglandins d. Interleukin-6 ANS: C

Essential fatty acids and polyunsaturated fatty acids are converted into prostaglandins as part of the eicosanoid cascade. Interleukin-6 is a marker of inflammation. Adipokines and cytokines are proinflammatory molecules. Insulin is a protein hormone produced by the pancreas.

6. Which of the following is not a biomarker of inflammation? a. Hemoglobin A1C b. Sedimentation rate c. High-sensitivity C-reactive protein d. TNF-alpha

ANS: A

Biomarkers of inflammation include high-sensitivity C-reactive protein, interleukin-6, TNF-alpha, and sedimentation rate. Hemoglobin A1C is used to determine average blood glucose over a 3-month period.

7. 70% of the immune system resides in

.

a. the thymus gland b. the GI tract c. white blood cells d. lean body tissue ANS: B

Because 70% of the immune system is contained in the GI tract it is important to assess its condition when evaluating inflammation. The thymus gland and white blood cells play important roles in the immune system. Lean body tissue does not, although increased amounts of adipose tissue can be proinflammatory.

8. Dietary factors that help to maintain healthy fluid viscosity and therefore a healthy

immune system include all except a. carbohydrate. b. hydration. c. plant-based diet. d. monounsaturated fat.

ANS: A

Dietary factors that help to maintain healthy fluid viscosity are hydration, a plant-based diet, polyunsaturated fatty acids, and monounsaturated fatty acids. Carbohydrate is not known to have an effect.

9. Cytochrome P450 enzymes are essential for a. production of cholesterol. b. detoxification transport of toxins for elimination. c. production of prostacyclins. d. All of the above.

ANS: D

Cytochrome P450 enzymes are essential for the production of cholesterol, steroids, prostacyclin, and thromboxane A2. They are involved in the hydroxylation of endogenous and exogenous toxic molecules in the detoxification transport of toxins.

10. Which of the following nutrients may contribute physiologically to all immune responses? a. Vitamin E b. Vitamin C c. Vitamin D d. Folate ANS: C

Vitamin D functions as a prohormone with multiple roles, including hormone and immune modulation, antiinflammatory, and antitumor effects and apoptosis support. This suggests that vitamin D is able to physiologically contribute to the regulation of all immune responses, by means of the vitamin D receptor.

11. Curcumin is a powerful flavonoid found in

.

a. turmeric b. apples and onions c. green vegetables d. fatty fish ANS: A

Curcumin is the most studied flavonoid compound researched to date and is found in the spice turmeric. Quercetin is another example of a flavonoid and it is found in apples and onions.

12. Medical nutrition therapy for maintaining a healthy gut microbiome includes a. fermented foods. b. avoiding processed foods. c. prebiotics. d. All of the above.

ANS: D

Medical nutrition therapy recommendations for increasing fermented foods, lowering intake of processed foods, and avoiding gastrointestinal irritating foods and any known antigens for an individual are basic to improving the microbial ecology. Therapeutic use of functional foods, such as probiotics and prebiotics, can be indicated to restore gut health.

is a toxic substance within a biologic organism that is not normally present and

13.

does damage to the metabolism. a. Antioxidant b. Xenobiotic c. Glutathione d. GALT ANS: B

Xenobiotics are toxic substances not normally found in the organism that damage metabolism. Glutathione is a powerful antioxidant, and GALT refers to the immune tissue in the GI tract.

Chapter 08: Behavioral-Environmental: The Individual in the Community Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Which of the following is the focus of the traditional public health approach to health

care? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Patient care ANS: A

The traditional public health approach to health care is through health promotion at the primary prevention level. Secondary prevention focuses on risk appraisal and reduction before development of disease. Tertiary prevention focuses on treatment and rehabilitation to prevent the progression of disease or to reduce the debilitating consequences of the disease.

2. Which of the following is not one of the core functions of public health? a. Community assessment b. Food security c. Policy development d. Public health assurance ANS: B

Although how they are performed varies depending on the community setting, the three core functions of public health are community assessment, policy development, and public health assurance. Food security may be one of the issues addressed in public health but is not a focus in all public health programs.

3. While performing a community assessment, you determine that you need information

about local cardiovascular morbidity and mortality. Which of the following would be an appropriate resource for this information? a. Census Bureau b. Centers for Disease Control and Prevention c. Department of Health and Human Services

d. Area Office on Aging ANS: B

The Centers for Disease Control and Prevention (CDC) collects information regarding morbidity and mortality, as do state and local public health agencies. The Census Bureau collects demographic information useful in describing the population base of a community. The CDC and the Administration on Aging are two agencies within the U.S. Department of Health and Human Services. The local Area Office on Aging is able to provide information about the elderly population in the local community.

4. Where is the dietary information collected during NHANES reported? a. Diet and Health Knowledge Survey b. National Nutrient Data Bank c. Dietary Guidelines for Americans d. What We Eat in America ANS: D

In 2002, the National Health and Nutrition Examination Survey was joined with the Diet and Health Knowledge Survey to become the National Food and Nutrition Survey. This ongoing survey includes a dietary component, which is reported in What We Eat in America. The National Nutrient Data Bank keeps information about the nutrient content of foods. The Dietary Guidelines for Americans are updated every 5 years based on the latest information regarding food and nutrition for maintaining health.

5. What agency(ies) is(are) responsible for NHANES? a. DHHS b. FDA c. USDA d. Both DHHS and USDA ANS: D

Both the DHHS and the USDA play a role in the completion of NHANES. DHHS is responsible for the sample design and data of the survey, and the USDA is responsible for dietary data collection methodology, maintenance of the database used to code and process data, and data review and processing.

6. What is the name of the survey that currently collects information on nutrient intake and

health status in the United States? a. Diet and Health Knowledge Survey

b. National Health and Nutrition Examination Survey c. Nationwide Food Consumption Survey d. Continuing Survey of Food Intake of Individuals ANS: B

NHANES was the original survey that includes assessment of health status of Americans.

The Nationwide Food Consumption Survey, the Continuing Survey of Food Intake of Individuals, and the Diet and Health Knowledge Survey all focused on only the dietary and nutrient intake of Americans. The DHKS also included some examination of nutrition knowledge and attitudes.

7. One of the strongest arguments for the use of organic food is a. that the cost of organic food is decreasing. b. organic food is not more susceptible to contamination. c. to prevent sensitivity to pesticide contamination. d. to prevent antibiotic resistance.

ANS: D

Antibiotic-resistant strains of pathogenic bacteria are a growing problem. Antibiotics are in widespread use in the meat and dairy industry. Organic meats and dairy products are raised without the use of antibiotics. The American Medical Association has gone on record to oppose the nontherapeutic use of antibiotics in agriculture.

8. Which of these food programs is not funded through the USDA Food and Nutrition

Service? a. Child and Adult Care Food Program b. Commodity Supplemental Food Program c. The Emergency Food Assistance Program d. Emergency Food and Shelter Program ANS: D

The Emergency Food and Shelter Program is funded through the Federal Emergency Management Agency to aid those in need in response to disaster. This program provides persons in need with funds to acquire food and temporary shelter. The Child and Adult Care Food Program, Commodity Supplemental Food Program, and The Emergency Food Assistance Program are all Food and Nutrition Service programs through USDA. 9. Which of the following is a qualification for a school to receive federal cash

reimbursement and food donations under the National School Lunch Program?

a. The school must be located in a low-income urban area. b. The school must be located in a low-income rural area. c. The school must serve a lunch meeting specific nutritional requirements. d. The school must serve a minimum of 200 meals per day 5 days each week.

ANS: C

For a school to receive federal cash reimbursement, it must serve a lunch that meets one-third of the RDAs for protein, iron, calcium, vitamin A, vitamin C, and calories as well as the Dietary Guidelines, and the school must offer free and reduced-price lunches to children whose families meet the income guidelines. Location of the school does not matter as much as the income of the families of students who attend the school. The school does not have to serve a minimum number of meals.

10. Which version of the Dietary Guidelines for Americans was the first to include food

safety? a. 2005 b. 2000 c. 1980 d. 1977 ANS: B

Before the 2000 version, the focus of the Dietary Guidelines for Americans was on the prevention of chronic disease; however, because of concerns regarding foodborne illness outbreaks, food safety was included in the 2000 and 2005 versions. Food safety continues to be a concern because many Americans eat away from home, and inappropriate food handling is the means by which food becomes contaminated.

11. Which pathogen causes hemorrhagic colitis (painful, bloody diarrhea), which can result

from eating undercooked ground beef and meats? a. Escherichia coli b. Campylobacter jejuni c. Staphylococcus aureus d. Yersinia enterocolitica ANS: A

E. coli contamination was connected to undercooked ground beef in one fast-food restaurant chain in the 1990s. A common source for this pathogen is water contaminated with human waste. C. jejuni can cause bloody diarrhea but comes from consuming raw milk and undercooked chicken and shellfish. S. aureus promotes nausea and vomiting and affects foods that may be mixed by hand, such as meat and pasta salads. Y. enterocolitica can cause fever and bloody diarrhea in children but more often comes from contaminated and undercooked pork products.

12. Which of the following pathogens has been identified by the CDC as potentially usable by

bioterrorists? a. Salmonella b. Staphylococcus aureus c. Bacillus cereus d. Listeria monocytogenes ANS: A

The seven foodborne pathogens identified by the CDC as potential bioterrorist weapons are tularemia, brucellosis, Clostridium botulinum toxin, epsilon toxin of Clostridium perfringens, Salmonella, E. coli, and Shigella.

13. Which of the following is one of the CDC’s operations related to food security and disaster

planning? a. PrepNet (Food Threat Preparedness Network) b. F-Bat (Food Biosecurity Action Team) c. FoodNet (Foodborne Diseases Active Surveillance Network) d. Center for Food Safety and Applied Nutrition ANS: C

The CDC’s operations related to food security and disaster planning include FoodNet, PulseNet, and the Centers for Public Health Preparedness. PrepNet and F-Bat are operations of the Food Safety and Inspection Service. CFSAN is a program within the FDA. 14. Organic agriculture a. is declining in the United States because of decreased demand. b. is dangerous because the food does not meet state and federal food standards. c. promotes a more sustainable food system. d. promotes antibiotic resistance.

ANS: C

Organic agriculture promotes a more sustainable food system by reducing soil erosion, rehabilitating poor soils, and sequestering carbon in soil. Organic foods meet all the food safety requirements that nonorganic foods meet. Because organic meat production does not allow antibiotics to be routinely used, it may help prevent antibiotic resistance in humans. Sales of organic foods in the United States totaled 49.4 billion dollars in 2017.

15. Which of the following is not true of Frieden’s Health Impact Pyramid? a. It is based on evidence-based research. b. Interventions focusing on lower levels of the pyramid tend to be more effective

because they reach a broad segment of society and require less individual effort. c. It is a five-tier pyramid that can be used by individuals in a community to

determine their own health care priorities. d. It includes clinical interventions that require limited contact but confer long-term

protection.

ANS: C

In 2010, Dr. Thomas Frieden published an article that described a new way of thinking about community-based health services. His five-tier pyramid derived from evidence-based research describes the potential impact of various types of public health interventions. It includes clinical interventions that require limited contact but confer long-term protection. Interventions focusing on the lower segments of the pyramid tend to be more effective because they reach a broad segment of society and require less individual effort.

16. The Hunger-Free Kids Act of 2010 did which of the following? a. Expanded the after school meal program b. Expanded WIC program coverage from 6 months to 1 year c. Improved the nutrition quality of school-based lunch programs d. All of the above ANS: D

The Hunger-Free Kids Act expanded the after school meal program. It created a process for a universal meal program that allows schools with a high percentage of low-income children to receive meals at no cost. It allowed states to increase WIC coverage from 6 months to 1 year and improved the nutritional quality of foods served in school-based and preschool settings by developing new nutrition standards.

17. How could a heart-healthy cooking class and demonstration be a form of primary

prevention? a. The class is made available to the general public. b. The class is made available to people with risk of heart disease. c. The class is made available to people diagnosed with heart disease. d. The class is made available to spouses and caregivers of people with heart disease.

ANS: A

As primary prevention focuses on health promotion before actually having a disease, making the class available to anybody in the general public would be a type of primary prevention. Secondary prevention focuses the class for those at risk of developing heart disease. Tertiary prevention is for those who already have the disease and their spouses and care providers.

18. Although responsibility for public health is shared across different levels of government,

which responsibility is usually handled by the local health agency? a. Providing funding to support the capacity to carry out public health functions b. Ensuring that effective service delivery systems are in place c. Supporting the development and dissemination of public health knowledge d. Assessing the capacity to perform essential public health functions ANS: B

In the model of shared responsibility, the local health agency is most responsible for ensuring that services are available. The federal government functions in a supportive role, both in providing funding and in the development and dissemination of public health knowledge. Although community organizations and leaders may be involved, the state public health agency is responsible for assessment and monitoring activities in relation to the achievement of goals and objectives.

19. What government program educates the public about how to prepare for a national

emergency? a. Ready.gov b. Center for Food Safety and Applied Nutrition c. PrepNet (Food Threat Preparedness Network) d. FEMA ANS: A

Ready.gov is an Internet education tool developed by DHS to teach the public how to

prepare for national emergencies. PrepNet is a Food Safety and Inspection Service program that coordinates food security activities to protect the food supply. CFSAN focuses on issues related to seafood HACCP, safety of additives, biotechnology, supplements, and labeling. FEMA provides support services after a disaster occurs but not prevention or emergency preparation training.

Chapter 09: Overview of Nutrition Diagnosis and Intervention Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Which of the following is not true of a sentinel event? a. It is an unanticipated event that involves serious injury or death. b. It marks a point in the care of the patient that will extend their DRG. c. The outcomes of the event must be documented in the medical record. d. It can be psychologic injury.

ANS: B

A sentinel event has nothing to do with DRGs or reimbursement. It is an unanticipated event that involves death or serious physical or psychologic injury. The outcomes of this event must be documented in the medical record.

2. Which documentation style has been proposed to reflect the nutrition care process? a. PES b. Focus charting c. SOAP d. ADIME ANS: D

The nutrition care process includes four components: nutrition assessment (A), nutrition diagnosis (D), nutrition intervention (I), and nutrition monitoring and evaluation (ME).

PES is another term for the nutrition diagnosis statement and refers to problem, etiology, and signs and symptoms. Focus charting is a documentation style based on the identification of, and then charting in response to, problem occurrence. SOAP had been a standard format for documentation before being replaced by ADIME. SOAP includes Subjective (S), Objective (O), Assessment (A) and Plan (P).

3. Which of the following requires that health care providers ensure the protection of their

patients’ privacy? a. TJC b. MCOs c. HIPAA d. CMS

ANS: C

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is the federal law that called for improved efficiency and privacy in regard to the use of electronic transmission of patient data. Through this, patient information is considered private and confidential, and all health care providers are responsible for ensuring this. The Joint Commission (TJC) is a peer review organization that accredits health care organizations that are in compliance with minimum standards. Managed care organizations (MCOs) finance and provide care to subscribers of the service at a preset charge as a means of trying to control the costs of health care. The Centers for Medicare and Medicaid Services (CMS) is the federal division responsible for the administration of Medicare, Medicaid, and HIPAA. 4. Which of the following identifies the essential elements and activities that should occur in

a patient’s care? a. Case management b. Critical pathway c. Utilization review d. DRG ANS: B

A critical pathway is used by health care providers to identify what activities should occur at times throughout a patient’s care. This is a key component of case management, which focuses on the achievement of patient-focused goals in the delivery of health care.

Utilization review is a process of identifying and eliminating unnecessary health care treatments so as to provide the most cost-effective care. Diagnosis-related groups refer to a method of health care reimbursement established in the 1980s as a means of helping control health care costs.

5. Which of the following is a system of paying for the care of a patient based on their

diagnosis? a. Utilization management b. Patient-focused care c. Case management d. DRG ANS: D

Utilization management uses established standards to identify tests, procedures, and services in health care that have known benefits toward patient improvement. The utilization manager reviews the case management of a patient to ensure that only approved

activities that will help the patient are being performed. Patient-focused care is organized around the concept that the patient is the focus of the health care team, and the patient ultimately makes the decisions in regard to health care. Case management is the overall management organized around the achievement of patient health care goals.

Diagnosis-related group (DRG) is a system of paying for the care based on the diagnosis of the patient.

6. Utilization management is a. a system to protect personal health information. b. a system of cost efficiency. c. a critical pathway. d. a medical staffing system.

ANS: B

Utilization management strives for cost efficiency by eliminating or reducing unnecessary tests, procedures, and services. HIPAA is a system for protecting personal health information. A critical pathway identifies essential elements that occur in a patient’s care.

7. Nutrition risk screening using the electronic health record is best done by a. a physician. b. an RDN. c. the admitting health professional. d. the patient.

ANS: C

Nutrition risk screening is a very simple and efficient way to ensure that appropriate patients are seen by a dietitian. Upon admission very simple yes/no questions about weight prior to admission and gastrointestinal problems prior to admission are used to generate the consult for the RDN. 8. The nutritional value of the average clear liquid diet is a. no protein and 500 to 700 kcal. b. 5 to 10 g protein and 500 to 600 kcal. c. 20 to 30 g protein and 100 to 1200 kcal. d. 40 to 50 g protein and 500 to 700 kcal.

ANS: B

The clear liquid diet consists of foods such as tea, broth, carbonated beverages, clear juices without pulp, and gelatin. As a result, this diet is very nutritionally incomplete and usually

only provides 500 to 600 kcal and 5 to 10 g protein. Ideally, a patient should be transitioned to a more nutritionally complete diet as soon as the patient can tolerate more solid foods.

9. A newly admitted patient is observed to have poorly fitting dental plates. Which type of

diet would be most appropriate for this patient? a. General or regular house diet b. Liquid diet c. Consistency-modified diet d. Diet increased in energy value ANS: C

When a patient has poorly fitting dentures, it affects the patient’s ability to chew.

Difficulties with chewing and swallowing are best accommodated by a consistency-modified diet. The regular house diet, although nutritionally complete, may include foods that the patient will have difficulty chewing and swallowing, and this may be reflected by a decreased or incomplete intake. Liquid diets tend to not be nutritionally complete, and in particular, they lack fiber. A person with poorly fitting dentures would need extra calories only in the instances when either increased energy needs are determined or there exists a concern in regard to the patient’s weight.

10. Which of the following has a negative influence on patient acceptance and intake of meals

and food in the hospital? a. Patient selection of menus b. Improper food temperatures c. Eating with others d. Nurse’s communication of the diet ANS: B

Poor acceptance of meals in the hospital may be caused by improper food temperatures, unfamiliar foods, changes in the eating schedule, the patient’s medical condition, or the effects of medical therapy. Having the option of selecting menu items, eating with others, and positive communications from nurses and other health care team members can help improve patient intake.

11. When providing nutritional care for the terminally ill patient, dietary restrictions

a. should be maintained throughout the illness. b. are rarely appropriate and should not be used. c. should be followed to the best of the patient’s ability. d. should be focused on preventing disease progression.

ANS: B

When providing care for a terminally ill patient, the primary goals should be to provide comfort and quality of life. Dietary restrictions are usually implemented to prevent disease advancement; however, in the case of a terminally ill patient, using dietary restrictions will not necessarily promote quality of life. When providing nutrition care in these instances, it is more important to focus on aspects of nutritional care that can facilitate symptom and pain control.

12. Which of the following identifies a patient’s health care preferences in regard to

end-of-life issues? a. Discharge planning b. Disease management c. Case management d. Advance directives ANS: D

Advance directives are legal guidelines established by a patient that designate personal health care intervention preferences or identify a person to make decisions when the patient does not have the capacity to do so. Discharge planning is a team approach to preparing for the continuity of health care after the patient leaves the hospital. Disease management is a disease-specific approach to preventing the progression of a disease while providing care in the outpatient setting. Case management encompasses discharge planning and disease management in regard to the achievement of patient health goals.

13. What is another name for the practice guidelines that define the appropriate and consistent

care for a patient with a specific diagnosis or medical problem? a. Standards of care b. Critical pathway c. Evidence-based practice d. Discharge planning ANS: A

Standards of care are the basis for providing consistent quality of care to patients within a particular health care institution. They act as the overall guide to the care. A critical

pathway more specifically pinpoints when particular activities of care will occur during the patient’s time in the health care facility. Evidence-based practice refers to providing care based on the best, most successful practices in health care that have been demonstrated through research, consensus, or other evidence. Discharge planning prepares for taking care of the patient when the patient leaves the health care facility.

14. The Joint Commission requires the identification of nutrition risk of hospital patients to

occur within a. 12 hours of admission. b. 24 hours of admission. c. 48 hours of admission. d. 24 hours of admission, except on the weekend.

ANS: B

Although The Joint Commission does not specify how patients should be identified for nutrition risk, all patients need to be screened for nutrition risk within 24 hours of admission, regardless of whether the patient is admitted during the week or on the weekend. Many hospitals accommodate this by including questions regarding nutrition risk in the initial nursing assessment performed on the patient. If the patient meets the hospital’s nutrition risk criteria, this is communicated to the clinical nutrition staff so that further nutrition assessment can be performed.

15. During which step of the nutrition care process should patient-centered goals and

objectives be identified? a. Nutrition assessment b. Nutrition diagnosis c. Nutrition intervention d. Nutrition monitoring and evaluation ANS: C

Patient-centered goals and objectives identify the desired outcomes of nutrition care, and these are established in the nutrition intervention step after the nutrition problems are identified. During nutrition assessment, data are collected and analyzed so as to identify the nutrition problems in the nutrition diagnosis step. Nutrition monitoring and evaluation watches for the progress and achievement toward the goals and objectives.

16. Which of the following statements is true regarding The Joint Commission? a. The Joint Commission specifies how nutrition care standards are to be done to

achieve compliance.

b. The Joint Commission requires a nutrition assessment be completed within 24

hours of admission. c. The Joint Commission specifies that a qualified dietitian must be involved in

establishing a hospital’s nutrition care process. d. The three sections of the “Accreditation Manual for Hospital” are patient-focused

functions, staff-focused functions, and structures with functions.

ANS: C

The Joint Commission requires that a qualified dietitian must be involved in establishing the nutrition care process but does not specify who should accomplish the process. The Joint Commission provides standards for compliance but does not tell institutions specifics on how to meet the standards. Nutrition screening must be completed within 24 hours. The sections of the “Accreditation Manual for Hospital” include patient-focused functions, organization-focused functions, and structures with functions.

17. Which of the following is not one of the benefits of electronic health records? a. Easier accessibility for health care team members b. Improved legibility of documentation c. Easier to change and update forms used for documentation d. Increased efficiency in documentation and providing care ANS: C

Customized screens and drop-down menus are easier to incorporate before the EHR is implemented for use in a health care system than later as changes require access to the programming. Many forms included have extraneous options for selection in documentation so as to limit the need for revisions. With an EHR, the patient’s records are available throughout most of the health care system’s computer access sites, thus eliminating the need for waiting for other health care providers to finish using the record.

Because all documentation is typed, records are easier to read.

18. “Inadequate energy intake” is an example of a nutrition a. etiology. b. diagnosis. c. symptom. d. intervention.

ANS: B

PES statement refers to “problem” or diagnosis, “etiology,” and “signs or symptoms.”

Inadequate energy intake is an example of a nutrition problem or diagnosis.

19. Which type of diet would most likely be reflected by a modification of the regular hospital

diet by rearrangement of the number or frequency of meals? a. High-fiber diet b. Sodium-restricted diet c. Allergy diet d. Diabetic diet ANS: D

A diet for diabetes may modify the regular hospital diet by rearranging the number or frequency of meals so as to promote blood glucose control in relation to patient activity and medication provision. A high-fiber diet is a diet modified in consistency for increased fiber. A sodium-restricted diet is a diet modified by a decrease in sodium. An allergy diet is a diet that calls for the elimination of specific foods or food substances.

Chapter 10: Food-Nutrient Delivery: Planning the Diet With Cultural Competency Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Which of the following is not part of the Daily Reference Intake (DRI)? a. Adequate Intake (AI) b. Estimated Average Requirement (EAR) c. Healthy Eating Index (HEI) d. Recommended Dietary Allowance (RDA) ANS: C

The DRI Model includes four reference points—AI, EAR, RDA, and Upper Intake Level (UL). The HEI measures how well people’s diets conform to recommended healthy eating patterns.

2. Daily Values (DVs) shown on the nutrition facts label are a. recommended intakes for specific nutrients. b. reference points based on a 2000-calorie diet. c. the same as DRIs. d. listed as grams or milligrams.

ANS: B

For most nutrients, the nutrition fact label shows the percentage of the DV. DVs are not recommended intakes for individuals; they are reference points. DVs are listed as percentages, not in milligrams or grams.

3. A food constituent that is not defined as a nutrient but has a biologic effect that may

influence health is a a. sustainable food. b. organic food. c. cariogenic food. d. functional food.

ANS: D

Functional food constituents have a biologic effect and may influence health and susceptibility to disease. Sustainable food and organic food are agricultural terms. A cariogenic food is one that promotes tooth decay.

4. MyPlate was developed by a. USDA and Department of Health and Human Services (DHHS). b. the National Cancer Institute. c. the Food and Drug Administration. d. the Ministry of Health.

ANS: A

The MyPlate offers a method for determining appropriate patterns for daily food choices and was developed by the USDA and DHHS. The Ministry of Health publishes Canada’s food guide.

5. “Low-fat” on a food label means that food a. contains 25% less fat than a reference product. b. contains less than or equal to 3 g of fat per serving. c. contains one-third fewer fat calories than a reference product. d. is naturally low in fat.

ANS: B

Nutrient content terms such as low-fat must now meet government definitions that apply to all foods. To qualify as low-fat, it must be 3 g or less per serving. When a product contains 25% less fat than a reference product, it can be labeled as “reduced fat.”

6. Dietary Guidelines for Americans are revised a. every 2 years. b. every 10 years. c. every 5 years. d. as needed.

ANS: C

The U.S. Dietary Guidelines were first published in 1980 and are revised every 5 years.

The most recent guidelines were released in 2015.

7. Nutrient intakes are most likely to be low in a. populations living in the South. b. preschool children. c. those older than 65 years. d. those living below the poverty line.

ANS: D

Nutrient intakes are most likely to be low in persons living below the poverty level.

Intakes of nutrients reported to be low in the general population are even lower in the poverty group.

8. There is an RDI for all of the following nutrients except a. fiber. b. biotin. c. iron. d. selenium.

ANS: A

The RDI for biotin is 0.3 mg, for iron is 18 mg, and for selenium is 70 mcg. There is no RDI for fiber.

9. A lactoovovegetarian a. eats only eggs and vegetables. b. eats dairy products and eggs but no other animal products. c. does not eat any food of animal origin. d. is a vegetarian who occasionally eats poultry.

ANS: B

Vegetarians eliminate meat and poultry, but may eat fish. A vegan eats nothing of animal origin. A lactoovovegetarian eats nonanimal products and eggs and dairy.

10. An example of an approved health claim is a. acai berries help prevent cancer. b. grapefruit can assist in weight loss because it helps burn calories. c. diets low in sodium may reduce the risk of high blood pressure. d. eating fish meals twice a week can improve immunocompetence.

ANS: C

A health claim is allowed only on appropriate food products that meet specified standards.

The government requires that healthy claims be worded in ways that are not misleading. A claim cannot imply that the food product itself helps prevent disease. Grapefruit helping burn calories is misleading as is the statement that eating fish can improve immunity.

Health benefits of fish are specific to levels of omega-3 fat contained in the fish.

11. Pork is prohibited in which of the following religions? a. Jewish, Muslim, and Seventh Day Adventist b. Catholic, Muslim, and Buddhist c. Mormon, Jewish, and Muslim

d. Mormon, Hindu, and Seventh Day Adventist ANS: A

Pork is prohibited in the Jewish, Muslim, and Seventh Day Adventist religions. It is avoided by most in the Buddhist and the Hindu religions.

12. Tolerable upper intakes (UIs) of nutrients were established to a. define nutrient intakes that may promote health. b. reduce the risk of adverse toxic effects. c. define the level of nutrient that will meet the requirements of 97% to 98% of the

healthy population. d. provide data on estimated safe and adequate daily dietary intakes.

ANS: B

ULs were established for many nutrients to reduce the risk of adverse or toxic effects from consumption of nutrients in concentrated forms. RDAs are aimed at 97% to 98% of the healthy population’s nutrient requirements. Estimated safe and adequate daily dietary intakes were established for nutrients known to be essential for life, but recommended intakes cannot be established because of insufficient data.

13. DRIs have

age groupings.

a. 10 b. 5 c. 8 d. 16 ANS: A

Because nutrient needs are highly individualized depending on age, sexual development, and reproductive status of females, the DRI framework has 10 age groupings, including age-group categories for children, men, and women 51 to 70 years and those older than 70 years of age. It separates three age-group categories each for pregnancy and lactation; the groups are younger than 18 years, 19 to 30 years of age, and 31 to 50 years of age.

14. The Healthy Food in Health Care Pledge a. encourages vendors to supply foods without harmful chemicals and antibiotics. b. encourages hospital food service to minimize food waste and support the use of

food packaging that is ecologically protective. c. promotes locally sourced foods when possible. d. All of the above.

ANS: D

The Healthy Food in Health Care Pledge was started by the Health Care Without Harm organization to encourage health care food service departments to change their practices. It includes eight areas of commitment. It encourages local sourcing of food, using products without harmful chemicals, and preventing food waste whenever possible. Other areas of focus include sustainable foods, patient education, and community engagement.

15. Which of the following would not be required to have a nutrition label? a. Canned corn b. Hot dogs c. Fresh ground turkey d. American cheese ANS: C

The Nutrition Labeling and Education Act excludes foods prepared on site such as bakery and deli items and raw foods such as meat and produce.

16. Serving size on nutrition labels is determined by a. the government, which sets individual standards. b. the manufacturer of the product. c. the types of stores that sell the product. d. the package size of the product.

ANS: A

Serving sizes of products are set by the government based on reference amounts commonly consumed.

17. Overcoming restricted health literacy can be accomplished by a. providing nutrition counseling using visuals and images. b. using simpler words and avoiding medical jargon. c. sticking to three key points. d. All of the above.

ANS: D

Communication with clients who have poor literacy skills requires using materials with visuals to avoid materials with lots of words. Keep words and explanations simple and avoid the use of medical jargon. Focus on no more than three key concepts per session to avoid overloading the client with information.

Chapter 11: Food and Nutrient Delivery: Complementary and Integrative Medicine and Dietary Supplements Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE

1. Which type of holistic therapy is based on the belief that you treat like with like? a. Homeopathy b. Naturopathy c. Ease Asian Medicine d. Chiropractic ANS: A

Homeopathy helps the body heal itself through the law of similars in which remedies to symptoms are diluted substances that cause the symptoms. Naturopathy focuses on nature as the provider of healing and uses multiple modalities including botanical medicine, treatment with plant-based preparations, as an aspect of treatment. Chiropractors use physical manipulations to help correct imbalances in the musculoskeletal system. East Asian Medicine focuses on establishing balance in regard to life-force energy.

2. Which type of holistic therapy is based on the belief that Qi is the balancing force of the

body? a. Homeopathy b. Naturopathy c. East Asian Medicine d. Phytotherapy ANS: C

Qi or chi refers to the life force or energy that is the center of the body functions. Health and wellness are assumed when chi is balanced and in harmonious flow with the body.

Illness occurs when there are disturbances in this flow.

3. What is the term that refers to the dislocation of part of the body, which is thought to

interfere with normal nerve function? a. Moxibustion b. Subluxation c. Meridian

d. Pharmacognosy ANS: B

Subluxations are musculoskeletal problems that chiropractors focus on manipulating to promote healing and wellness. Moxibustion is the use of heat in the attempt to restore chi.

Meridians are the channels that carry the chi in traditional Oriental medicine.

Pharmacognosy is the science of natural substances and is one of the areas included in naturopathy.

4. What is the name of the process in which a homeopathic remedy is shaken more than 100

times? a. Moxibustion b. Succussion c. Pharmacognosy d. Potentization ANS: B

Succussion is the shaking of a diluted remedy that leads to the potentization or increased power of a remedy. Moxibustion applies heat to points along the meridia of the chi to help bring it back into balance. Pharmacognosy refers to training in botanical medicine.

5. Which botanical formulations involve water-based extraction and brewing? a. Extracts b. Infusions c. Tablets d. Tinctures ANS: B

More concentrated than teas, infusions steep fresh or dried herbs in water for about 15 minutes. Extracts involve dissolving the active ingredients in herbs in an organic solvent.

A tincture is a type of extract in which the herbs are placed in alcohol to draw out the active components. Tablets are a pill form of taking herbs.

6. According to the National Center for Complementary and Integrative Health (NCCIH), art

and music therapy are classified as a. manipulative therapies. b. energy therapies. c. alternative medical systems. d. mind-body therapies.

ANS: D

Art and music therapy, along with meditation and prayer, are classified as mind-body therapies by the NCCIH. Manipulative therapies include massage, yoga, and chiropractic medicine. Energy therapies include Quigong, magnetic therapy and Reiki. Alternative medical systems include East Asian medicine, ayurveda, and homeopathy.

7. Which type of CIM is most frequently used in the United States? a. Yoga b. Special diets c. Chiropractic manipulation d. Nonvitamin, nonmineral dietary supplements ANS: D

According to the Centers for Disease Control (CDC), nonvitamin, nonmineral dietary supplements are the most commonly used modality of CIM in US. Chiropractic care is the second, Yoga is third, massage is fourth, meditation is fifth and special diets are sixth.

8. Which of the following is not one of the reasons that there has been an increased usage of

CIM in the United States? a. CIM is often not as expensive as conventional medicine. b. CIM is used when conventional medicine has little to offer in effective treatment. c. CIM is used when conventional medicine has significant risks and side effects. d. CIM has a history of efficacy in treatment of some conditions.

ANS: A

Unlike conventional medicine, most CIM is not generally covered by health insurance.

The cost of this care must be borne by the patient, and it is not necessarily cheaper than conventional care. CIM will be an option for people who believe that chronic conditions cannot be treated effectively by conventional medicine. Conventional medicine’s treatment of back pain or neck pain may focus on surgical interventions that patients will see as having significant risk involved. CIM has been shown to be effective in the treatment of pain and arthritis among other conditions.

9. If you suspect a dietary supplement has caused a serious adverse effect, where would this

be reported? a. The Medwatch program b. The FDA c. The FTC

d. The Office of Dietary Supplements ANS: A

Medwatch is a program under the FDA that tracks adverse effects from dietary supplements. The FDA regulates many aspects of the food, drug and dietary supplement industries so it is important to direct reports to the correct program within the FDA. The Federal Trade Commission oversees truth in advertising for consumer products including dietary supplements and the Office of Dietary Supplements will report on trends of adverse effects and warnings but does not register reports from dietary supplement manufacturers, retailers or consumers.

10. According to the FDA, which of the following descriptions applies to a dietary

supplement? a. Ingested to affect structure or function of the body b. Consumed for its taste, aroma, or nutritive value c. Used to diagnose, cure, mitigate, treat, or prevent disease d. Applied to the body for cleansing, beautifying, or altering appearance ANS: A

A dietary supplement will be taken to either affect structure or function of the body or to supplement the diet. Food is consumed for its taste, aroma, or nutritive value. Only drugs are classified as being able to diagnose, cure, mitigate, treat, or prevent disease. Cosmetics are applied to the body for cleansing, beautifying, or altering appearance.

11. The most commonly used dietary supplement in the United States is a

supplement.

a. calcium b. vitamin C c. vitamin E d. general multivitamin-mineral supplement ANS: D

General multivitamin-mineral supplements are used by 36% of women and 31% of men in the United States. Vitamin E and vitamin C supplements are each used by about 12% of the population, and calcium supplements are used by about 10% of the population.

Calcium-based antacids are used by almost 25% of the population.

12. Which of the following types of claims was first established under DSHEA? a. Authoritative statements

b. Health claims c. Nutrition claims d. Structure-function claims ANS: D

Structure-function claims were developed under DSHEA to provide for label statements that address physiologic effects of product content in supplements. This was a compromise with the supplement industry so that the supplement producers did not have to provide documented evidence to support health claims. The problem with these claims is that consumers cannot distinguish between these and health claims. Authoritative statements were established under the FDA Modernization Act of 1997 to allow for health claims based on published statements from authoritative organizations. Both health and nutrition claims were established under the Nutrition Labeling and Education Act of 1990.

13. Which of the following assures that a dietary supplement is a quality product that contains

what the label states? a. CDR b. DSHEA c. FDA d. GMP ANS: D

Good Manufacturing Practices are a joint endeavor between the government and industry to develop high quality manufacturing guidelines for all dietary supplements. The Cochrane Database Review only reviews studies in regard to the efficacy of use of supplements. The Dietary Supplement Health and Education Act of 1994 did not establish standards or guidelines in regard to supplement production, nor did it give the FDA authority to ensure the quality and efficacy of dietary supplements.

14. During a nutrition assessment, a patient indicates that they use a particular dietary

supplement. At a minimum, what aspects of the supplement should be researched and reviewed before making a recommendation for continued use? a. The supplement’s efficacy, its application to the cited health problem, and its

safety b. The manufacturers website for the supplement, its safety, and integrative

treatments for the health problem c. The Cochrane Database evaluation of the supplement, the administration

instructions, and the potential side effects d. The form of the supplement, its application to the cited health problem, and its

mechanism of action ANS: A

To effectively work with patients using supplements, the practitioner needs to maintain access to a variety of current resources identifying the efficacy of various supplements, their application to particular health problems, and safety issues in regard to the supplement. Sometimes adequate information is available from the manufacturer, but this may not be possible. Also, the Cochrane Database Review may not always be the most up-to-date resource in regard to investigating the efficacy of a supplement. Patients using supplements take them for specified reasons. Counseling should address whether the supplement can provide the health benefit being sought.

15. Which program has developed fact sheets about dietary supplements that can be used by

health professionals to educate clients? a. NCCIH b. ODS c. FDA d. FTC ANS: B

The Office of Dietary Supplements has prepared information available to assist in educating consumers about various dietary supplements. The National Center for Complementary and Integrative Health promotes research on integrative medicine. The Food and Drug Administration has published tips for supplement users in regard to making informed decisions when selecting supplements. The Federal Trade commission is responsible for truth in advertising for dietary supplements.

16. Decoction is made by a. steeping fresh or dried herbs in hot water for a few minutes. b. extracting active components of an herb in glycerol. c. enclosing herbal material in a hard shell made from plant-derived cellulose. d. boiling plant components for 30 to 60 minutes.

ANS: D

A decoction is the most concentrated type of water-based beverage, involving boiling the plant parts to extract the most active ingredients. A tea is a beverage made by steeping for

a few minutes. Glycerite is an extraction that uses glycerol instead of alcohol to extract active components from an herb. Capsules use either an animal-derived gelatin shell or one made from cellulose.

17. Which of the following trends regarding use of dietary supplements is true? a. Supplements are used more frequently by younger as opposed to older adults. b. Supplements are used more frequently by black people vs white people. c. Supplements are used more frequently by people who read food labels. d. Supplements are used more frequently by people with BMIs above 25 kg/m2.

ANS: C

Dietary supplement use is more frequent among people of better health, including those with BMIs below 25 kg/m2, nonsmokers, those who are physically active, and those who use food labels in making healthy eating decisions. Dietary supplement use increases with advancing age, white race, and women.

18. Which CIM would be considered a manipulative therapy? a. Homeopathy b. Yoga c. Cognitive behavior therapy d. Magnetic therapy ANS: B

Yoga is considered to be a manipulative therapy because it involves manipulation of the body. Homeopathy is classified by NCIH as an integrative medical system. Cognitive behavior therapy is a type of mind-body therapy. Magnetic therapy is a type of medicine that is based on energy therapy.

19. All of the following are populations that could benefit from dietary supplement use except: a. Older adults b. Those living in poverty c. Adolescent males d. Smokers ANS: C

Although every person needs to be evaluated individually for their risk for nutrient deficiency, adolescent males are not on the list of the most at risk populations according to the Academy of Nutrition and dietetics. Adolescent females, older adults. Those living in poverty and smokers are all considered to be at risk.

20. All of the following are the mechanisms of excipients in dietary supplements except: a. Provide bulk in supplements b. Help mask unpleasant flavors c. Improve flow in machinery d. Increase nutrient density ANS: D

While some excipients may have nutritional value, most are added to dietary supplements to improve the flow through machinery in production, mask unpleasant flavors, and provide mass and bulk to fill a tablet or capsule.

Chapter 12: Food and Nutrient Delivery: Nutrition Support Methods Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. The patient most likely to experience refeeding syndrome is a patient who has a. enteral feeding initiated after 7 days NPO. b. parenteral feeding initiated after 7 days NPO. c. enteral feeding after 24 hours NPO. d. parenteral feeding after 24 hours NPO. ANS: B

Although all patients who have received no nutrition for an extended period of time are at risk of developing refeeding syndrome, those who have been replenished by parenteral nutrition are at particular risk because of the direct infusion of carbohydrate, electrolytes, and fluids into the blood system. Digestion and absorption mediate the development of refeeding syndrome. With parenteral nutrition, electrolyte and fluid balances should be monitored to prevent potential imbalances and complications.

2. After assessment of a patient has determined that oral intake is inadequate, what is the next

determination to be made? a. Is the GI tract functional? b. What type of tube should be placed? c. What type of formula should be used? d. What amount and composition of CPN are appropriate?

ANS: A

The choice for use of enteral versus parenteral nutrition should be made based on whether the GI tract is functioning and capable of supporting the use of enteral nutrition. If the GI tract works, the preference is to meet the patient’s nutritional needs through enteral nutrition. Tube type, formula type, and CPN composition are all decisions that need to be made later.

3. Which condition would most likely require parenteral nutrition as the medical nutrition

therapy? a. Severe acute pancreatitis b. HIV/AIDS

c. Failure to thrive d. Oral or esophageal trauma ANS: A

Severe acute pancreatitis may result in inadequate digestive and absorptive capacity in the gastrointestinal tract. In this situation, providing enteral feeding may not be able to provide adequate nutrition. Pancreatitis may be associated with severe abdominal pain associated with feeding or with ileus. Enteral nutrition can be provided to patients with HIV/AIDS, patients who have failure to thrive, and patients with oral or esophageal trauma because the gastrointestinal tract is still accessible in these conditions.

4. What type of enteric tube enters the body at the nose and terminates at the stomach? a. Nasogastric

b. Nasojejunal c. Percutaneous endoscopic gastrostomy d. Percutaneous endoscopic jejunostomy ANS: A

A nasogastric tube is inserted through the nares and runs down the throat and esophagus to end in the stomach. A nasojejunal tube is inserted in the same manner, but its terminus is in the jejunum. A percutaneous endoscopic gastrostomy (PEG) tube is placed through the abdominal wall, so it feeds directly into the stomach. A percutaneous endoscopic jejunostomy is similar to a PEG except that it feeds into the jejunum.

5. The following is not a potential complication of nasoenteric feeding tubes. a. Thrombophlebitis b. Sinusitis c. Vocal cord paralysis d. Pulmonary injury ANS: A

Thrombophlebitis is a complication of peripheral PN. Sinusitis, vocal cord paralysis, and pulmonary injury can all be complications of nasoenteric feeding tubes.

6. The calorie concentration provided by most general-purpose formulas is

kcal/ml.

a. 0.5 b. 1 to 1.2 c. 1.5 d. 2 ANS: B

Most standard enteral formulas for use with the general patient population provide 1 to 1.2 kcal/ml. When a fluid restriction is required, formulas that are concentrated to 1.5 to 2 kcal/ml are appropriate.

7. For a fluid-restricted patient, an appropriate formula to select for use would be

kcal/ml. a. 0.8 b. 1 c. 1.2 d. 1.5

ANS: D

Patients with cardiopulmonary, renal, or hepatic failure may require fluid restriction. Most standard formulas of 1 to 1.2 kcal/ml concentration contain about 85% water. A concentrated formula with 1.5 to 2 kcal/ml is about 70% water. All patients on enteral nutrition support require water flushes to maintain the integrity of the feeding tube and to ensure adequate fluid.

8. The most important technique for prevention of aspiration in an enterally fed patient is a. to position the patient with head and shoulders above the chest. b. to use a calorically dense enteral formula. c. to use a large bore feeding tube. d. to administer feedings at a slow rate.

ANS: A

The role of enteral feeding in the development of aspiration is controversial. Many experts believe that the primary source of aspiration into the airway is saliva and throat contents, not formula. Aspiration can usually be prevented by positioning the patient with the head and shoulders above the chest whenever feeding occurs.

9. Which one of these routes of parenteral access is considered long term? a. Peripheral intravenous catheter b. Peripherally inserted central catheter c. Single-lumen catheter inserted into the subclavian vein d. Catheter inserted into the external jugular vein ANS: B

Peripherally inserted central catheter (PICC) lines are inserted into a vein in the antecubital area of the arm and threaded into the subclavian vein, allowing greater mobility for the patient and decreased infection risk. Tunneled versions of single- or multiple-lumen catheters into the subclavian or the external jugular vein are also types of long-term access.

Peripheral IV catheters and single-lumen, nontunneled catheters placed in the subclavian or internal or external jugular veins are also short-term catheters.

10. The osmolarity of a 1-L bottle of 5% dextrose solution is

mOsm/L.

a. 50 b. 500 c. 200 d. 250 ANS: D

The grams of dextrose in 1 L or 1000 ml of 5% dextrose are equal to 1000 ml  5% = 50 g.

For the osmolarity of a dextrose solution, multiply the grams of dextrose per liter by 5 (50 g  5 = 250 mOsm/L).

11. Which trace element needs to be initially given at higher levels when there is a risk of

refeeding syndrome? a. Zinc b. Copper c. Chromium d. Phosphorus ANS: D

When refeeding syndrome occurs, serum levels of phosphorus, potassium, and magnesium fall below normal levels, resulting in the electrolyte imbalances associated with refeeding syndrome. As a patient’s stores of these nutrients may be depressed after extended time without eating, infusion of glucose contributes to further decreasing blood levels of these minerals as they are shifted into cells with glucose. Potential cardiac and pulmonary complications can be avoided by supplementing the patient with phosphorus, potassium, and magnesium and by limiting the initial amounts of glucose administered when feeding resumes.

12. In general, a patient’s parenteral feeding can be discontinued when enteral nutrition meets

of the patient’s need. a. 25%

b. 50% c. 75% d. 100% ANS: C

When a patient is meeting 75% of nutrition needs through either enteral or oral nutrition, the parenteral nutrition may be discontinued. This process may take up to 2 to 3 days as the patient is weaned from parenteral nutrition. Parenteral nutrition administration is not stopped all at once because this could contribute to fluid and electrolyte imbalances or rebound hypoglycemia.

13. The functions of the

system are better maintained with enteral feedings than with

parenteral feedings. a. cardiovascular b. renal c. gastrointestinal d. pulmonary ANS: C

Enteral nutrition stimulates the gastrointestinal system and its immunity to maintain the integrity of the mucosal lining. Indirect evidence has suggested that enteral nutrition preserves mucosal integrity during critical illness in humans.

14. For the patient with delayed gastric emptying, nausea and vomiting, or other indications of

risk of aspiration, the feeding tube should be placed through the a. mouth into the stomach. b. nose into the stomach. c. mouth into the duodenum or jejunum. d. nose into the duodenum or jejunum.

ANS: D

Nasoduodenal or nasojejunal tubes bypass the stomach, thus reducing the likelihood of instigating nausea or vomiting, not relying on the stomach’s motility, and because they are post-pyloric, reducing the risk of aspiration as formula would have to go past two sphincters to work its way back to the trachea. Tubes placed through the mouth are not commonly used because they can interfere with a patient’s ability to talk.

15. Feeding tube diameter is measured in a. French size.

b. millimeters. c. inches. d. centimeters.

ANS: A

Feeding tube outer diameter is measured in French size. 1 French unit is equal to 0.33 mm.

16. A common complication of enteral tube feeding is a. hyponatremia. b. refeeding syndrome. c. diarrhea. d. hypoalbuminemia.

ANS: C

Although diarrhea is the most commonly reported complication associated with enteral feeding, often the enteral nutrition is not the cause. More likely reasons for the diarrhea to occur include bacterial overgrowth, antibiotic use, gastrointestinal motility disorders, and administration of hyperosmolar medications and electrolyte supplements. Adjusting the medications and their administration can correct the diarrhea. Prebiotics and probiotics, pectin, bulking agents, and antidiarrheal medications are used to treat the diarrhea.

17. A patient is receiving an intravenous solution that provides 120 g of dextrose

monohydrate. How many calories does this provide the patient? a. 132 kcal b. 240 kcal c. 408 kcal d. 480 kcal ANS: C

As dextrose monohydrate is a molecule of glucose and water, it has a lower calorie concentration than other carbohydrates (3.4 kcal/g vs. 4 kcal/g). 120 g  3.4 kcal/g = 408 kcal.

18. The maximum osmolality of parenteral solution that the cephalic or brachial vein may

tolerate for infusion is

mOsm/kg.

a. 300 to 500 b. 500 to 800 c. 800 to 900 d. 900 to 1200 ANS: C

Because the cephalic and brachial veins are common sites used for peripheral parenteral nutrition, highly concentrated parenteral solutions with more than 800 to 900 mOsm/kg are not tolerated. The provision of fat is possible because it is isotonic, but protein and carbohydrate may have to be limited. Also, the addition of electrolytes, multivitamins, and trace elements increases osmolality, making it difficult to provide complete nutrition in a limited volume.

19. Possible advantages of using homemade tube feedings include the following: a. They are better reimbursed by insurance. b. They may help an immunocompromised patient.

c. They can be used with any French size feeding tube. d. They can create a bond with the caregiver.

ANS: D

Generally homemade (real food) tube feedings are chosen because they offer the benefit of whole foods and can create a bond with the caregivers who are often family members.

They can be less expensive if there is no reimbursement available for enteral formulas.

They should not be used in immunocompromised patients and must be used with a large bore feeding tube to prevent clogging.

20. In home care, what is the recommended administration method for enteral nutrition? a. Bolus feeding b. Gravity drip

c. Cyclic pump d. Continuous pump ANS: A

Because the provision of the enteral nutrition will generally be by the family or caregivers in the home, the best method for administering enteral nutrition is the easiest, bolus feeding. This method does not require special equipment, such as a hanging pole, or equipment that may require maintenance, such as pumps. The family can be trained to start with half of one can of formula infused four to six times a day and can work their way up to the patient’s total needs as tolerated.

Chapter 13: Education and Counseling: Behavioral Change Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. One of the five tenets of cultural competency is a. you must know a culture’s communication style to be an effective counselor. b. cultural competency eliminates racism. c. culture is defined as race, religion, and ethnicity. d. culture is mutable and multiple.

ANS: D

Knowing about a culture does not eliminate racism, and part of cultural competency is to avoid any stereotyping, including how a specific culture wants to communicate. Culture is mutable and multiple, and any understanding of particular cultural context is always incompletely true, always partial, and always somewhat out of date.

2. A client is aware that a dietary behavior problem exists but is not sure whether to do

something about it. What stage of change is this client in? a. Precontemplation b. Contemplation c. Preparation d. Relapse ANS: B

During contemplation, the client goes back and forth in considering the advantages and disadvantages of making a behavior change. In precontemplation, the client is not even aware that a problem may exist. During preparation, the client needs help in finding an acceptable change strategy to address the problem. In relapse, the client needs help to restart doing the actions that she had previously been doing to bring about the behavior change.

3. Which of the following is not a stage of change? a. Precontemplation b. Motivation c. Relapse d. Action

ANS: B

The transtheoretical model, or stages of change, includes the stages of precontemplation, contemplation, preparation, action, maintenance, and relapse. Motivation may be applied as a technique of interviewing to achieve a willingness to change in the client.

4. Which stage of change is characterized by the patient’s feelings of ambivalence? a. Precontemplation b. Contemplation c. Preparation d. Maintenance ANS: B

Ambivalence occurs when the patient has mixed feelings and is considering the “pros” and “cons” of behavior change. This is characteristic of the stage of contemplation. The precontemplation stage is characterized by the need for awareness of a problem existing.

Preparation involves the need to identify acceptable change strategies. Maintenance has the challenge of sustaining an accomplished change without occurrence of relapse.

5. Which of the following is not an activity that facilitates behavior change? a. Self-efficacy b. Empathy c. Reframing d. Discrepancy ANS: C

The six steps that are important when working with clients struggling with behavior change are expressing empathy, understanding cultural factors, developing discrepancy, avoiding arguments and defensiveness, rolling with resistance, and supporting self-efficacy. Reframing is a technique in which the counselor changes the client’s interpretation of data by offering a new perspective. This is used when a client is demonstrating resistance to change.

6. The most important thing to establish in the first counseling session is a. the counseling relationship. b. likes and dislikes in the counseling environment. c. fees for service. d. reimbursement potential by insurance providers.

ANS: A

The counseling relationship needs to be developed during the first counseling session. The environment and the way the counselor communicates, both physically and verbally, can help establish rapport and trust on the part of the client. Without this, the client may not feel the necessity to continue with counseling.

7. What does double-sided reflection involve doing? a. Monitoring a counseling session from behind a two-way mirror b. Using the client’s previously expressed ideas to show a discrepancy c. Asking questions multiple times d. Reframing ANS: B

Double-sided reflection is a technique used to overcome resistance behaviors. The intent behind this is to give the client the opportunity to think about and examine what is said so as to open the discussion more, allowing for the opportunity to facilitate change.

Reframing involves offering a different perspective to what the client has said, not necessarily comparing current statements with past statements by the client.

8. Resistance to change can be overcome by all the following techniques except a. affirming. b. double-sided reflection. c. agreeing with a twist. d. reflecting.

ANS: A

Techniques used for addressing resistance to change include reflecting, double-sided reflection, shifting focus, agreeing with a twist, emphasizing personal choice, and reframing. Affirming is a technique used when counseling clients not ready to change.

Affirmation involves acknowledgment that the counselor understands what the client is doing or thinking is normal.

9. When a counselor elicits self-motivational statements, this includes all of the following

except a. optimism. b. problem recognition. c. reframing. d. intention to change.

ANS: C

Reframing is a technique where the counselor makes a statement that provides a different perspective to the patient’s view. Self-motivational statements are created by the client when she recognizes that a problem or concern exists and that she can do something about it. Problem recognition, concern, intention to change, and optimism are types of questions that the counselor can ask that will result in the client developing self-motivational statements.

10. Which of the following is a client’s belief in his ability to carry out change? a. Self-efficacy b. Self-management c. Self-monitoring d. Self-reflection ANS: A

Self-efficacy is a goal of counseling as behavior change can only occur if the client believes that he is capable of changing. Self-management is a technique used by a counselor that involves the client’s decisions in facilitating change. Self-monitoring refers to any means by which a client records or tracks activity related to behavior change.

Self-reflection is when the client is given the opportunity to think about and express thoughts related to behavior change.

11. When counseling a client who speaks a different language, the most effective way to

communicate is to

a. use a family member or close friend who speaks the language and can translate. b. use a visual aid that has been developed using international symbols. c. find a counselor who speaks the same language and can do the counseling. d. use a professional interpreter.

ANS: D

Unofficial translators are not usually a good choice because of the lack of understanding of nutrition and health. Using professional interpreter is also not without limitations but is the best option.

12. Educating and counseling with cultural competency should acknowledge surface and deep

structure. Surface structure includes things like a. the client’s appearance.

b. language and food preferences. c. social beliefs. d. health diagnoses.

ANS: B

Surface structure includes things such as food preferences, traditions, and language. Deep structure includes psychologic and social beliefs and the context of the intervention.

13. What counseling activity is based on the idea that thoughts and beliefs that affect behavior

can be changed to promote behavior change? a. Cognitive behavioral therapy b. Transtheoretical model c. Reflective listening d. Shifting focus ANS: A

Cognitive behavioral therapy focuses on changing maladaptive thoughts and beliefs through cognitive restructuring. This technique is particularly effective in working with patients with body image issues. The transtheoretical model is not a counseling activity itself but rather a model for setting up counseling related to the stage a person is in regarding a needed behavioral change. Reflective listening is a technique used with patients who are not ready for change and involves the counselor communicating understanding of the patient’s feelings through a statement. Shifting focus is a means used for dealing with patient resistance that involves the counselor changing the focus of a patient from a perceived barrier to change to one more appropriate.

14. Which of the following techniques is appropriate for use with a patient ready to change

behavior? a. Elicit self-motivational statements. b. Negotiate change. c. Establish an action plan. d. Develop discrepancy.

ANS: C

During the ready-to-change session, the goal should be to work with the patient to set goals for change that include a plan of action. Eliciting self-motivational statements is used for the patient in the precontemplation stage to help create awareness of an existing problem in the patient. Negotiation for change occurs in the unsure-about-change session.

Developing discrepancy is an activity used by the counselor throughout the counseling

process that helps the patient identify the benefits and disadvantages of the behavior change.

15. Assessment of a patient’s stage of change should be completed a. when the patient is referred for counseling. b. at the beginning of the first counseling session. c. by the end of the first counseling session. d. before the second counseling session.

ANS: C

Because the first counseling session is used to establish rapport and the counseling relationship, as well as to obtain information to assess the patient’s current eating behaviors, assessment of the patient’s stage of change cannot occur before or early in the first session. Ideally, assessment of the stage of change occurs by the end of the first counseling session so that plans and goals in preparation for the next session can be shared with the patient.

16. Which technique is not useful in working with clients during a not-ready-to-change

counseling session? a. Asking open-ended questions b. Affirming c. Agreeing with a twist d. Summarizing ANS: C

When dealing with clients during the precontemplation stage, the goal is to facilitate their ability to consider change. For this to occur, strong communication skills are necessary.

These include asking open-ended questions, listening reflectively, providing affirmation, and summarizing the client’s statements. Agreeing with a twist is a means of dealing with resistant behavior by agreeing with the client and then redirecting the focus of the conversation.

17. During which type of counseling session is one of the goals to identify barriers to change? a. Not-ready-to-change session b. Unsure-about-change session c. Ready-to-change session d. First counseling session ANS: A

One of the goals of the not-ready-to-change session is to identify and reduce the client’s resistance and barriers to change. The unsure-about-change session may include a summary of perceived barriers to change. The ready-to-change session includes identification of barriers to adherence to change. The first counseling session is used to identify the stage of change of the client.

18. If a counseling session ends with the client not ready to change, which of the following

should the counselor do? a. Establish goals for the client.

b. Arrange for follow-up contact. c. Persuade the client to perform some change. d. Express disappointment with the client.

ANS: B

If a patient is not ready to change, the counselor should acknowledge the client’s positive accomplishments and offer the client the opportunity to resume counseling when the patient is ready. Setting goals for the client or expressing disappointment may promote feelings of failure and resentment on the part of the client. Attempting to push, persuade, coax, confront, or tell the client what to do takes the client out of the decision making and does not motivate the client to carry through with dictated actions.

Chapter 14: Nutrition in Pregnancy and Lactation Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Which of these statements is NOT true about colostrum? a. It is higher in fat than mature milk. b. It is higher in immunoglobulins than mature milk. c. It is higher in protein than mature milk. d. It is lower in lactose than mature milk.

ANS: A

Colostrum is the thick, yellow, milky fluid that is the first milk available after birth. It is higher in protein and lower in fat and carbohydrates than mature milk. It is also lower in lactose and higher in immunoglobulins than mature milk.

2. According to the National Academy of Sciences, women with normal preconception

weight should gain how much during a singleton pregnancy? a. 10 to 15 lb b. 20 to 25 lb c. 25 to 35 lb d. 35 to 45 lb ANS: C

Women with BMIs between 18.5 and 24.9 before conception are considered to be of normal weight and are advised to gain between 25 and 35 lb during the course of the pregnancy. Underweight women who start their pregnancies with a BMI under 18.5 are advised to gain 28 to 40 lb. Women with a prepregnancy BMI of 25 to 29.9 are advised to gain 15 to 25 lb. Women with a BMI greater than 30 are advised to limit weight gain to 11–20 lb. Women pregnant with multiples will need to gain more, but the amounts vary by the prepregnant weight and the number of fetuses.

3. Which of the following will result from the normal physiologic adaptation during

pregnancy? a. Decreased serum hemoglobin b. Proteinuria c. Hypoglycemia

d. Constipation ANS: A

As the blood volume expands by 50% during pregnancy, this results in a dilution of some blood constituents, such as serum hemoglobin, albumin, and other blood proteins. This also promotes an increase in glomerular filtration rate; however, the kidneys do not increase the volume of urine excretion. Marked proteinuria is cause for concern. Some glucosuria may normally occur because of decreased efficiency in renal tubule reabsorption during pregnancy but not to the level of promoting hypoglycemia.

Constipation is more likely to occur when inadequate water is taken in by the pregnant woman.

4. How can the risk of neural tube defects occurring in utero be reduced?

a. Increasing folic acid intake throughout the childbearing years b. Ensuring adequate niacin intake during the first 6 weeks of pregnancy c. Providing an adequate protein intake throughout the pregnancy d. Increasing vitamin C during the first trimester ANS: A

Folic acid supplementation has been shown to lower the risk of neural tube defects but serum folate levels must be optimal at the time of conception. For this reason, routine folic acid supplementation is recommended for women of childbearing age. Niacin needs during pregnancy coincide with the increased energy needs during pregnancy. Sufficient protein during pregnancy allows for the growth of tissues in both the mother and the fetus.

Vitamin C may be beneficial in reducing the chance of preterm labor.

5. What is the most appropriate recommendation to make when counseling a newly pregnant

patient about alcohol consumption? a. Avoid alcohol for the first trimester; then no more than 1 oz of alcohol per day. b. Avoid alcohol completely throughout the entire pregnancy. c. Limit consumption to 1 oz of alcohol per day. d. Limit consumption to 2 oz of alcohol per day.

ANS: B

The American College of Obstetricians and Gynecologists and the March of Dimes both recommend no alcohol through the entire pregnancy. Fetal alcohol syndrome results from fetal exposure to alcohol. This could be attributable to alcohol’s effects on cell differentiation, dietary deficiencies associated with alcohol use, and alterations in metabolism.

6. For managing leg cramps in pregnancy, which of the following minerals has the most

scientific support for its use? a. Manganese b. Potassium c. Calcium d. Magnesium ANS: C

Optimal calcium intake, as well as increased fluid intake, may reduce the prevalence of leg cramps. The literature is conflicting concerning the effectiveness of magnesium supplementation on preventing and treating leg cramps. Manganese and potassium have not been investigated in this regard.

7. How do the dietary recommendations for breastfeeding mothers differ from those for

pregnant women? a. Intake of all nutrients is the same as preconception intake for lactating women. b. The intake level during lactation should be severely restricted to promote weight

loss. c. Fluids are forced for pregnant women and limited during lactation. d. Intake of many nutrients is needed at higher levels during lactation.

ANS: D

Although nutrient needs are increased during both pregnancy and lactation above those of women before conception, lactation needs are often greater when women must produce breastmilk, the sole source of food for the infant. Women expend 85 kcal for every 100 ml of milk they produce, and the nutritional profile of the milk may reflect her diet to some extent. Therefore, for the assured health of the infant, breastfeeding mothers have to continue to maintain and replete their nutritional stores.

8. The recommended energy intake in the second and third trimesters is the sum of the

energy requirement for a nonpregnant woman and a daily addition of about the second and

kcal in

kcal in the third trimesters, respectively.

a. 130; 166 b. 257; 359 c. 340; 452 d. 407; 558 ANS: C

The DRIs for energy needs for pregnancy add 340 kcal/day during the second trimester and another 112 kcal/day during the third trimester. These increases are necessary for optimal growth of both the mother and fetus during the pregnancy but actual caloric needs can vary widely between individuals. Targeting appropriate weight gain yields more benefit than calculating individual caloric requirements.

9. What advice should be given to a pregnant woman about eating fish? a. They should eat only vegetable sources of omega-3 fat. b. There is no specific recommendations about fish. c. They should eat two or three servings of fish per week. d. They should eat two or three servings of low-mercury fish per week.

ANS: D

There are specific recommendations for DHA intake during pregnancy. The main food source is fatty, cold-water fish, but many of these sources have high levels of mercury. It is recommended that pregnant women eat two or three servings per week of low-mercury fish such as sardines and salmon. Vegetable sources of omega-3 fat are not as efficient sources as DHA. 10. A woman has a BMI indicating overweight before pregnancy. Which of the following

guidelines for weight gain during pregnancy is recommended? a. Weight gain is contraindicated during this pregnancy.

b. Guidelines for weight gain for overweight women are not currently established. c. Weight gain of 15–25 lb should be targeted. d. It is not necessary to control weight gain during pregnancy.

ANS: C

An overweight BMI is defined as 25 to 29.9. Women with BMIs in this range before pregnancy should target a weight gain of 15 to 25 lb. Overweight and obese women who are attempting to become pregnant should not promote any weight loss during the pregnancy.

11. According to the DRI, how much additional protein above that of a nonpregnant woman

should a pregnant woman consume during the second half of her pregnancy? a. 10 g

b. It depends on her current weight c. 25 g d. 71 g ANS: B

Additional protein intake is necessary for protein deposition in both the mother and the fetus. During the first half of pregnancy, the protein requirement is the same as that of a nonpregnant woman; however, during the second half, the requirement increases from 0.8 g/kg/d to 1.1 g/kg/d. For a woman at ideal prepregnant weight who gains appropriately, this results in an average requirement of 46 g/d for women in early pregnancy to 71 g for women in the second half of pregnancy. However, anyone who has a higher prepregnant weight and/or gains more than the recommended weight will need more than that.

12. What recommendation about sodium should be given for most pregnant women? a. Aggressive restriction is warranted. b. Sodium intake can be around 2300 mg/day. c. Sodium intake should not exceed 1000 mg/day. d. Sodium intake should not exceed 2000 mg/day.

ANS: B

Pregnancy does not place any additional demands in regard to sodium intake or restriction.

Excessive sodium restriction stresses the renin-angiotensin-aldosterone system. Although higher than the DRI, ACOG recommends the intake of sodium should not be less than 2300 mg/d for those without underlying conditions. Using iodized salt at home and limiting the intake of processed foods are both encouraged.

13. What should a pregnant woman do to relieve nausea and vomiting during the early months

of her pregnancy? a. Drink liquids with meals and have small, frequent feedings. b. Eat high-fat foods and include liquids with meals. c. Eat small, frequent meals low in fat. d. Eat three regular meals per day.

ANS: C

Eating small, frequent dry meals of either carbohydrate or protein seems to reduce nausea in pregnant women. Although taking liquids between meals has been historically advised, no research has validated the suggestion. Meals high in fat tend to stay in the stomach longer, more likely promoting nausea and vomiting. The best recommendation is to eat whatever does not promote nausea and avoid odors that trigger nausea in the individual.

14. What are signs and symptoms of preeclampsia? a. Hypertension, proteinuria, and edema b. Hypotension, hyperalbuminemia, and excessive urine output c. Abdominal cramping and weight loss d. Weight loss, edema, and hypertension ANS: A

Gestational hypertension is evident when a pregnant woman develops elevated blood pressure. Preeclampsia develops when hypertension progresses with protein spilling into the urine, often in conjunction with edema. However, new onset of thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms may also be diagnostic. Eclampsia is characterized by new onset of grand mal seizures. Weight loss is not common; however, impairment of uterine blood flow can result in reduced placental size and fetal intrauterine growth restriction.

15. For the first 6 months of lactation, what is the recommended energy intake? a. 200 kcal less than the amount for pregnant women b. 330 kcal more than the amount for nonpregnant women c. 550 kcal more than the amount for pregnant women d. The same as the amount for pregnant women in the third trimester ANS: B

During the first 6 months of lactation, breastfeeding women need 330 kcal more than nonpregnant women to promote adequate milk production. This is similar to the kilocalorie needs of a pregnant woman during her second trimester. Of course, the actual amount of energy needed will vary between women.

16. Which hormone promotes letdown? a. Colostrum b. Progesterone c. Oxytocin d. Prolactin ANS: C

Oxytocin stimulates the myoepithelial cells of the mammary gland to contract, causing milk to move toward the nipple for feeding. Progesterone promotes the development of the mammary glands during pregnancy. Prolactin promotes milk production. Colostrum is the first milk that a woman produces around term.

17. What nutrient does the American Academy of Pediatricians (AAP) recommend to be

supplemented from birth for breast-fed infants, although the DRI for the nutrient in lactating women is at the same level as that in nonpregnant women? a. Vitamin A b. Calcium c. Zinc

d. Vitamin D ANS: D

Because of reports of clinical rickets, the AAP recommends an additional 10 mcg (400 IU) of vitamin D daily for infants, starting at birth. The vitamin A status of the breastfeeding mother may affect the infant, but the DRIs have an increased value for vitamin A intake of lactating women. The DRIs for zinc are also increased for lactation. The calcium content of breastmilk is not related to the calcium intake of women, so the DRIs for calcium do not increase during lactation.

18. Milk production is most affected by a. calories consumed by the mother. b. mother’s hydration status.

c. frequent emptying of the breast. d. protein consumed by the mother.

ANS: C

Although the diet of the mother does affect the milk composition, the frequency of suckling has the biggest effect on milk production.

19. Which of the following is NOT a required condition for success of the Lactation

Amenorrhea Method of birth control? a. Mother is taking an estrogen supplement. b. Infant is less than 6 months old. c. Mother is amenorrheic. d. Mother is fully and exclusively breastfeeding.

ANS: A

The Lactation Amenorrhea Method of birth control does not involve any medication or device. It is 98% effective at 6 months postpartum when all three requirements are met: infant is less than 6 months old; mother is amenorrheic and is breastfeeding exclusively.

The infant is not given anything other than milk from the breast and suckling occurs only at the breast and not with a pacifier.

20. Which of the following is a contraindication to breastfeeding? a. Multiple births b. Postpartum depression c. Active untreated tuberculosis d. Reduction mammoplasty ANS: C

Contraindications for breastfeeding are rare. Breastfeeding is contraindicated for mothers with active untreated tuberculosis, as well as a few other infectious diseases, those who abuse drugs without medical supervision, and those on certain medications. Infants with classic galactosemia should also not receive breastmilk. In the U.S., breastfeeding is contraindicated for HIV-positive mothers, but it is recommended throughout the world for mothers on retroviral medication. Women who have had their breast reduced may still be able to breastfeed depending on the amount of tissue removed and the type of surgery performed. Breastfeeding multiple infants is challenging but possible with support. The release of hormones during breastfeeding provides a calming and relaxing feeling which may help reduce postpartum depression. Successful breastfeeding may also assist in less stress and a positive feeling of bonding with the infant.

Chapter 15: Nutrition in Infancy Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Which of the following describes the growth expectations for most infants? a. The birth weight is usually regained by the end of the first month. b. Infants triple their birth weight by 6 months of age. c. Infants double their birth weight by 4 to 6 months of age. d. Infants triple their length by 3 years of age.

ANS: C

Infants usually double their birth weight by 4 to 6 months of age and triple their weight by 1 year. Infants usually lose about 6% of their birth weight during the first few days postpartum, but this weight is usually regained by 7 to 10 days postpartum.

2. To meet the fluoride needs of a breast-fed infant, what should parents be instructed to do? a. Begin giving fluoride supplements immediately after birth. b. Supplement the mother’s diet with fluoride. c. Begin giving fluoridated water when the baby’s teeth erupt. d. When the infant starts eating solid foods, the foods will provide enough fluoride.

ANS: C

Because human milk has low fluoride content regardless of the mother’s fluoride intake, after 6 months of age, when an infant’s teeth begin to appear, the baby should start receiving fluoridated water on a daily basis. Fluoride supplementation is not recommended before 6 months of age, partially to prevent the likelihood of fluorosis. Fluoride provision through food depends on the water supply used in the preparation of the food. Because communities where fluoridation has not been instituted still exist, adequate fluoride provision through foods alone cannot be guaranteed.

3. Why should honey not be used in home-prepared formulas for infants? a. The added sweetener will cause the infant to crave sweets. b. The sugars present cannot be digested by the infant. c. The honey will settle out in the formula and cause a curdled appearance. d. The infant has no immunity to the botulism spore that may be present.

ANS: D

Honey may be a carrier of Clostridium botulinum spores, which can reproduce and make toxins that can cause death. The spores are resistant to heat treatment and are not destroyed by current processing methods. Infants are born with a preferential taste for sweets; therefore, providing sweet foods will not necessarily exert a craving for more. The simple carbohydrates in honey are digestible by infants. Only water, breastmilk, and rice cereal should be mixed with infant formula—nothing else.

4. Why are infants particularly susceptible to developing dehydration? a. Their mass-to-surface ratio is low. b. Their insulation is poor, resulting in increased water loss. c. Their renal concentrating ability is less than that of older children. d. The increased liquidity of their stools results in greater fluid loss.

ANS: C

Under normal conditions, breastmilk and formula provide infants with adequate water.

However, if formula is boiled, water evaporation can lead to concentration of formula solids. This places stress on the immature kidneys of the infant. This is also why providing commercially prepared adult foods to an infant could be problematic—the higher sodium concentration of these foods could exceed the infant’s renal solute load. Infants should be monitored when they live in hot, humid conditions and when they have episodes of diarrhea or vomiting. Watching for the number of wet diapers is one of the ways to do this.

5. When should the addition of iron to the diet of both formula-fed and breast-fed infants

begin? a. 6 weeks b. 4 to 6 months c. 6 to 9 months d. 1 year ANS: B

The iron stores in infants are adequate enough to provide for growth up to double their birth weight, which, in most cases, comes around 4 to 6 months. Although the iron in breastmilk is highly bioavailable, continuing to only breastfeed an infant past 4 to 6 months of age will lead to depletion of the infant’s iron stores by 6 to 9 months. To prevent this depletion, additional sources of iron are needed in the infant’s diet.

6. Which vitamin is not adequately provided by breastmilk? a. Vitamin C b. Niacin c. Vitamin D d. Vitamin A ANS: C

The breastmilk of an adequately fed, lactating woman provides sufficient amounts of all vitamins except vitamin D. AAP recommends that all infants less than 6 months old be kept out of direct sunlight. There is an increased risk of lower vitamin D levels in infants with dark skin, and those residing in northern latitudes and higher altitudes. Therefore, AAP recommends all infants receive supplemental vitamin D. 7. When should the introduction of pureed and strained foods to the infant’s diet begin? a. 2 months

b. 4 months c. 6 months d. 12 months ANS: C

Introduction of semisolid foods depends on both the infant’s developmental readiness and his or her nutrient needs. Around 6 months, mature sucking movement is refined and munching movements begin signaling the time to introduce strained or pureed foods.

However, to be able to feed an infant foods, other than formula, the infant needs to be able to demonstrate head and neck control, voluntary movements of the tongue, chewing movements, and the ability to sit unsupported.

8. What is the appropriate serving size for foods offered to a small child? a. 1 tsp for each year of age b. 1 Tbsp for each year of age c. 1/2 cup of each food served d. 1 cup total food per meal ANS: B

A general guide for serving infants and young children is 1 Tbsp of each food for each year of age. Foods should be served on plates appropriate to the child’s size. The child will indicate hunger if the served amount does not provide satiety. Larger portions and forced feeding may lead to either over- or underfeeding of the child.

9. For a breast-fed infant, which nutrient(s) should be the earliest to be supplemented? a. Fluoride and vitamin D b. Iron and magnesium c. Vitamin C d. Vitamin K ANS: D

Most states require that infants receive a vitamin K injection soon after birth to prevent hemorrhagic disease of the newborn. This is more common among breast-fed infants than formula-fed infants because the vitamin K content of breast milk is not adequate during the first week. Fluoride and iron supplementation is recommended after 6 months of age.

Vitamin D supplementation is recommended daily.

10. Compared with formula-fed infants, why do breast-fed infants experience a reduced

incidence of infections? a. Human milk is higher in fat. b. Human milk has anti-infective factors. c. Commercial infant formula is higher in iron. d. Commercial infant formula is higher in fat.

ANS: B

Human milk provides secretory immunoglobulin A, lactoferrin, and lysozymes, which all contribute to preventing infection in the infant’s gastrointestinal tract. The lactoferrin contributes to improved bioavailability of the iron in breastmilk and makes the iron unavailable to gut flora. Commercial formula has higher iron content because of its reduced bioavailability compared with breastmilk. Human milk is higher in fat content than formula, but the arachidonic acid and docosahexaenoic acid present are more

involved in the infant’s neurologic development.

11. Compared with later stages of the life cycle, which of the following describes the infant’s

protein requirement? a. It is lower on a per-kilogram basis than that of the older child. b. It is lower on a per-kilogram basis than that of an adult. c. It is higher on a per-kilogram basis than that of an adult. d. It is the same on a per-kilogram basis as that of an adult.

ANS: C

Infancy is a period of rapid growth, with the infant doubling in weight around 4 to 6 months. At no other time postpartum does a human gain in weight and size this quickly.

To allow for this growth, the protein needs on a weight basis are greater than those at any other point in the life cycle.

12. What is the recommendation for vitamin supplementation of infants fed commercially

prepared formula? a. It is rarely needed. b. Supplement only vitamins. c. Only water-soluble vitamins should be supplemented. d. Only fat-soluble vitamins should be supplemented.

ANS: A

Commercially prepared infant formulas are fortified with all necessary vitamins; therefore, infants being fed formulas rarely need supplementation. The Food and Drug Administration regulates the manufacture of infant formulas so that the nutrient levels provided are consistent with the Infant Formula Act. 13. What should the caregiver avoid feeding an infant to reduce the risk of choking? a. Cheese and pudding b. Grapes and hot dogs c. Graham crackers and cheese d. Pasta, such as macaroni ANS: B

Foods with skins or rinds, such as grapes and hot dogs, and foods that stick to the roof of the mouth, such as peanut butter, should not be offered to infants and young children.

Foods should be well cooked, mashed, or finely chopped to limit the hazard of choking.

14. What are the recommended guidelines regarding the use of low-fat and nonfat milk for

infants? a. These are appropriate for overweight infants during the first year. b. These are appropriate for any infant during the first year. c. These are inappropriate for infants during the first year. d. These are inappropriate for infants during the first 3 months of life.

ANS: C

All forms of cow’s milk are not recommended for provision to infants younger than the age of 1 year. Cow’s milk may cause gastrointestinal blood loss, may provide an excessive

renal solute load, and is an inadequate source of iron and linoleic acid.

15. Which feeding practice will avoid the development of tooth decay in infants? a. Give the infant a bottle with fruit juice at bedtime. b. Give the infant a bottle with milk at bedtime. c. Put the infant to bed without a bottle. d. Give the infant a bottle at bedtime only when he or she appears fussy.

ANS: C

Giving an infant a bottle at bedtime with either milk or fruit juice allows the teeth to be bathed in the simple carbohydrate that promotes dental caries development. To promote dental health, infants should be fed and burped and then put to bed without a bottle. Also, infants and young children should be limited to 4 fl oz of juice per day.

16. Why should whole cow’s milk not be given to infants younger than 1 year of age? a. It decreases the renal solute load. b. It can lead to obesity in toddlers. c. It lacks the anti-infective quality of formulas. d. It is associated with lower intakes of iron and linoleic acid.

ANS: D

Cow’s milk is a poor source of both iron and linoleic acid. Protein and other nutrients in cow’s milk increase the renal solute load, placing stress on the infant’s kidneys. Also, the protein in cow’s milk may cause gastrointestinal bleeding in the infant, promoting an increased need for iron. Use of whole milk for feeding young children has not been demonstrated to promote obesity.

17. What would be a behavior demonstrated by a 7- to 9-month-old to indicate that she is

sated and finished eating? a. She falls asleep. b. She pays more attention to her surroundings. c. She plays with or throws her utensils. d. She hands her cup or bottle to her mother.

ANS: C

By age 7 to 9 months, an infant has the developmental coordination to pick up and handle utensils through a refined pincer grasp. This allows her to be more active in participating in her feeding, as well as in signaling when she is done. Falling asleep when sated is common in infants up to 5 months of age. From 4 to 6 months, losing attentiveness toward the food and paying more attention to the surrounding environment are signals of being done eating. A 10- to 12-month-old infant will hand her mother her cup or bottle as a signal of being done.

18. When plotting an infant’s weight or length on a percentile growth chart, a curve is

produced that can be used to follow the infant’s growth. What is this curve called? a. Growth velocity b. Growth channel

c. Catch-up growth d. Lag-down growth ANS: B

As a growth pattern develops on a growth chart, the curve produced is known as the growth channel and is reported as a percentile based on the chart. Growth velocity is a measure of the rate of growth during a specified period of time and usually starts high in infancy and then decreases as the person gets older. Catch-up growth is when a smaller infant starts to reach his or her genetic growth potential by increasing growth rate during the first year of life, and lag-down growth is when a larger infant’s growth rate decreases to its genetic potential.

19. How many kilocalories are provided by 6 fl oz of breastmilk or standard infant formula?

a. 60 kcal b. 120 kcal c. 180 kcal d. 300 kcal ANS: B

Breastmilk and standard infant formula provide 20 kcal/fl oz (6  20 = 120 kcal).

20. For how long do both the American Academy of Pediatricians and the Academy of

Nutrition and Dietetics recommend exclusive breastfeeding of infants? a. For 3 months b. For 6 months c. For the first year d. Up until the age of 2 years ANS: B

Both the AAP and the AND recommend breastfeeding as the sole source of infant nutrition until the infant is 6 months old. Afterward, they both recommend that breastfeeding continue with complementary foods supplemented until the age of 1 year.

Chapter 16: Nutrition in Childhood Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Which of the following are appropriate general guidelines for measurements to assess the

growth of a child? a. Growth measurements should be made at 1, 4, and 10 years. b. After the child’s channel on the growth chart has been determined, it is not

necessary to reevaluate on a regular basis. c. Growth measurements of height, weight, and weight for height should be

determined at regular intervals. d. After the growth pattern is established, it will not change until adolescence.

ANS: C

Children change their eating and activity patterns, causing changes in growth. Because these changes are not always predictable, by checking growth measures at regular intervals, potential growth problems can be identified and treated early. Depending on the child’s eating and activity, a child for whom a growth channel had been established could stray from that channel.

2. Food insecure families in the United States a. contribute to poor outcomes in children. b. are associated with inadequate iron intake in children 3 years and under. c. are served by SNAP, WIC, and school lunch. d. All of the above.

ANS: D

In 2016 in the United States, 12.3% of households experienced food insecurity. Federal food assistance programs provided services to about 59% of them. Food insecurity is associated with poor outcomes in children. It increases the risk of iron deficiency anemia in children 3 years and under.

3. What is the American Academy of Pediatrics’ recommendation on the use of supplements

for children? a. Routine multiple vitamin and mineral supplements should be given. b. No routine supplementation is needed except fluoride in nonfluoridated areas.

c. Maximal doses of vitamins and minerals should be given because it is uncertain

that children will eat enough of the nutrients in food. d. Supplements should not be restricted because children are growing so rapidly that

overdosing is unlikely.

ANS: B

The American Academy of Pediatrics (AAP) supports the use of diet as the means for providing adequate intake of vitamins and minerals to healthy children. Fluoride is the only mineral advocated for supplementation in children without access to fluoridated water. However, some children may be at risk for inadequate nutrition, and for these exceptions, the AAP is supportive of supplementation. These include children from deprived families, children with anorexia or those following fad diets, children with chronic disease, and children following diets to treat obesity.

4. What may a child be at risk for if she drinks large amounts of apple or pear juice

throughout the day and limited amounts of water or milk? a. Diarrhea b. Hypervitaminosis A c. Overhydration d. Gallstones ANS: A

The high osmolality of apple and pear juices can contribute to carbohydrate malabsorption and diarrhea and therefore should not be used in situations in which fluid replacement is needed. Additionally, excessive fruit juice consumption has been associated with growth failure in children. The juice can replace other food sources of energy and protein, contributing to the child’s not feeling hungry but not providing the nutrients necessary for adequate growth. Juice intake is not associated with gallstone development.

5. Which of the following results from zinc deficiency in a child’s diet? a. Increased fat stores b. Short stature c. Chronic diarrhea d. Mental retardation ANS: B

Zinc is necessary for growth, and improving zinc intake has been beneficial in treating stunted growth and underweight in children. Children develop increased fat stores by taking in an excess of calories compared with energy needs. Chronic diarrhea may be associated with excess intake of fruit juices. Mental retardation may result from a number of nutrient deficiencies and from lead toxicity.

6. The recommendation for fiber in preschool and school age children a. is 5 g/day. b. is 14 g/kcal. c. is 14 g/day. d. is not part of the DRIs. ANS: B

Dietary Recommended Intakes (DRIs) for fiber in children are the same as those for adults—14 g/kcal. Surveys indicate that current intake in the United States is much lower than this recommendation.

7. Which children are at risk for having a zinc intake lower than the recommended level? a. Those who do not eat meat or seafood b. Those who do not receive zinc supplementation c. Those who do not eat a variety of fruits d. Those who do not like many vegetables ANS: A

Primary sources of zinc in the diet are foods of animal origin. Because of the costs of meat and seafood, children from families with low incomes are more at risk for developing zinc deficiency. Fruits and vegetables are not primary sources of zinc.

8. What is the most accurate means for determining the energy requirements (EER) of a

child? a. Based on growth rate b. Based on age and height c. Based on age d. Based on calories per kilogram ANS: D

Although the EER equations for children older than 3 years of age include age, weight, and height as factors, for children between 13 and 35 months of age, the EER equation only includes the weight factor. The growth rate is highly variable throughout childhood, so it should not be used as a base factor for determination of energy needs. Children vary in weight, height, and body size at any age, which is the basis for the development of growth charts. Because of this variation, age should not be used as the sole base factor for determining energy needs. Calorie needs can be determined on a per centimeter of height basis, but this is independent of the child’s age.

9. What is an appropriate food serving size for a 2-year-old child? a. 2 tsp b. 2 Tbsp c. 1/2 cup d. 1 cup ANS: B

The general recommendation for serving sizes for children is one tablespoon of food per year of age. This may be adjusted according to the child’s appetite. For a 1- to 3-year-old child, milk and juice may be served in 1/2-cup volumes or less. Cooked cereals may be 1/4 to 1/2 cup in volume, and dry cereal may be 1/4 to 1/2 cup in volume.

10. What does the American Academy of Pediatrics recommend in regard to calories from fat

in the diet of a young child? a. Limit fat calories to 30% of total caloric intake. b. Limit fat calories to 20% of total caloric intake. c. Fat calories should only be limited in extreme circumstances. d. Fat calories should be limited for every child older than 1 year of age.

ANS: A

The AAP recommends that children older than 2 years of age adopt a lower fat diet so that

no more than 30% of calories come from fat. This recommendation comes from the knowledge that obesity and cardiovascular disease development begins during childhood.

11. What reason would most likely explain why a 1-year-old child is experiencing iron

deficiency? a. Excessive fruit juice consumption b. Excessive milk consumption c. Child is feeding herself, particularly finger foods d. Child is eating table foods ANS: B

Milk anemia results from excessive intake of milk to the exclusion of other foods, and this could occur in a 1-year-old child because young children prefer milk to meat. Excessive fruit consumption is more associated with toddler ages, 2 to 3 years. At 1 year of age, a child will participate in feeding herself finger foods, but a caregiver should still assist in the feeding process. By 1 year of age, most children can eat the same foods as adults, and a well-selected diet can provide adequate iron.

12. Which factor has not been associated with failure to thrive? a. Food restriction caused by parental concerns about obesity b. Inadequate fiber intake c. Excessive fruit juice intake d. Providing small, frequent meals ANS: D

Because of children’s small stomach size and variability in hunger sensation, providing small, frequent meals with age-appropriate, nutrient-dense foods promotes a child’s intake of foods. Lack of appetite and inappropriate feeding practices contribute to failure to thrive. Parents may inappropriately restrict foods or amounts of food out of fear their children will develop obesity or other chronic diseases. Inadequate fiber intake is associated with constipation development, which can impair a child’s appetite. Excessive fruit juice intake replaces calories from other nutrient-dense foods and limits intake of nutrients necessary for growth, such as protein.

13. A child’s BMI is plotted on a growth chart at the 90th percentile. How would this child’s

BMI be interpreted? a. The child has a normal BMI. b. The child is at risk for becoming overweight. c. The child is overweight. d. The child is obese.

ANS: B

A child’s BMI between the 85th and 95th percentile is defined as being at risk for becoming overweight. An overweight child is one whose BMI is above the 95th percentile.

For a child to be considered obese, the BMI has to be significantly above the 95th percentile.

14. What may be a consequence of a child experiencing an early adiposity rebound? a. An increased ratio of lean mass to fat mass as an adolescent

b. An increased ratio of lean mass to fat mass as an adult c. An increased ratio of fat mass to lean mass as an adult d. An increased height-to-weight ratio as an adult ANS: C

Adiposity rebound is associated with the gain of body fat starting between 4 and 6 years of age, and the earlier this occurs, the more likely it is that the person will be heavier as an adult. This will be reflected in a greater BMI (or weight-to-height ratio) as an adult and an increase in fat mass in proportion to overall body weight. The degree of fatness during adolescence is also a contributing factor to the development of adult obesity.

15. Which of the following is not associated with impaired academic performance in children? a. Iron deficiency

b. Food insecurity c. Skipping breakfast d. Bringing lunch from home ANS: D

Although lunches brought from home tend to provide fewer nutrients and less variety than those served in school, they do provide school age children with some nutritional value.

Children in poverty tend to be more likely to experience iron deficiency, food insecurity, and skipping of meals. These each have been demonstrated to result in poor performance in regard to academic skill development. The School Breakfast Program provides a means to ensure that children from families with lower incomes have the opportunity for a nutritious breakfast before the school day.

16. Which of the following may cause a preschool child to eat less food at a meal? a. Providing the child with a short-handled spoon or fork b. Providing food at a warm temperature, not too hot or cold c. Scheduling feeding time right after play or activity d. Serving foods so they do not touch one another on the plate ANS: C

Preschoolers tend to not eat well when they are tired, so a short rest or quiet activity should be scheduled before feeding time. Young children eat better with reduced size utensils that are easier for them to hold. Young children avoid foods with temperature extremes, and they tend to not want to eat mixed foods or foods that touch each other on the plate.

17. Which of the following tends to be a positive development in childhood eating habits that

can result from peer influences? a. Selection of nutritious versus nonnutritious foods b. Willingness to try new foods c. Table manners d. Adequate time to eat ANS: B

Eating with other children affects food attitudes and choices. This can be both negative and positive. On the negative side can be the development of food refusals and behaviors associated with meal time. On the positive side, children who see other children trying different foods will be more willing to try the new foods as well. Children cannot differentiate foods based on nutritional value, so they cannot self-select nutritious foods

over nonnutritious foods. Table manners are generally dictated by an adult influence.

18. During which stage of cognitive development can children identify foods that are “good

for you” but probably could not give a reason? a. Sensorimotor stage b. Preoperational stage c. Concrete operations stage d. Formal operations stage ANS: B

Classifying foods as “good” or “bad” without explanation is a characteristic of preoperational thinking. Sensorimotor cognitive development occurs in the first 2 years of life as an infant progresses from automatic reflexes to interactions with the environment.

Concrete operational cognition involves more cause-and-effect thinking. Formal operational cognition involves hypothetical and abstract thinking.

Chapter 17: Nutrition in Adolescence Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Which of the following represents the growth experienced by a child during adolescence? a. 50% of the adult height and 20% of the adult weight b. 30% of the adult height and 30% of the adult weight c. 20% of the adult height and 50% of the adult weight d. 10% of the adult height and 20% of the adult weight ANS: C

Although there is great variability in timing of growth among adolescents, the average adolescent gains 20% of his or her adult height during puberty and 40% to 50% of adult body weight. The gain in weight accompanies the gain in height; however, weight gain tends to continue after linear growth has stopped.

2. When does the greatest increase in height during puberty occur? a. Over the 18- to 24-month “growth spurt” period b. Continually over the entire time c. During the first year of puberty d. Primarily toward the end of puberty ANS: A

Although linear growth occurs throughout the 4 to 7 years of puberty, the greatest increase is during the growth spurt. Growth slows down but continues after sexual maturation.

3. The DRI for calcium for all adolescents is

with an upper level intake of

. a. 800 mg; 1000 mg b. 3000 mg; 5000 mg c. 1300 mg; 3000 mg d. There is no RDA for calcium for adolescents.

ANS: C

Calcium intake is likely to be low in adolescents. The DRI for all adolescents is 1300 mg with an upper limit of 3000 mg. Calcium intake declines with age in adolescents, especially in females. Research suggests that the high soft drink consumption at this age

contributes to decreased calcium intake by displacing milk intake.

4. What is menarche? a. A low hemoglobin level b. A diet high in fat c. Vitamin A deficiency d. The onset of menstruation ANS: D

Menarche is the onset of menstruation in adolescent young women, associated with Tanner stage 4. Menarche actually occurs in late puberty.

5. An adolescent female of gynecologic age of 3 years becomes pregnant. Her prepregnancy

BMI was 18.0. According to the IOM, how much weight should she try to gain during her pregnancy? a. 15 lb b. Up to 25 lb c. Up to 35 lb d. Up to 40 lb ANS: D

Before her pregnancy, this girl’s BMI would be interpreted as underweight; therefore, she should attempt to gain from 28 to 40 lb, with a goal toward the upper part of the range. A BMI over 29.9 would require a weight gain of 11 to 20 lb. For a BMI between 25 and 29.9, the goal would be the upper end of the 15 to 25 lb range. For a normal BMI of 18.5 to 24, the goal would be the upper end of the 25 to 35 lb range.

6. Which nutrient is important in later adolescence to protect against birth defects in

pregnancy? a. Protein b. Iron c. Folic acid d. Calcium ANS: C

Folic acid needs increase in later adolescence to support lean tissue growth and to protect against neural tube defects in pregnancy. Protein needs are based on weight and gender.

Iron needs increase at the onset of menarche. Calcium needs increase to support bone and muscle growth.

7. What would be the correct interpretation of an adolescent who has a BMI above the 85th

percentile? a. The adolescent is overweight. b. The adolescent is obese. c. The adolescent is at risk for becoming overweight. d. The adolescent is overfat.

ANS: C

As in children, the plotting of an adolescent’s BMI above the 85th percentile but below the 95th percentile is interpreted as being at risk for becoming overweight. A BMI above the 95th percentile is interpreted as being overweight. For an interpretation of obesity, the

BMI would have to be significantly above the 95th percentile.

8. In general, how does the onset of puberty in girls compare with that in boys? a. It begins sooner. b. It begins later. c. It lasts longer. d. It is not different.

ANS: A

Female pubertal changes begin about 1 to 2 years before male changes. Female puberty begins between ages of 8 and 12 years old and males start between ages of 9 and 14 years.

Menarche can occur as early as 9 years of age.

9. Which of the following does not describe typical eating behavior in adolescents? a. Skipped meals b. Adequate fruit and vegetable intake c. Frequent dependence on fast foods d. Inadequate time for meals ANS: B

Eating snack foods, soft drinks, and fast foods are commonly reported eating behaviors among adolescents; however, only about one-third of adolescents eat meals with their families every day. These adolescents are more likely to eat more fruits and vegetables.

Teens identify lack of time as a reason for inadequate nutrition, and this contributes to the skipped meals and their dependence on fast foods.

10. Which of the following is a method for rating sexual maturation? a. Periods of adolescence b. Gynecologic age c. Tanner stages d. Peak gain velocity ANS: C

Tanner stages are used to determine degree of sexual maturation during puberty. “Periods of adolescence” refers to the years in age during which cognitive and emotional development occur. Gynecologic age is a reference to the number of years between menarche and chronologic age. Peak gain velocity refers to linear growth only.

11. In adolescence, which of the following is most likely to impact nutritional status? a. Independence b. The future c. Trusting adults d. Body image ANS: D

Adolescents are concerned with their body size, shape, and image. A misperception of weight and shape has the potential to contribute to dieting, fasting, and disordered eating.

Seeking increased independence, trusting in adults, and thinking about the future are less likely to have an impact on nutritional intake and status.

12. How is hypertension diagnosed in adolescents?

a. Blood pressure of 130/85 mm Hg b. Blood pressure of 140/90 mm Hg c. Blood pressure of 160/100 mm Hg d. Average of three blood pressure readings that exceed the 95th percentile ANS: D

Blood pressure levels are different between adults and adolescents; therefore, a different set of standards is used for adolescents. Percentile charts are available that report blood pressures based on age, gender, and height. These standards should be used to determine hypertension in an adolescent as opposed to applying adult standards.

13. Adequate intake of which nutrient is of greatest concern when working with adolescent

athletes? a. Carbohydrate b. Protein c. Water d. Iron ANS: C

Although athletic activity increases the need for almost all nutrients, the one that has the most likelihood of inadequate intake is water. Dehydration that occurs from inadequate replenishment of fluids during physical activity and decreased ability to dissipate heat is the second most common noncardiac cause of death among adolescent athletes. Athletes need more carbohydrate to meet energy demands and more protein to prevent muscle loss.

Iron intake may be a problem when working with female adolescents.

14. Among adolescents, which type of eating disorder is associated with restrictive eating

behaviors and low body weight? a. Anorexia nervosa b. Bulimia nervosa c. Disordered eating not otherwise specified d. Excessive eating disorder ANS: A

Anorexia nervosa is characterized by dangerously low body weight, preoccupation with thinness, and restrictive food intake. Bulimia nervosa is characterized by a fairly normal weight, binging and purging. Binge eating is characterized by frequent, recurrent episodes of binge eating and loss of control over eating. The definition for “eating disorder not otherwise specified” can accommodate the variations in growth, the presence of menstrual periods, and cognitive development associated with adolescence. Excessive eating disorder is not defined by the DSM-IV. 15. What method of weight control is most used by adolescents? a. Fasting or refraining from food b. Eating fewer calories and less fat c. Use of diet pills d. Purging with laxatives, diuretics, and vomiting ANS: A

Seventeen percent of female and 7% of male high school students reported fasting or refraining from food as means of weight control. A total of 7% of females and 4% of males reported using diet pills. A total of 6% of females and 3% of males reported using purging as a means of weight control.

16. When are adolescents most likely to visit a fast-food restaurant? a. Right after school b. During dinnertime through the week c. During dinnertime on the weekend d. During lunchtime on the weekend ANS: A

Teens more frequently visit fast-food restaurants on the way home from school. This may have to do with the location of the fast-food restaurants in relation to their schools because many are located within a short walking or driving distance. Weekday dinnertime is the next most frequently reported visit time. On the weekends, adolescents visit fast-food restaurants more during the lunchtime than during the dinnertime hours.

17. Which nutrient is required in higher amounts by women after menarche? a. Zinc b. Folic acid c. Calcium d. Iron ANS: D

The DRI for iron among females increases from 8 mg/day before the onset of menses to 15 mg/day after the onset of menses. Among adolescent males, recommended intakes increase from 8 to 11 mg/day, with higher levels required during the growth spurt.

18. Stage 1 of obesity in adolescence should be treated with a. structured meal plans and a multidisciplinary health team. b. a diet and recording of food intake and activity. c. a vegan diet and exercise. d. general education on diet and exercise.

ANS: D

Overweight adolescents start out at Stage 1 and need only general information without a lot of restrictions. Stage 2 adds the component of food monitoring. A very structured meal plan and multidisciplinary medical team is indicated in the severely overweight at Stage 4.

Vegan diets can be dangerous because of their very restrictive nature.

Chapter 18: Nutrition for Transgender People Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Which of the following is not a known consequence of testosterone therapy during

transition? a. Bone mass b. Blood lipid profile c. Increased vitamin C requirement d. Weight changes ANS: C

Gender-affirming interventions that may influence the nutritional management of transgender patients sometimes includes testosterone. This therapy can result in changes in body shape and weight, body composition, lipid profile and cardiovascular health. It is not known to increase vitamin C requirement.

2. Best practice for nutritional care of transgendered patients includes a. always using reference values consistent with the patient’s sex assigned at birth. b. using reference values that are consistent with the patient’s stated gender. c. using reference values that have been specifically determined for transgender

people. d. expressing data as a range between female and male values for specific aspects of

nutrition assessment.

ANS: D

There are no specific laboratory norms for transgender patients. Reference values used should align with the patient’s medical transition and the data should be expressed as a range between the female and male values for certain aspects of the nutrition assessment such as estimating energy needs.

3. The following is true of the US transgender population. a. They are at increased risk for food insecurity. b. They are 20% of the US population. c. All patients considered transgender seek to medically transition. d. Most insurance plans cover care for medical and surgical transitioning.

ANS: A

Unemployment, homelessness, substance abuse and mental health disorders disproportionately impact the transgender population. Many are living in poverty as evidenced by a 29% poverty rate; or double the rate among the general adult population.

This leads to an increased incidence of food insecurity. Transgender individuals who do not have supportive families are almost twice as likely to become homeless. Not all transgender people seek medical transition and it is important to treat each patient individually. They are less likely to have health insurance and insurance coverage for gender-affirming care differs by state and by plan. Services “related to sex change” are often specifically excluded. They are estimated to be .06% of the US adult population.

4. What is gender dysphoria?

a. Characteristics in appearance that are not considered consistent with sex at birth b. A person who identifies as neither male or female c. Distress that is caused by a discrepancy between a person’s gender identity and

that person’s sex assigned at birth d. Refers to a person who wants to dress in a fashion not consistent with their sex

assigned at birth ANS: C

Gender dysphoria is the term used to describe the distress caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth and the associated gender role and/or primary and secondary sex characteristics.

5. Challenges to providing optimal gender-affirming nutrition care include a. standardized screening and referral protocols. b. knowledge deficit among nutrition professionals. c. lack of evidence-based practice guidelines. d. All of the above.

ANS: D

Research on nutrition care of transgender people is limited. There are no evidence-based guidelines established. There is currently a lack of education and training for nutrition professionals working with this population.

6. Which of the following statements is true of how gender-affirming hormone therapy

affects hematologic laboratory values? a. Only feminizing hormone therapy stimulates a change. b. Only masculinizing hormone therapy stimulates a change. c. Neither feminizing or masculinizing hormone therapy stimulates a change. d. Both feminizing and masculinizing hormone therapy stimulates a change.

ANS: D

Gender-affirming hormone therapy may stimulate changes in hematologic laboratory values. Feminizing therapy may result in a reduction of red blood cell count, hemoglobin and hematocrit. Anti-androgen use lowers testosterone levels which results in reduced erythropoiesis.

7. When working with transgender populations who are overweight it may be best to a. offer education on a higher protein, lower carbohydrate diet plan. b. offer education in a weight neutral, non-diet approach.

c. focus on their body composition rather than weight. d. align their diet education with the type of medical or surgical intervention they are

receiving.

ANS: B

The interrelationships of body size, body shape and gender expression are uniquely intertwined for a transgender person. Body dissatisfaction may be the most significant stressor they experience. These factors along with the knowledge that these patients are particularly at risk of disordered eating the non-diet approach to healthy eating, such as Healthy at Every Size, may be ideal.

TRUE/FALSE

1. When communicating with a transgender patient it is best to use “they” as their pronoun to

avoid making a mistake.

ANS: F

As with other aspects of care, the best approach is individualized. It is recommended that the patient be asked what pronoun they prefer.

Chapter 19: Nutrition in the Adult Years Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Which of the following are biologically active, naturally occurring substances in plants

that act as natural defense systems and show potential for reducing the risk for cancer and cardiovascular disease? a. Prebiotics b. Phytochemicals c. Butyrates d. Xenobiotics ANS: B

Phytochemicals include substances such as flavonoids, anthocyanins, and carotenoids that provide color, aroma, and flavor to foods. Prebiotics are carbohydrates that are used by beneficial gastrointestinal bacteria to promote their growth and inhibit the growth of harmful bacteria. Butyrate is a short-chain fatty acid that is used by colonic mucosal cells as an energy source. A xenobiotic is a compound foreign to the body, usually harmful.

2. Which of the following is a comorbid diagnosis associated with obesity? a. Osteoporosis b. Premenstrual syndrome c. Type 2 diabetes mellitus d. Chronic lung disease ANS: C

Obesity is associated with a number of other medical conditions, including diabetes, cardiovascular disease, and cancer. Osteoporosis is seen more often in smaller women. No evidence links obesity to an increase in the symptoms associated with premenstrual syndrome. Chronic lung disease is more associated with cigarette smoking.

3. Increased dietary intake of what is associated with a reduced risk of chronic disease? a. Grains, fruits, and vegetables b. Legumes c. Vegetable oils d. Trans-fatty acids

ANS: A

The Dietary Guidelines for Americans, which were established to promote decreased risk of chronic disease, emphasize the increased intake of grains, fruits, and vegetables.

Legumes are considered to be a subcategory of vegetables. Vegetable oils vary in the fatty acid profile; therefore, consideration should be given to this before selecting ones to use.

Trans-fatty acids are harmful in regard to the development of cardiovascular disease and should be avoided.

4. A trend in adults in the United States is that they a. are spending more money on food away from home. b. are eating more family meals at home. c. generally meet the dietary recommendations for promoting health.

d. use the MyPlate tool to plan their diets.

ANS: A

According to the consumer price index, it is estimated that Americans spend more than 50% of their food dollars away from home. The sit-down family meals at home have given way to eating on the run, take-out meals, and drive-through restaurants. Although there is an increase in the number of consumers familiar with MyPlate, the intake of fruit and vegetables remains below recommendations.

5. Which is an appropriate nutritional guideline for the adult years? a. Focus primarily on lipid intake. b. Follow a nutrient-dense diet with a variety of foods. c. Follow a high-protein, low-carbohydrate diet. d. Follow a vegan diet.

ANS: B

The Dietary Guidelines for Americans focus on eating a variety of nutrient-dense foods.

Focusing on lipid intake limits awareness of the variety of benefits that arise from the intake of whole grains, fruits, and vegetables. A high protein and low carbohydrate diet is not routinely recommended since it further inhibits intake of a variety of nutrients, including fruits and vegetables. A carefully chosen vegan diet supplemented with specific nutrients can be healthy, but vegan diets (and other very restrictive diets) are generally considered a risk factor for inadequate nutrition.

6. Which of the following is an effect of the decreased circulation of estrogen associated with

menopause? a. Increase in bone remodeling b. Increase in HDL levels c. Increase in LDL levels d. Increase in energy levels ANS: C

Estrogen has a protective effect in regard to bone and cardiovascular health. When estrogen circulation decreases, an increase is seen in LDL levels. Estrogen plays a role in bone remodeling, and with loss of estrogen, a decrease in bone mass occurs. Decreased estrogen is associated with a decrease in HDL. Symptoms of menopause include a decrease in energy level.

7. When do perimenopause and menopause begin in women?

a. Early 30s b. Late 40s c. Elder years d. Mid 30s ANS: B

Although genetics, general health, and the timing of menarche affect the timing, generally, perimenopause and menopause begin in a woman’s late 40s.

8. The role of nutrition and dietetic professionals in the adult years involves a. addressing the role of nutrition in the leading causes of death and debility. b. incorporating basic education on food access, selection, and preparation.

c. setting mutually acceptable, achievable goals for optimal performance and health. d. All of the above.

ANS: D

The adult years offer opportunities for prevention as well as intervention. It is critical for the dietetic professional to consider how to assess clients and group needs and be able to address the total picture of optimal health.

9. The leading cause of death and debilitation among adults in the United States is a. accidents. b. cancer. c. diabetes. d. heart disease.

ANS: D

In the United States, the leading causes of death and debilitation among adults previous to the COVID-19 pandemic were (1) heart disease, (2) cancer, (3) chronic lower respiratory disease, (4) cerebrovascular accident, and (5) accidents. COVID-19 is currently ranked as the 3rd leading cause of death in the U.S. 10. A potential benefit of soy is reducing the risk of developing which of the following? a. Osteoarthritis b. Cardiovascular disease c. Alzheimer disease d. Obesity ANS: B

The American Heart Association recommends the use of soy as an alternative to animal protein; therefore, the benefit is seen through a reduction in saturated fat intake. The effect of soy intake on the risk of developing osteoarthritis, Alzheimer’s, or obesity has not been shown.

11. Which of the following is not one of the defining characteristics of metabolic syndrome? a. Abdominal obesity b. Hypertension c. Elevated blood lipids d. Physical inactivity ANS: D

The metabolic syndrome is diagnosed through the identification of three of the five

following factors: abdominal obesity, high blood pressure, high blood triglycerides, low HDL, and elevated blood glucose. Although physical inactivity can contribute to the development of these factors, it is not one of the defining characteristics of metabolic syndrome.

12. Which of the following nutrients should men avoid taking as supplements during their

adult years? a. Iron b. Anthocyanin c. Lycopene d. Vitamin D

ANS: A

Unless men are diagnosed with iron deficiency anemia, they should avoid intake of additional iron. Excessive iron intake is problematic because it is an oxidant in the body.

Lycopene is an antioxidant found in tomato products, pink grapefruit, and watermelon, and increased intake of lycopene has been reported as reducing the risk of prostate cancer.

Anthocyanin is a flavonoid that has antioxidant properties, particularly in regard to reducing oxidation of LDL. Vitamin D intakes have been found to be deficient in much of the population, and supplementation is not considered to be a risk.

13. Which group is at risk of not eating the DRI of nutrients and may benefit by the use of

multivitamin supplements? a. Athletes b. Premenopausal women c. Those with food allergies d. Men older than age 50 years ANS: C

People with food allergies are at particular risk because they are often forced to eliminate whole food groups from their diet. Several segments of the adult population fall into high-risk groups that are unlikely to meet their nutrient needs because of life stage, alcohol or drug dependency, food insecurity, chronic illness, or choosing a restrictive diet.

Chapter 20: Nutrition in Aging Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Which of the following can result from achlorhydria associated with aging? a. Decreased calcium and nonheme iron absorption b. Diminished absorption of vitamin B12 c. Decreased absorption of carbohydrates d. Increased intestinal transit time ANS: B

Gastric acid and intrinsic factor are both necessary to absorb B12. Achlorhydria is the absence of hydrochloric acid in the stomach. Reduced acid production also affects the absorption of nonheme iron but not necessarily calcium. The acid is also needed for the denaturation of protein.

2. Increased intake of which nutrient may be required in a patient who has pressure ulcers? a. Water b. Vitamin B12 c. Protein d. Potassium ANS: C

Pressure ulcers require protein for wound healing. The amount of protein recommended depends on the stage of the pressure ulcer. Protein deficiency contributes to the development of the pressure ulcer. A multivitamin and mineral supplement is recommended, but there are no specific recommendations for increased vitamin B12 or potassium.

3. Why does constipation occur in elderly adults? a. Increased motility in the small intestine b. Decreased motility in the small intestine c. Increased motility in the large intestine d. Decreased motility in the large intestine ANS: D

Constipation involves a reduction of bowel movements, and one potential reason is a

decrease in the motility in the large intestine. The longer intestinal contents remain in the colon, the more water is absorbed and the harder the stool is to transit and eliminate.

Delayed transit time, medications, and reduced stimulation of the gut through reduced physical activity all contribute to the development of constipation.

4. The Omnibus Reconciliation Act (OBRA) a. is aimed at assisted living facilities. b. pays for dietitian consults for those older than 65 years of age. c. is reform legislation aimed at improving skilled nursing care. d. is reform legislation aimed at congregate meal sites.

ANS: C

In 1987, Congress passed OBRA to improve quality of care in skilled nursing facilities by strengthening standards. It does not apply to assisted living facilities or congregate meal sites. Although the legislation requires that nutritional assessments be done periodically, it does not directly pay for dietitian services.

5. Which changes are associated with the normal process of aging? a. Loss of lean body mass, decreased metabolic rate, and decreased function b. Loss of lean body mass, increased metabolic rate, and increased physical activity c. Increased lean body mass, increased metabolic rate, and increased physical activity d. Increased muscle strength and function ANS: A

As lean body mass decreases, the loss of muscle mass results in decreased strength, function, and metabolic rate. Sarcopenia occurs more rapidly in people with limited physical activity; therefore, elderly adults who are also obese tend to be less active and retain excessive adipose tissue.

6. Home-delivered meals provided for under the Older Americans Act nutrition program are

administered by what agency? a. USDA b. USDHHS c. ALF d. CMS ANS: B

In the U.S. Department of Health and Human Services (USDHHS), the Agency on Aging administers a network of local agencies to provide both home-delivered and congregate meals for elderly adults. This is the only food assistance program through USDHHS. All other food assistance programs are provided through the U.S. Department of Agriculture (USDA). Assisted-living facilities (ALFs) are residential programs that provide access to supportive health care to older residents. The Centers for Medicare and Medicaid Services (CMS) provides health care services but no food assistance.

7. Presbyopia is a. inability to swallow. b. loss of sense of taste. c. inability to focus clearly at close distance. d. lack of dentition.

ANS: C

Presbyopia generally occurs in the 4th decade of life and results in the need for reading glasses. Dysphagia is difficulty or inability to swallow. Dysgeusia is the loss of sense of taste or an altered sense of taste. Dentition refers to teeth.

8. What is dysgeusia? a. Diminished sense of smell b. Loss of sense of taste c. Dry mouth from decreased salivation d. Result of hypochlorhydria ANS: B

Some change in the sense of taste is associated with aging; however, a total loss of taste sensation more often is associated with the use of medications, diseases of the kidney or liver, diabetes, hypertension, head injury, neurologic conditions, and zinc or niacin deficiencies. Hyposmia is a diminished sense of smell and can contribute to a reduced taste sensation. Xerostomia is dry mouth. A reduction in hydrochloric acid production in the stomach can result in nutrient malabsorption.

9. Nutrition screening using the BMI as an indicator a. is the best indicator for those 85 years of age and older. b. may not be accurate because of body composition changes in elderly adults. c. is better than using mid-arm muscle circumference. d. is not part of the Mini Nutritional Assessment (MNA).

ANS: B

The MNA includes six questions and the BMI or calf circumference. However, BMI may not yield accurate results because fat mass increases and lean tissue decreases with aging.

10. A supercentenarian is a. a woman who is currently 65 years of age who is expected to live to be 100 years

old. b. someone born today who can expect to live to be 100 years old or older. c. someone who is 100 years old or older with no disease. d. someone older than 110 years.

ANS: D

A supercentenarian is a new group of individuals identified to be older than 110 years of age. This population is now big enough to warrant research.

11. Which of the following statements about elderly adults is false? a. Among the oldest old, there are more women than men. b. More elderly men than women are married. c. Most elderly live in nursing homes. d. The life expectancy of older adults is greater than it was 100 years ago.

ANS: C

Only about 3% of today’s elderly adults live in a nursing home. Women tend to outlive men, so there are more women alive than men at ages 85 years and older. In 1900, the life expectancy was into the 40s. Now life expectancy is 77 years.

12. Which of the following theories of aging is a predetermination theory? a. Genetic theory b. Wear and tear theory c. Free radical theory d. Somatic mutation theory ANS: A

Predetermination theories of aging focus on a built-in mechanism that determines when aging begins and death will occur. The genetic theory explains that life span is determined by heredity, and thus this falls into the predetermination theory category. Another class of theories is the accumulated damage theories. These describe aging as a process in which the body’s systems break down over time because of damage. Wear and tear, free radical, and somatic mutation theories identify different ideas behind how this damage occurs.

13. Which of the following theories of aging is an accumulated damage theory? a. Rate of living theory b. Pacemaker theory c. Immune system theory d. Cross-link theory ANS: D

Accumulated damage theories describe aging as a process in which the body’s systems break down over time because of damage. The cross-link theory is one of these because it describes aging changes as results of inappropriate cross-links in protein, DNA, and structural molecules that inhibit the normal functions of the body. Predetermination theories of aging focus on a built-in mechanism that determines when aging begins and death will occur. Rate of living, pacemaker (or biologic clock), and immune system theory all focus on predetermined programming that leads to aging.

14. How would a pressure ulcer be classified if it involves a partial-thickness skin loss

involving the epidermis and dermis, presenting as an abrasion or shallow crater? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 ANS: B

A Stage 2 pressure ulcer involves a partial-thickness skin loss. Stage 1 pressure ulcers involve intact skin, but the skin may appear red, may feel firm or boggy, and may promote an itching or painful sensation. Stages 3 and 4 pressure ulcers are full-thickness wounds.

Stage 3 pressure ulcers involve the subcutaneous tissue, and Stage 4 pressure ulcers go through the fascia and may affect muscle or bone.

15. Which of the following is not true of The Dining Practice Standards? a. Are guidelines for long-term care dining.

b. Recommend against canned nutrition supplements. c. They encourage strict dietary control for diabetes and heart disease. d. They are endorsed by the Centers for Medicare and Medicaid.

ANS: C

The Dining Practice Standards were developed by a multidisciplinary group who wanted to improve the dining experience and nutritional care for elders living in long-term care.

They were endorsed by the Centers for Medicare and Medicaid. The standards promote person-centered care, liberalized diets, and food first with less reliance on canned supplements.

16. Which of the following is not one of the four syndromes known to be predictive of adverse

outcomes in older adults?

a. Depression b. Diabetes c. Cognitive impairment d. Malnutrition ANS: B

The four syndromes known to be predictive of adverse outcomes in older adults that are prevalent in patients with frailty (known as failure to thrive) include impaired physical functioning, malnutrition, depression, and cognitive impairment.

17. A 70-kg man with a Stage 4 pressure ulcer needs

g/day of protein and

kcal/day. a. 84; 2100 b. 70; 2800 c. 105; 2450 d. 140; 2100 ANS: C

Those with Stage 4 pressure ulcers require 35 to 40 kcal/kg/day and a minimum of 1.5 g of protein per kg. In patients who are obese, these figures must be adjusted.

18. The 2010 health care reform legislation expanded Medicare to include a. an annual wellness visit. b. education and counseling. c. expanded coverage for reimbursement for dietitians. d. All of the above.

ANS: D

The 2010 health care reform legislation changed Medicare to include an annual wellness visit and a personalized prevention assessment. Prevention services include referrals to education and preventive counseling or community-based interventions to address risk factors. Expansion of medical nutrition therapy reimbursement for registered dietitians was anticipated, but subsequent changes to the legislation have put that coverage into question.

Chapter 21: Nutrition in Weight Management Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. An increased incidence of which of the following diseases is not associated with obesity? a. Heart disease b. Osteoporosis c. Gallbladder disease d. Sleep apnea ANS: B

Conditions such as diabetes, heart disease, hypertension, gallbladder disease, sleep apnea, osteoarthritis, and certain cancers worsen as the degree of obesity increases. Women of slight build and those who are underweight have a higher risk of developing osteoporosis.

2. The rate of weight loss for men on energy-deficient diets is more rapid than for women

because men a. generally have less fat to lose. b. are more successful at weight reduction programs. c. have higher resting metabolic rate and lean body mass than women. d. are more likely to exercise while trying to lose weight.

ANS: C

Men lose weight faster than women of similar size because of their higher proportion of lean body mass and the resulting increase in resting metabolic rate. This results in higher calorie expenditure in men, leading to weight loss occurring more quickly. The amount of fat men and women have is affected by a variety of genetic and lifestyle factors, so men do not necessarily have less fat than women. The use and success of additional therapies beyond diet depend on individual choice and commitment to weight loss.

3. Which of the following results from the use of fasting as a means of weight loss? a. Excessive weight gain after refeeding b. An initial rapid weight loss from diuresis c. A decrease in ketone formation d. Carbohydrate craving ANS: B

More than half of the weight loss associated with fasting is caused by loss of fluid and loss of lean body tissue. Because of this, fasting is seldom prescribed for weight loss.

Excessive weight gain after refeeding can occur when weight loss is associated with a decrease in metabolic rate from the body adapting to starvation.

4. The NWCR identified which behavior that resulted in successful long-term weight loss? a. Use of very low-calorie diets b. Use of pharmaceuticals c. Attending support groups d. Eating breakfast ANS: D

The NWCR consists of more than 5000 individuals who have been successful in long-term weight loss maintenance. It found that there was very little similarity in how individuals lost weight, but there were some common behaviors they all have for keeping weight off: (1) eating a relatively low-fat diet, (2) weighing themselves regularly, (3) engaging in high levels of physical activity, and (4) eating breakfast almost every day.

5. What happens to the resting metabolic rate (RMR) as a result of exercise as part of a

weight management program? a. RMR increases as adipose tissue is increased with exercise. b. RMR decreases as adipose tissue is decreased with exercise. c. RMR decreases as lean body mass is decreased with exercise. d. RMR increases as lean body mass is increased with exercise.

ANS: D

Resistance training increases lean body mass, increasing the RMR and the ability to use more energy. This promotes weight loss through the loss of body fat in place of lean body tissue.

6. Which enzyme removes dietary triglyceride from the blood? a. Hormone-sensitive lipase b. Lipoprotein lipase c. Cholecystokinin (CCK) d. Insulin ANS: B

Lipoprotein lipase hydrolyzes triglycerides from VLDL into fatty acids and glycerol. The glycerol travels back to the liver while the fatty acids are incorporated into adipocytes.

Hormone-sensitive lipase hydrolyzes triglycerides packaged within the adipocytes so that fatty acids and glycerol can be released back into circulation. CCK’s action at the brain level is to inhibit food intake. Insulin is the hormone that promotes lipid storage.

7. The greatest percentage of body fat is set a. at birth. b. at 6 years of age. c. at 6 months of age. d. before birth by genetics.

ANS: C

During normal growth, the greatest percentage of body fat (approximately 25%) is set at 6

months of age. At age 6 years in lean children, adiposity rebound occurs with an increase in body fat.

8. During starvation, the body’s adaptive response is a a. drop in the RMR as much as 15% in 2 weeks. b. rise in the RMR as much as 15% in 2 weeks. c. drop in the RMR as much as 25% in 1 month. d. rise in the RMR as much as 25% in 1 month.

ANS: A

The resting metabolic rate drops by 15% within 2 weeks of starvation to conserve energy as a protection against future lack of energy and food intake. As starvation continues, ketone production provides the primary energy substrate for most tissues throughout the body. However, the brain, nerve tissues, and red blood cells need glucose as their primary energy source. Without food intake, the only way to provide this glucose is through gluconeogenesis that uses protein from lean body tissue.

9. Obese women should lose weight before becoming pregnant because of the possible

impact of what compound released when adipose tissue is mobilized? a. Ghrelin b. Insulin c. Semi-volatile organic compounds d. Pro- and anti-inflammatory cytokines ANS: C

Semi-volatile organic compounds (SVOCs) accumulate in adipose tissues from exposure to toxins, chemicals, and pesticides. When adipose tissue is mobilized during weight loss, SVOCs are released. Obese women should lose weight before becoming pregnant because the impact of SVOCs on the developing fetal brain is not yet known. Ghrelin is a hormone produced primarily by the stomach and acts on the hypothalamus to stimulate hunger and feeding. Insulin acts in the central nervous system and the periphery nervous system to regulate food intake and is involved in the synthesis and storage of fat. Adipose tissue actively secretes a wide range of pro- and anti-inflammatory cytokines, but these have not been shown to be detrimental to pregnancy.

10. What methods of weight reduction have the highest rates of success? a. Diet combined with exercise b. Diet combined with lifestyle modification c. Diet, exercise, and lifestyle modification all combined d. Exercise combined with lifestyle modification ANS: C

Weight reduction programs that integrate diet with physical activity and lifestyle modifications are the most likely to succeed. Whereas the promotion of weight loss by decreasing calorie intake is a primary component, physical activity has been demonstrated as being necessary for helping to maintain the weight loss. Behavior modification helps the person seeking weight loss learn about lifestyle and environmental factors that contribute to the promotion of weight gain. Inclusion of the understanding of what beyond

food and activity contributes to obesity can help the patient make lifestyle changes to support the weight loss.

11. Which of the following was not recommended by the National Weight Control Registry

(NWCR) as a method to maintain weight? a. Eating a relatively low-fat (24%) diet b. Eating breakfast almost every day c. Replacing full calorie drinks with zero-calorie substitutes d. Engaging in high levels (60 to 90 min/day) of physical activity ANS: C

Artificial sweeteners and fat substitutes improve the acceptability of limited food intakes for some people. However, there is no evidence that using artificial sweeteners reduces food intake or results in weight loss, and they are not recommended by the NWCR. 12. Aerobic exercise is effective in weight management because it a. promotes the use of fat for fuel. b. decreases lean body mass in proportion to fat. c. increases resistance to insulin. d. decreases sensitivity to insulin.

ANS: A

Aerobic activity benefits weight management by promoting calorie expenditure. As the duration of aerobic activity continues, glycogen stores are used, and then fat stores start being used as the body’s energy source. This results in a decrease in body fat. In combination with resistance training, lean body mass is maintained or increased, causing an increase in resting energy expenditure and continued loss of body fat. Aerobic exercise improves the body’s sensitivity to insulin.

13. The metabolic syndrome is associated with which of the following groups of disorders? a. Glucose intolerance, gout, and hypertension b. Gout, hypertension, and hyperlipidemia c. Glucose intolerance, hyperlipidemia, and hypertension d. Hypoglycemia, hyperlipidemia, and hypertension ANS: C

The metabolic syndrome emphasizes central body adiposity that is strongly related to cardiovascular disease, hypertension, and type 2 diabetes mellitus. In the assessment of the metabolic syndrome, a patient demonstrates three of the following five factors: large waist circumference, hypertriglyceridemia, depressed HDL, hypertension, and hyperglycemia.

14. Which of the following diets advocates that carbohydrates should contribute no more than

40% of the total calories? a. Low-carbohydrate diet b. Protein-sparing modified diet c. Very low-calorie diet d. Zone Diet ANS: D

The Zone Diet and the South Beach Diet are two diets that promote an intake of

carbohydrate to less than 40% of total calories. The claim behind this is that this level of carbohydrate intake will result in reduced insulin secretion. Insulin is responsible for fat storage, and if less is secreted, less fat deposition will occur. Typical low-carbohydrate diets tend to have levels of 20% of total calories or less. A protein-sparing modified diet is a type of very low-calorie diet (VLCD) that provides protein but limits calories. The idea behind this is that if protein were provided by the diet, lean body tissue could be preserved while the patient lost weight. VLCDs provide the patient with only 200 to 800 calories/day and should be conducted under the care of a physician.

15. Which of the following does the NIH identify as being an appropriate candidate for

bariatric surgery? a. A person with metabolic syndrome

b. A patient with BMI of 25 to 29 with high blood pressure c. A patient with BMI of 30 to 34 d. A patient with BMI of 40 or higher ANS: D

Bariatric surgery is an acceptable treatment for people with extreme obesity. A person with a BMI greater than 40 or person with a BMI greater than 35 with comorbidities would be an ideal candidate. Combinations of diet therapy, exercise, and lifestyle modification should be attempted before surgical intervention is sought.

16. What should be the treatment goal in regard to a child or adolescent who is identified as

overweight? a. Promote weight loss of 1 to 2 lb/week. b. Promote weight loss to reduce BMI below the 85th percentile. c. Promote weight maintenance and increased physical activity. d. Promote weight loss of 10 to 12 lb/year.

ANS: C

As children and adolescents are still in growth phases, restriction of energy and nutrient intake and promotion of weight loss may impair appropriate growth and physical maturation. Unless the child is experiencing other medical conditions aggravated by excessive weight, the recommended approaches to weight control are providing adequate calories to maintain weight and increasing the child’s physical activity, allowing the child to grow into his weight. If a child or adolescent has exceeded his optimal adult weight, then a slow, 10- to 12-lb/year weight loss is recommended.

17. Which of the following bariatric surgeries promotes weight loss through a combination of

food restriction and malabsorption? a. Gastric banding b. Roux-en-Y gastric bypass c. Vertical banded gastroplasty d. Liposuction ANS: B

The roux-en-Y gastric bypass creates both a reduced stomach reservoir to limit food intake and connects the small intestine to an opening near the reservoir to bypass some of the absorptive surface of the small intestine. Gastric banding and vertical banded gastroplasty only create the limited size reservoir for food intake. Liposuction is technically a cosmetic surgery because it is usually limited to removal of subcutaneous tissue.

Chapter 22: Nutrition in Eating Disorders Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. In conjunction with anorexia nervosa, cardiovascular complications may include a. amenorrhea. b. bradycardia. c. edema. d. ventricular enlargement.

ANS: B

Cardiovascular complications may include bradycardia, orthostatic hypotension, cardiac arrhythmias, and pericardial effusion.

2. Which of the following is a characteristic of bulimia nervosa? a. The patient is of normal or near normal weight. b. The patient binges but does not purge. c. The patient does not have a body image problem. d. A typical binge lasts all day.

ANS: A

A person with bulimia nervosa is commonly within the normal weight range, although some may be slightly under- or overweight. A person with bulimia nervosa is very concerned about body shape and size. Binge eating, which involves short periods (usually 2 hours or less) of intake of large amounts of food, and purging behaviors are commonly used by a person with bulimia nervosa.

3. Which of the following is often exhibited in patients with anorexia nervosa? a. Enamel wasting b. Esophagitis c. Muscle wasting d. Russell sign ANS: C

Loss of lean body mass and muscle wasting are common physical attributes in individuals with anorexia nervosa. Enamel wasting, esophagitis, and Russell sign (scarring of the dorsum of the hand) are signs that a person uses vomiting as a purging behavior. Although

some people with anorexia nervosa may be of the binge eating and purging type, these signs are more commonly seen in people with bulimia nervosa.

4. In which eating disorder might a person chew and spit out, but not swallow, regurgitated

food? a. Anorexia nervosa b. Bulimia nervosa c. Rumination disorder d. Binge eating disorder ANS: C

Rumination disorder involves regurgitating then either re-chewing, re-swallowing, or spitting out the food. It is an unspecified feeding or eating disorder. Although people with anorexia nervosa or bulimia nervosa may perform binge eating activities, these are generally associated with purging after the food is swallowed. A person with binge eating disorder will have recurrent episodes of binge eating but will not follow them with some inappropriate compensatory behavior.

5. In which eating disorder might a person have an intense fear of becoming overweight even

though she is underweight? a. Anorexia nervosa b. Bulimia nervosa c. Avoidant/restrictive food intake disorder d. Binge eating disorder ANS: A

Although a person with anorexia nervosa may have a low BMI, this person will have a body image distortion, causing the person to feel fat even when wasted in appearance.

People with bulimia nervosa tend to be within normal weight standards but are also concerned with body image. People with avoidant/restrictive food intake disorder consume restrictive diets but do not have a distorted body image. People with binge eating disorder tend to be overweight.

6. In which eating disorder might a person binge often but not try to compensate for this

behavior? a. Anorexia nervosa b. Bulimia nervosa c. Purging disorder d. Binge eating disorder ANS: D

In binge eating disorder, a patient will demonstrate binge eating behaviors but no means of compensating for the excessive intake of food. These people tend to be overweight. The person with binge eating disorder feels incapable of controlling eating, which results in feelings of depression, disgust, and guilt. In bulimia, binge eating is commonly followed by purging or some other compensatory mechanism, such as fasting or excessive exercise.

Anorexia can be restrictive or binging/purging. Purging disorder purges without the binging.

7. In which eating disorder might a person exercise excessively without binge eating? a. Anorexia nervosa b. Bulimia nervosa c. Pica d. Binge eating disorder ANS: A

People with anorexia nervosa use exercise to promote weight loss when severely restricting nutrient intake. People with bulimia nervosa engage in compensatory activities such as purging, exercise or fasting to make up for the intake of a binge episode. Pica is the consumption of nonnutritive items such as dirt and is not associated with exercise.

Binge eating disorder is not associated with compensatory behaviors.

8. Lanugo is soft, downy hair growth associated with a. anorexia nervosa. b. binge eating disorder. c. bulimia nervosa. d. eating disorder not otherwise specified.

ANS: A

Lanugo is soft, downy hair growth associated with anorexia nervosa. People with anorexia nervosa also appear cachectic, and their prepubescent body habitus causes them to appear younger.

9. How frequently should binge episodes occur for a binge eating disorder to be diagnosed? a. At least once a week for 3 months b. At least 2 days/week for 3 months c. At least 2 days/week for 6 months d. At least 6 days/week for 2 months ANS: A

The DSM-5 definition of binge eating disorder specifies that binge episodes must occur at least once a week for 3 months. In regard to bulimia nervosa, the definition specifies binge episodes and inappropriate compensatory behaviors at least once a week for 3 months.

10. After a binge episode, how much of the energy intake can be eliminated through purging? a. 100% b. 75% c. 50% d. None ANS: C

The rule of thumb is that most purging activities cause only 50% of the calories taken in through a binge to be eliminated. This means that half of the calories taken in during the binge are retained in the body.

11. For the diet therapy in individuals with anorexia nervosa, what percentages of protein,

carbohydrate, and fat are recommended, respectively? a. 20%, 50%, and 30% b. 10%, 50%, and 40% c. 30%, 40%, and 30% d. 25%, 40%, and 35%

ANS: A

Distribution of the calories is necessary as many people with anorexia nervosa try to avoid fat. A dietary fat range of 25% to 30% of calories is recommended to ensure overall caloric intake, which needs to increase for the person with anorexia nervosa to gain weight. Protein should provide 15% to 20% of total calories. This should be protein of high biologic value. Patients with anorexia nervosa often ask for vegetarian diets, but these should be discouraged. Carbohydrates should provide from 50% to 55% of total calories.

12. How do anorexia nervosa and bulimia nervosa commonly affect the patient’s metabolic

rate? a. They increase the metabolic rate to higher than normal.

b. They decrease the metabolic rate to lower than normal. c. They have no effect on metabolic rate, maintaining it at the normal level. d. They promote an extreme increase in metabolic rate.

ANS: B

For patients who experience a loss of lean body tissue, a concurrent decrease in metabolic rate occurs. For patients with bulimia nervosa, this may be unpredictable; however, during times of dietary restraint between binge episodes, the patient with bulimia nervosa may experience a semistarvation state, which will result in a decrease in RMR. 13. The treatment goal for a patient with bulimia nervosa who is mildly overweight should be a. weight loss to ideal weight. b. daily exercise to help decrease weight. c. a structured exercise routine to help decrease weight. d. weight maintenance.

ANS: D

The actions pursued by the person with bulimia nervosa are aimed at weight loss; however, the immediate goals for treatment should focus on interrupting the binge-purge cycle, restoring normal eating behaviors, and stabilizing body weight. Exercise may be used later to help with weight loss, but this is secondary to helping the patient with bulimia nervosa understand and avoid patterns of binge eating and purging.

14. During the treatment of patients with eating disorders, which of the following is an

additional feature that should be monitored in the food records of patients with bulimia nervosa as opposed to anorexia nervosa? a. Eating behaviors b. Exercise c. Emotions and feelings when eating d. Use of alternative sweeteners ANS: C

Because of bingeing, purging, and restrictive eating, the patient with bulimia nervosa often has impaired hunger and satiety cues. By recording emotions and feelings whenever she eats, the patient with bulimia nervosa can learn to recognize these cues. Additionally, patients with bulimia nervosa are more receptive to nutrition counseling than patients with anorexia nervosa, and discussion of the recorded feelings can be used in the counseling to help promote behavioral changes.

15. How many calories should be provided in the diet of a patient with anorexia nervosa to

initiate weight gain? a. 25 to 30 kcal/kg/day b. 30 to 40 kcal/kg/day c. 40 to 50 kcal/kg/day d. 70 to 100 kcal/kg/day ANS: B

Because of the low weight of patients with anorexia nervosa, 30 to 40 kcal/kg/day is sufficient to start weight gain. To continue to promote weight gain, increase energy intake as tolerated. To eventually reach healthy weight gain, some patients with anorexia nervosa may need to be advanced to 70 to 100 kcal/kg/day in their diet therapy.

16. Urine specific gravity should be checked when patients being treated for eating disorders

are weighed to a. monitor for muscle wasting. b. check for dehydration or fluid loading. c. check for presence of ketones. d. identify use of medications to suppress appetite or promote purging.

ANS: B

To obtain a reliable weight of a patient with an eating disorder, the patient should be weighed daily on the same scale, wearing only a gown, and before eating and after voiding. The urine is checked for urine specific gravity to determine its density.

Concentrated urine reflects dehydration. A patient with an eating disorder may consume water to simulate weight gain, and a diluted urine specific gravity will reflect this. Other measures of the urine may be used to determine muscle wasting and ketosis.

17. Low T3 syndrome is a a. low metabolic state associated with anorexia nervosa. b. reduction in thyroxine associated with anorexia nervosa. c. decrease in triiodothyronine associated with bulimia nervosa. d. decrease in reduced triiodothyronine associated with anorexia nervosa.

ANS: A

Low T3 or active triiodothyronine is a characteristic of a reduced state of metabolism in patients with anorexia nervosa. Thyroid hormone production remains normal; however, peripheral deiodization of thyroxine favors the formation of reduced triiodothyronine. The reduced form of triiodothyronine is less metabolically active than the regular form. This alteration in metabolism resolves as weight gain occurs.

18. During the acute stage of anorexia nervosa, what is the focus of psychologic management

in treatment? a. Understanding and changing dysfunctional attitudes related to eating b. Addressing psychopathology that reinforces eating-disordered behaviors c. Improving interpersonal and social functioning d. Positive behavioral reinforcement of weight gain ANS: D

The immediate, short-term goal in treatment of anorexia nervosa is to initiate weight gain.

From a psychologic management point of view, this entails the positive encouragement of

actions taken by the patient to initiate weight gain. Such actions include praise, reassurance, coaching, and encouragement. Long-term goals of psychologic management are more focused on understanding and changing attitudes and psychologic conflicts that promote disordered eating, as well as improving the patient’s interpersonal and social functioning.

19. Delayed gastric emptying and gastric distension are common in a. binge eating disorder. b. bulimia nervosa. c. anorexia nervosa. d. eating disorder not otherwise specified.

ANS: C

Complaints of gastric discomfort associated with distention are common in anorexia nervosa because of delayed gastric emptying. The complaints generally occur as the calorie prescription is increased and between-meal snacks become necessary.

20. After a binge episode, how much of the energy intake can be eliminated through purging? a. 100% b. 75% c. 50% d. None ANS: C

The rule of thumb is that most purging activities cause only 50% of the calories taken in through a binge to be eliminated. This means that half of the calories taken in during the binge are retained in the body.

Chapter 23: Nutrition in Exercise and Sports Performance Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Which of the following is not involved in the anaerobic production of ATP through the

lactic acid pathway? a. Pyruvic acid b. Creatine phosphate c. Nicotinic acid dehydrogenase d. Adenosine diphosphate ANS: B

Lactic acid is the end product of anaerobic glycolysis. The coenzyme, nicotinic acid dehydrogenase (NAD) converts pyruvic acid to lactic acid. Adenosine diphosphate combines with creatine phosphate to resynthesize ATP and is not part of the lactic acid pathway.

2. During extended physical activity, such as endurance events, the major fuels used for

cellular energy are a. glucose and fatty acids. b. glycogen and ketones. c. amino acids and fatty acids. d. glucose and ketones.

ANS: A

With prolonged physical activity, aerobic production of energy is predominant. The primary substrates for this are glucose and fatty acids. Muscle glycogen is used in short-term, anaerobic activity. Ketones become an energy source when a low carbohydrate and high fat diet is consumed. Amino acids may be lost to promote gluconeogenesis if an athlete has inadequate carbohydrate intake.

3. Which of the following pathways is not used to generate energy in muscle cells during any

type of exercise? a. Glycogenolysis b. Gluconeogenesis c. Glycolysis

d. Beta oxidation ANS: B

Gluconeogenesis occurs in the liver, and although glucose produced by this pathway may travel to the muscle, energy generation in the muscle itself is not dependent on gluconeogenesis. During anaerobic conditions, glycogenolysis breaks down muscle glycogen stores to provide glucose for glycolysis. During aerobic conditions, glycolysis can still occur. Beta oxidation of fatty acids becomes a primary energy source for muscle cells as activity continues.

4. Which of the following molecules is required in mitochondria of muscle cells to use fatty

acids as energy resources? a. Carbon dioxide

b. Acetyl CoA c. Myoglobin d. Lactic acid ANS: B

Beta oxidation of fatty acids produces acetyl CoA, which enters the mitochondria and goes through the Krebs cycle to produce ATP. Carbon dioxide is one of the end products of energy metabolism. Myoglobin acts within the muscle as an oxygen acceptor to hold a supply of oxygen readily available for use by the mitochondria. Lactic acid is a product of anaerobic glycolysis.

5. Which of the following activities relies heavily on the anaerobic pathway in muscle cells? a. Jogging b. Sprinting c. Hiking d. Dancing ANS: B

Activities that involve high intensity and short duration rely on anaerobic metabolism for energy. Sprints or running drills use muscle glycogen anaerobically to provide the energy quickly. Longer duration activities such as jogging, hiking, and dancing cause a switch to aerobic glycolysis of the glucose produced from muscle glycogen breakdown.

6. Athletes need to increase their water intake to a. enhance renal excretion of waste products from muscle activity. b. improve intestinal absorption of nutrients after digestion. c. maintain water balance in the body as a whole and within cells. d. increase skin evaporation of water as a cooling mechanism.

ANS: C

Depending on the type of physical activity performed, athletes need to have adequate water intake to prevent dehydration. Fluid loss through sweating is affected by the length and intensity of activity as well as by the environment. Sweating provides a cooling mechanism for the body; however, if fluid is not replaced, dehydration will impair the body’s thermoregulation and the athlete’s ability to perform.

7. Strict adherence to a vegan diet increases the risk of deficiency of what nutrient(s)? a. Vitamin C b. Thiamin

c. Antioxidants d. Vitamin B12 ANS: D

A strict vegan diet does not contain meat which is the food source for vitamin B12. Vegan diets are rich in fruits, vegetables and whole grains that provide adequate supplies of vitamin C, thiamin, and antioxidants.

8. How does intensity of the exercise affect the use of fuel sources? a. As intensity decreases, carbohydrate is the larger fraction of the energy source. b. As intensity increases, fatty acids are the larger fraction of the energy source. c. As intensity increases, carbohydrate is the larger fraction of the energy source.

d. As intensity decreases, fatty acids are the larger fraction of the energy source.

ANS: C

High-intensity activities rely on anaerobic metabolism of carbohydrates.

Moderate-intensity activities rely mostly on aerobic metabolism of carbohydrates and some utilization of fatty acids. Low-intensity activities also rely on aerobic metabolism of carbohydrate and fatty acids; however, as the duration of activity increases, more fatty acid utilization occurs. This is part of the reason that the Dietary Guidelines recommend 60 to 90 minutes of activity for people wishing to lose weight. can be the result of inappropriately low fluid replacement after athletic

9.

competition. a. Impaired thermoregulation b. Decreased calcium levels and fatigue c. Cerebral edema and bradycardia d. Diuresis and osmotic diarrhea ANS: A

Adequate fluid replacement is necessary to maintain body temperature. When fluid is not replaced, the body’s core temperature can increase, promoting heat stress. Replacement of electrolytes should accompany fluid replacement because sodium is lost through sweat.

Calcium balance is maintained through adequate intake of calcium from food sources.

Cerebral edema and bradycardia occur in situations of fluid overload. With decreases in body water, the kidneys conserve fluid as opposed to promoting elimination. Osmotic diarrhea may occur if highly osmotic fluids, such as apple juice, are used for fluid replacement.

10. For athletes participating in events lasting more than 1 hour, what can a pre-event

high-carbohydrate intake do? a. It can cause hyperglycemia. b. It can increase muscle glycogen stores. c. It can cause hypotension. d. It can improve strength during an event.

ANS: B

Carbohydrate feedings consumed 3 to 4 hours before physical activity can restore liver glycogen stores and muscle glycogen stores and provide additional blood sugar for energy at the beginning of the activity. Additional intake of carbohydrate during the activity provides sufficient energy for later stages of the exercise and helps delay fatigue. During

exercise, insulin efficiency prevents the development of hyperglycemia and hypotension.

11. What is the primary source of energy for exercise of low to moderate intensity? a. Fatty acids b. Glycogen c. Amino acids d. Glycerol ANS: A

Low- to moderate-intensity activities use fatty acids as a primary source of energy.

High-intensity activities rely on glycogen and glucose as energy sources because these can be broken down faster than fat. Amino acids may be used for gluconeogenesis when other substrates for energy production are limited. Glycerol may be used as an energy source by entering partway through the glycolytic pathway.

12. What is the first source of glucose for the exercising muscle? a. Blood glucose b. Liver glycogen c. Muscle glycogen d. Muscle protein ANS: C

The breakdown of glycogen stored in the muscle makes glucose available for anaerobic metabolism at the beginning of physical activity. As muscle glycogen stores are used, blood glucose is taken up by the muscle for continued energy utilization. To maintain a supply of glucose for energy, liver glycogen will be broken down for release of glucose.

Pyruvate and lactate can be recycled back to the liver for gluconeogenesis.

13. Carbohydrate intake immediately after a training session is important because a. energy stores are depleted. b. carbohydrate is needed to reverse the feeling of fatigue. c. hypoglycemia is a common end result of prolonged exercise. d. the most effective glycogen replacement occurs after a training session.

ANS: D

The highest rates of muscle glycogen synthesis occur when large amounts of carbohydrate are consumed immediately after exercise. Carbohydrate ingestion of 1.2 g/kg/hr during the post exercise recovery period resulted in 150% greater glycogen synthesis.

14. A desirable pre-event meal 3 to 4 hours before competition is one that provides a. high fiber and vitamin content. b. 200 to 350 g of carbohydrate and is low in fat. c. an equal mix of protein and carbohydrate. d. 200 to 350 g of protein and fat and is low in carbohydrate.

ANS: B

Providing 200 to 350 g of carbohydrate (or 4 g/kg) is sufficient to replenish muscle glycogen and provide for additional blood sugar. The meal should be eaten 3 to 4 hours

before the event, and it should not provide more than 25% of total calories from fat. This is to ensure adequate emptying of the stomach before the activity. Some protein can be included but should not be emphasized, particularly in relation to animal sources, because these can increase the fat intake during the meal.

15. Which of the following best characterizes the role of iron in exercise? a. Low serum ferritin levels can have a detrimental effect on exercise performance. b. Exercise performance is affected only in cases of severe iron deficiency anemia. c. Mild iron deficiency has no detrimental effects. d. Iron plays no significant role in muscle activity.

ANS: A

As adequate iron is necessary for oxygen transport in both blood and muscle as well as in the production of ATP, low serum ferritin levels of iron can limit aerobic endurance and the capacity for work. Iron is also lost through sweat. Iron supplementation may help improve iron stores, but no evidence is available regarding the impact of iron supplementation on improving performance.

16. Which of the following ergogenic aids is used to increase the oxygen-carrying capacity to

increase VO2 max and endurance? a. Beta-hydroxy-beta-methylbutyrate (HMB) b. Iron supplements c. Steroids d. Erythropoietin (EPO) ANS: D

EPO is a hormone produced by the body that stimulates red blood cell production. This can result in an increase in serum hematocrit and increased oxygen-carrying capacity. Iron supplements may improve iron stores but have not been shown to enhance performance.

Beta-HMB and steroids are generally taken as means of increasing muscle mass. Steroids can have an anabolic effect in regard to increasing blood cell production.

17. Which of the following is a potential androgenic effect of taking steroids? a. Decreased body fat b. Increased libido c. Changes in genital size d. Vocal cord changes ANS: C

Androgenic effects of steroid use include the development of the secondary sex characteristics of men, such as changes in genital size and function and growth of auxiliary pubic and facial hair. Anabolic effects of steroid use include increases in muscle mass, bone mineral density, and blood cell production; a decrease in body fat; increased size of the heart, liver, and kidneys; changes in the vocal cords; and increased libido.

18. Which of the following is not one of the benefits of caffeine use as an ergogenic aid? a. Enhances fatty acid mobilization b. Facilitates calcium transport in muscle contractility c. Reduces fatigue by reducing plasma potassium accumulation d. Cleanses out metabolic end products by promoting diuresis

ANS: D

The diuretic effect of caffeine can have a negative effect on the athlete by promoting excessive fluid losses and potential dehydration. High intake of caffeine before events is banned by the International Olympics Committee because of the benefits of conserving glycogen by promoting fatty acid mobilization, enhancing muscle contractility, and reducing fatigue.

19. How much protein should be consumed daily by athletes in strength training? a. 0.8 to 1 g/kg b. 1 to 1.5 g/kg c. 1.2 to 2 g/kg d. 2 to 3 g/kg

ANS: C

The usual protein intake in the United States is above the DRI of 0.8 g/kg. If athletes in strength training continue with the usual protein intake of 1.2 to 2 g/kg (12% to 20% of total calories), they should be taking in enough protein to promote muscle hypertrophy.

Higher protein intakes can compromise adequate intake of carbohydrate for energy. Also, high-protein intake can promote diuresis, dehydration, and possible calcium imbalance.

Chapter 24: Nutrition and Bone Health Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Which of the following dietary variables is not related to low bone mass? a. Inadequate calcium b. Excessive retinol c. Inadequate vitamin D d. Moderate alcohol ANS: D

Bone mass is maintained by adequate vitamin D and calcium intake and adequate phosphorus to maintain the serum calcium-to-phosphate ratio. A diet high in retinol was associated with an increased risk of osteoporosis and risk of fracture. Low to moderate alcohol consumption may be beneficial for bone health.

2. Which of the following is the bone tissue at the end of the long bones? a. Trabecular bone b. Cortical bone c. Haversian systems d. Osteons ANS: A

Trabecular bone is the spongy bone that is found in the knobby ends of the long bones.

Cortical bone, which consists of osteons or Haversian systems, is found in the shaft regions of the long bones.

3. Which of the following are bone-forming cells? a. Osteocytes b. Osteoblasts c. Osteoclasts d. Osteocalcins ANS: B

Osteoblasts are the cells responsible for the formation of bone tissue. Osteocytes are formed by osteoblasts and are incorporated into the mineralized bone. Osteoclasts are responsible for the resorption or breakdown of bone. Osteocalcin is a matrix protein of

bone.

4. Bone consists of minerals and an organic a. collagen b. cartilage c. matrix d. osteocalcin ANS: C

.

The organic matrix or osteoid of bone consists mostly of collagen, which provides both the strength and flexibility of the bone. Osteocalcin and osteopontin are two proteins that are part of the matrix. Cartilage is the connective tissue that occurs at the epiphyseal ends of bone.

5. Which of the following is necessary for the maturation of osteocalcin? a. Vitamin K b. Vitamin D c. Vitamin E d. Vitamin A ANS: A

Vitamin K is involved in the posttranslational carboxylation process or maturation of osteocalcin. Vitamin D’s role in bone formation is in regard to the adequate absorption of calcium from the gastrointestinal tract as well as the stimulation of osteoblast activity.

Adequate vitamin A intake is necessary for the promotion of bone growth and maintenance. Vitamin E does not have a direct role in bone formation.

6. Which of the following statements about exercise and bone is true? a. Weight-bearing aerobic exercise has little influence on BMD. b. Upper body strength activities may improve overall BMD. c. Walking several miles each day has a large impact on hip BMD. d. Swimming regularly has a large impact on vertebral BMD. ANS: B

Use of upper body strength activities has been shown to improve the BMD of the femur.

Weight-bearing aerobic exercise with high bone-loading force has a beneficial influence on BMD of older persons. Walking and swimming provide minor benefits to bone health in elderly adults.

7. Which of the following is a tool for diagnosing osteoporosis? a. Ultrasonography b. DEXA c. Osteoporosis risk assessment instrument d. Osteoporosis index of risk ANS: B

DEXA is a diagnostic tool for osteoporosis. A BMD T-score 2.5 SD below the mean is diagnostic for osteoporosis. The other tools listed are screening tools to help identify

patients at risk of osteoporosis.

8. What does uncoupling of bone remodeling mean? a. Bone formation precedes bone resorption. b. Bone formation both exceeds and precedes bone resorption. c. Bone resorption precedes bone formation. d. Bone resorption both precedes and exceeds bone formation.

ANS: D

The uncoupling of bone remodeling explains why after peak bone mass is achieved, throughout the rest of the life cycle, bone mass declines. Normal bone remodeling involves first bone resorption and then bone formation. However, when uncoupling occurs, more resorption than formation occurs. This results in bone loss.

9. Which of the following is not a characteristic of primary osteoporosis? a. Occurs as a result of the natural aging process in men and women b. Cessation of estrogen production in women c. Decrease in dietary calcium intake d. Occurs in men around the ages of 65 to 80 ANS: C

Although decreased dietary calcium intake is a risk factor for osteoporosis, it is not specific to primary osteoporosis. Primary osteoporosis in women results after menopause when estrogen production ceases. Primary osteoporosis is associated with aging and generally occurs in men around ages 65 to 80.

10. When is the peak bone mass of a female typically achieved? a. By the end of adolescence b. By approximately 30 years of age c. Within the decade preceding menopause d. After the onset of menopause ANS: B

Peak bone mass occurs by about 30 years of age. Long bones stop growing at age 18 in females and age 20 in males but bone mass continues for a few more years. Around the age of 40 years, BMD gradually declines.

11. Which two hormones regulate calcium concentration? a. Thyroid hormone and insulin b. Parathyroid hormone and calcitriol c. Corticosteroid hormone and estrogen d. Glucagon and insulin ANS: B

A decrease in serum calcium stimulates PTH to increase resorption from the kidney and bone. Calcitriol increases gut absorption of calcium and initiates osteoclastic activity for bone breakdown to release calcium. Excessive use of thyroid hormone or corticosteroids as medications can contribute to bone loss but not to calcium homeostasis. Glucagon and

insulin have not been associated with regulation of calcium.

12. Bisphosphonates treat osteoporosis by a. stimulating estrogen production. b. increasing calcium absorption. c. inhibiting osteoclasts. d. inhibiting phosphorus absorption.

ANS: C

Alendronate, risedronate, and zoledronic acid, which are bisphosphonates, are approved for the prevention of osteoporosis, especially for postmenopausal women. The bisphosphonates act as inhibitors on osteoclasts to reduce bone resorption.

13. Which of the following age-related changes in bone metabolism do not occur in elderly

subjects? a. Decreased intake of protein b. Reduction of skin biosynthesis of vitamin D c. Increased renal excretion of calcium d. Decline in osteoblast function ANS: C

Although an excessive sodium intake may contribute to an increased renal excretion of calcium, aging itself does not result in this physiologic change. Aging is associated with decreased intestinal absorption of calcium through alterations in the gastrointestinal mucosa and in vitamin D biosynthesis and metabolism. In contrast to osteoblast activity, osteoclast activity increases because of the uncoupling of bone remodeling.

14. The WHO’s definition of osteoporosis is a BMD greater than

standard deviations

below the mean for healthy 20- to 29-year-old adults. a. 1 b. 1.5 c. 2 d. 2.5 ANS: D

Compared with the mean BMD of 20- to 29-year-old adults, the World Health Organization defines osteoporosis as a BMD greater than 2.5 standard deviations below the standard.

15. Which of these is not a risk factor for developing osteoporosis? a. Hispanic ethnicity b. European or Asian ethnicity c. Cigarette smoking d. Female athlete triad ANS: A

People of European and Asian ethnicity experience more osteoporotic fractures than Blacks or Hispanics, who usually have a greater bone density. Cigarette smoking is a risk factor, probably because of toxic effects on bone. Young women with the female athlete triad of disordered eating, amenorrhea, and low BMD are at increased risk of having fractures.

16. Which of the following female patients is at risk for osteoporosis? a. An African American woman who was normal age at menopause and has a large

frame and poor intake of calcium. b. A White woman who is overweight, had multiple pregnancies and late menopause,

and consumes alcohol. c. A White woman who is underweight, had premature menopause, does not

exercise, and smokes cigarettes. d. An Asian woman who is premenopausal and has a large frame, a high calcium

intake, and a sedentary lifestyle.

ANS: C

Risk factors for the development of osteoporosis include being a woman of European or Asian descent, being underweight or sarcopenic, having experienced menopause or oophorectomy, lack of exercise, cigarette smoking, excessive alcohol or caffeine use, and limited intake of calcium and vitamin D. 17. What is the most beneficial type of exercise to include in an exercise program for a patient

at risk for osteoporosis? a. Swimming b. Weight bearing c. Nonweight bearing d. Isometric ANS: B

Weight-bearing activities place stress on the skeleton and stimulate osteoblast activity during the developmental periods of bone accretion. Swimming, regular walking, and isometrics do not place as much stress on the skeleton and are not associated with improvements in BMD.

Chapter 25: Nutrition for Oral and Dental Health Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. What role do nuts play in regard to the development of dental caries? a. They are cariogenic. b. They are cariostatic. c. They are anticariogenic. d. They are cariogenic when eaten with fruit.

ANS: B

Nuts do not contain a significant amount of fermentable carbohydrates and therefore are cariostatic. Other cariostatic foods include protein foods such as seafood, meat, eggs, and poultry; fats such as oils, butter, margarine, and seeds; and most vegetables.

2. Cheese is considered to be anticariogenic because it a. induces an alkaline saliva. b. induces an acidic saliva. c. induces a neutral saliva. d. decreases saliva production.

ANS: A

Cheese stimulates alkaline saliva, which reduces plaque bacteria. Because of this, combining cheese with a fermentable carbohydrate can reduce the cariogenicity of the meal. As long as the oral pH remains above 5.5, enamel demineralization does not occur.

3. Which of these is not a recommendation for people with xerostomia? a. Drink water with lemon. b. Chew xylitol-containing gum. c. Add peanut butter when eating crackers. d. Eat moist foods.

ANS: C

Xerostomia is a condition of dry mouth. Usually this results from a lack of or decrease in salivation that can occur from the use of medications or from medical conditions such as uncontrolled diabetes mellitus and several autoimmune conditions. Sticky foods such as peanut butter should be avoided.

4. When and for how long does tooth mineralization occur? a. From 2 months’ gestation through 5 years of age b. From 4 months’ gestation through 12 to 13 years of age c. From 2 months’ gestation through 12 to 13 years of age d. From 4 months’ gestation through 5 years of age ANS: B

Tooth formation begins at 2 to 3 months’ gestation, and tooth mineralization begins at 4 months’ gestation. Tooth mineralization continues through 12 to 13 years of age as the baby teeth are replaced by the adult teeth.

5. Which can reduce the cariogenicity of a meal when it follows the meal? a. Eating dessert b. Eating a snack of pretzels c. Chewing sugar-free gum d. Eating fruit ANS: C

Chewing sugar-free gum after a meal can help reduce its cariogenicity by promoting salivary stimulation, which clears fermentable carbohydrates from the surface of the teeth.

Eating dessert, pretzels, or fruit at the end of a meal can have a cariogenic effect by contributing to fermentable sugars being available for plaque formation.

6. Which of the following is a significant food source of fluoride? a. Brewed tea b. Beef c. Coffee d. Spinach ANS: A

Most foods, unless prepared with fluoridated water, contain minimal amounts of fluoride, except brewed tea.

7. Which of the following foods would be identified to a patient as being potentially

cariogenic? a. Raw carrots and apples b. Cheddar cheese c. Butter d. Crackers and pretzels ANS: D

Foods that are grains, fruits, or dairy or have added sugar are ones with the greatest cariogenic potential because they are sources of fermentable carbohydrates. Crackers and pretzels provide these types of carbohydrates that can stick to the teeth. Raw carrots and apples have dietary fiber, which tends to be cariostatic. Cheddar cheese is anticariogenic because of its effect on oral pH. Butter is cariostatic.

8. Which of the following can commonly occur after a patient develops gingival recession? a. Root caries b. Lingual caries

c. Increased salivation d. Increased enamel production ANS: A

When the gingiva recedes, this exposes the root of the tooth to plaque formation, causing root caries. Lingual caries, which occurs on the tongue side of the anterior teeth, is seen in people with bulimia or anorexia-bulimia. Caries development is associated with decreased salivation and erosion of tooth enamel.

9. Along with tooth susceptibility, bacterial presence in the plaque, and sufficient exposure to

promote acid production, what other factor is necessary for the development of dental caries?

a. An anaerobic environment b. An available substrate for bacterial metabolism c. Adequate saliva d. Alkaline pH ANS: B

Oral bacteria require fermentable carbohydrate as a substrate for the production of the acids that contribute to tooth decay. Because the oral and nasal cavities expose these bacteria to oxygen, the bacteria do not function anaerobically. Adequate saliva production and alkaline pH reduce the likelihood of dental caries.

10. The ingestion of which of the following is most likely to promote bacterial activity that

promotes dental caries? a. Sucrose, glucose, and fructose b. Xylitol, mannitol, and lactose c. Aspartame, saccharin, and cyclamate d. Xylitol, saccharin, and galactose ANS: A

Sucrose, glucose, and fructose are fermentable by oral bacteria that promote tooth decay.

Some nonnutritive sweeteners, such as aspartame and saccharine, are cariostatic. Others, such as xylitol and other sugar alcohols, are anticariogenic.

11. The caries process begins when the pH drops below what level? a. 7 b. 6.5 c. 5.5 d. 5 ANS: C

When oral pH falls below 5.5, oral bacteria can begin the demineralization process that leads to tooth decay.

12. Which of the following are characteristics of foods having a low cariogenic potential? a. High content of protein, calcium, and phosphorus b. Low content of protein, calcium, and phosphorus c. Low content of phosphorus and protein d. High content of magnesium and fat ANS: A

Milk and dairy products are considered to have low cariogenic potential because they have a high calcium and phosphorus content. Protein in food is considered to provide a cariostatic effect.

13. Why are foods that require a lot of chewing effective in promoting good dental health? a. They cleanse the tooth surface. b. They promote saliva flow. c. They lower the pH level of the mouth. d. They decrease the fermentation of carbohydrate.

ANS: B

Foods that require chewing stimulate saliva production, which then reduces the cariogenicity of the meal by cleansing the teeth. This leads to a decrease in fermentable carbohydrate and increased oral pH. 14. The optimal level of water fluoridation to protect against dental caries is

ppm.

a. 0.1 to 0.6 b. 0.7 to 1.2 c. 1.2 to 1.4 d. 1.4 to 2.0 ANS: B

Standards for fluoridation of a water supply provide between 0.7 and 1.2 ppm. At this level, the incidence of caries development is reduced, and there is low likelihood of teeth staining or mottling occurring. Infants and children should receive fluoride supplementation if the water supply is not fluoridated.

15. Under which conditions should an infant receive fluoride supplementation? a. At 6 months if breastfed in a fluoridated community b. At 6 months if breastfed and given water in a fluoridated community c. At 3 months if breastfed in a fluoridated community d. At 3 months if breastfed and given water in a fluoridated community ANS: A

Because fluoride is low in breastmilk, the infant will require additional fluoride around the time of tooth eruption, around 6 months of age. If an infant is only being breastfed without supplementation with drinking water between breastfeeding episodes, then the child should receive fluoride supplementation prescribed by a doctor.

16. Which of the following may result from oral candidiasis? a. Tooth loss b. Dry mouth c. Ulcer formation d. Odynophagia ANS: D

Oral candidiasis is a fungal infection that causes a burning sensation in the mouth that can lead to pain during chewing, sucking, or swallowing (odynophagia). Tooth loss results from poor oral care and trauma to the mouth. Dry mouth can be caused by use of medications, cancer treatments, and different medical conditions. Ulcers may form in the

mouth as a result of viral infections such as herpes simplex or cytomegalovirus.

17. What is the appropriate dietary management for a patient with Sjögren syndrome? a. Provide foods that are pureed in form. b. Provide oral liquid supplements. c. Provide moist, soft, nonspicy food. d. Begin fluid restriction.

ANS: C

Sjögren syndrome results in salivary gland dysfunction, which could cause xerostomia.

Providing moist, soft, nonspicy foods and increasing fluid consumption make it easier for the patient to eat without experiencing pain. Pureed foods are more commonly used in situations in which the patient has either chewing or swallowing difficulties. Oral liquid supplements may be necessary when oral intake is severely impaired, such as when stomatitis or ulceration of the mouth occurs.

18. When a patient is identified as wearing full dentures, what else should be included in the

nutrition assessment of the patient? a. Recent changes in the patient’s weight b. The patient’s regular daily fluid intake c. When the patient last had her own teeth d. The patient’s daily intake of cariogenic foods ANS: A

As dentures replace missing teeth, they need to be checked for appropriate fit. The fit of the dentures could be affected by weight changes. If a patient has lost weight recently, the dentures may fit loosely, and this could result in continuing decreased intake. Dentures do need to be cared for, so the patient or caregiver should perform regular cleaning. Fluid intake contributes to maintaining the dentures; however, adequacy of fluid intake is not associated with denture use. Dentures are made of materials that are not susceptible to cariogenicity.

19. To limit the chances of developing early childhood caries, which of the following should

never be provided in a bottle as part of prolonged night feeding? a. Formula b. Milk c. Juice d. All of the above ANS: D

Prolonged bottle feeding, especially at night, of juice, milk, formula, or other sweetened beverages is associated with early childhood caries.

Chapter 26: Medical Nutrition Therapy for Adverse Reactions to Food: Allergies and Intolerances Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE

1. Antibodies are also known as a. immunoglobulins. b. T-cells. c. phagocytes. d. cytokines.

ANS: A

Antibodies are associated with the immune system and are also referred to as immunoglobulins. T-cells are a diverse group of lymphocytes that secrete cytokines, inflammatory mediators. Phagocytes engulf foreign particles for destruction by T-cells.

2. What are the most common antibodies involved in food allergies? a. IgG b. IgM c. T-cells d. IgE ANS: D

Immunoglobulin E antibodies are the ones involved in classic allergic reactions. IgG is the predominant antibody produced during the secondary immune response. IgG has been actively investigated as being involved with food allergies; however, its clinical usefulness has yet to be substantiated. IgM is the predominant antibody produced by new B cells and is secreted during the first immune response. T-cells are not antibodies but are involved with the cell-mediated immune response.

3. Within what frame of time is the onset of symptoms related to a food allergy most likely to

occur? a. Within 2 hours b. Within 2 to 14 hours c. More than 24 hours d. More than 48 hours

ANS: A

Anaphylactic reactions to food usually occur within the first 2 hours after exposure. These are usually IgE-mediated allergies. Chronic and relapsing forms of food allergies may take more than 2 hours because they tend to be either a mix of IgE- and cell-mediated reactions or non-IgE- and cell-mediated reactions. A food-dependent, exercise-induced anaphylaxis is a particular type of physical allergy that occurs within 2 to 4 hours of rigorous activity after eating a specific food that is normally tolerated.

4. What symptoms are likely to occur in the person with a perceived intolerance to

monosodium glutamate (MSG)? a. Decreased heart rate, constipation, and hives b. Headache, flushing, abdominal pain, and nausea

c. Steatorrhea, edema, proteinuria, and nausea d. Anaphylaxis, toxic shock syndrome, and headache ANS: B

Adverse reactions to MSG include headache, nausea, flushing, abdominal pain, and asthma.

5. The term that refers to an adverse reaction to food that is caused by a nonimmunologic

mechanism is a. food allergy. b. allergic reaction. c. food intolerance. d. food sensitivity.

ANS: C

Food intolerance does not involve an immunologic reaction. Food intolerances may include toxic, pharmacologic, metabolic, or idiosyncratic reactions. A food allergy involves an immune reaction. Food sensitivity refers to a reaction when it is unclear whether it is immunologically mediated or not. An allergic reaction can be either immune or non-immune mediated.

6. When is the “window” for introducing complementary foods for allergy prevention? a. 4 to 6 months b. 1 year c. 2 years d. 5 years ANS: A

Introduction of complementary solid foods between 4 and 6 months is recommended for allergy prevention. Early introduction increases protection against allergies in infants at high risk.

7. If an infant is allergic to cow’s milk, how should goat’s milk be used? a. As a food source for the first 6 months of life b. As a food source for the first year of life c. Not used as food because of renal solute load d. Not used as food because it is too low in fat ANS: C

Goat’s milk is low in folate and has a high renal load. Goat’s milk protein is similar to

cow’s milk and has the potential to result in an allergic reaction.

8. In what types of foods are the most common food allergens found? a. High-simple-carbohydrate foods b. High-protein animal meats c. High-protein plant and marine foods d. High-saturated-fat foods ANS: C

The most common foods associated with food allergies are milk, egg, peanut, soy, wheat, fish, sesame and tree nuts. Meats and poultry are not commonly associated with food allergies.

9. Which diagnostic method tests for IgE sensitized to specific proteins in food? a. Skin-prick test b. Hydrogen breath test c. ALCAT d. Component resolved diagnostics ANS: D

Component resolved diagnostics (CRD) identifies IgE sensitized specific component proteins in food and not just whole protein extract. Skin prick test measures response to extracts placed on the skin. Hydrogen breath test is a nonimmunological test for intestinal bacterial imbalance. ALCAT measures the amount of cytokines released in response to antigen exposure and may help identify food intolerances that are not IgE mediated.

10. Which of the following methods is effective for diagnosis when symptoms are subjective

or when multiple food allergies are suspected? a. Open food challenge b. Single-blind food challenge c. Double-blind, placebo-controlled food challenge d. Elimination diet ANS: C

The DBPCFC is considered to be the gold standard for establishing a food and symptom relationship. The DBPCFC provides objective results because both the patient and physician are unable to detect differences between placebo foods and foods with the allergen of interest. The physician is on hand to monitor for allergic reactions. A single-blind food challenge may be useful because the person receiving the challenge does not know what is being offered. An open challenge is used as a follow-up to a DBPCFC that has negative results. An elimination diet may be used for diagnosis but takes extensive time to complete, taking weeks to complete instead of hours.

11. The Step Up 2-4-6 elimination diet starts by eliminating which foods? a. Eggs and soy b. Cow’s milk and gluten/wheat c. Peanuts/nuts and fish/shellfish d. Gluten/wheat and peanuts/nuts ANS: B

The Step Up 2-4-6 food elimination diet is used to treat eosinophilic esophagitis (EoE) and

begins with the elimination of cow’s milk and gluten/wheat foods. After 6 weeks if there is no resolution of symptoms, eggs and soy are also eliminated. If still no resolution peanuts/nuts and shellfish/fish are also eliminated. This approach is usually successful at identifying causative foods.

12. The most common food allergy found among infants is a. cereal allergy. b. cow’s milk allergy. c. fruit allergy. d. vegetable protein allergy.

ANS: B

Allergy to cow’s milk protein is the most common food allergy among infants.

13. Which food has one of the most frequent cross-reactivity allergies between latex and food? a. Milk b. Wheat c. Banana d. Fish ANS: C

Bananas, avocados, chestnuts, and kiwi are the most frequent food-latex cross-reactive allergies. Milk allergies have not been seen to cross-react with latex. Wheat and fish have been associated with latex cross-reactions but not as frequently as various fruits.

14. A patient who has a food allergy to shrimp would be considered at what level of

nutritional risk in allergy management? a. No nutritional risk b. Low nutritional risk c. Moderate nutritional risk d. High nutritional risk ANS: C

A shrimp allergy would be considered a moderate nutritional risk as shrimp are widely available in food products yet their elimination from the diet does not limit a person’s food choices or access to vital nutrients. In particular, this person should inquire about recipe ingredients when eating out and should also ask about and be careful about food preparation with equipment that may also be used in preparing shrimp. A low nutritional risk is associated with food allergies focused on a single vegetable or fruit because these can be replaced with others to ensure adequate nutrient intake. A high nutritional risk is associated with foods commonly used in the food supply that may provide vital nutrients that are difficult to replace. Milk, egg, and wheat allergies are examples of high nutritional risk food allergies.

15. Which food is the most common cause of near-fatal and fatal anaphylactic reactions? a. Nuts b. Shellfish c. Egg d. Wheat ANS: A

Peanuts and tree nuts are believed to cause the most near-fatal and fatal anaphylactic reactions to foods.

16. A child develops mild gastrointestinal symptoms after drinking fruit juice. This is an

example of what type of condition? a. Food allergy b. Food aversion c. Foodborne illness d. Food intolerance ANS: D

Food intolerance is a physiologic reaction that does not include immune responses.

Patients with food allergies would have a response by the patient’s immune system. A food aversion is an individual dislike or avoidance of a food for reasons that may be based more on knowledge and perception. Foodborne illness can also present with GI symptoms as well as headache and fever. It can be confused with an allergy. If symptoms persist or worsen, consider possible foodborne illness.

17. The first diagnostic tool to use in diagnosing a food allergy is a. a detailed clinical history. b. biochemical tests. c. immunologic tests. d. an oral food challenge.

ANS: A

Diagnosis of adverse food reactions requires identification of the suspected food, proof that the food causes adverse reactions, and verification of an immune- or nonimmune-mediated response. The first step in this process is a detailed clinical history.

Chapter 27: Medical Nutrition Therapy for Upper Gastrointestinal Tract Disorders Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. What type(s) of foods should be avoided in a patient with GERD because it(they)

decrease(s) LES pressure? a. High-acid foods b. Low-fat milk and yogurt c. High-protein foods d. Peppermint ANS: D

Peppermint is known to decrease the lower esophageal sphincter pressure, contributing to the development of esophageal reflux. High-acid foods may cause pain in the esophagus when it is already inflamed. Milk, yogurt, and high-protein foods may temporarily buffer gastric secretions, but they also stimulate the secretion of gastrin, pepsin, and acid.

2. The gastrointestinal effects of smoking include a. reduction of LES pressure. b. decreased salivation. c. prolonged acid clearance. d. All of the above.

ANS: D

The gastrointestinal effects of smoking include the reduction of lower esophageal sphincter pressure, decreased salivation, prolonged acid clearance, and compromised gastrointestinal integrity.

3. Which of the following statements is not associated with Helicobacter pylori? a. H. pylori increases the risk of atrophic gastritis and gastric cancer. b. H. pylori is a viral infection found in the intestine. c. H. pylori is a bacterial infection found in the gastric mucosa. d. H. pylori infection may be treated with antibiotics and acid suppression therapies.

ANS: B

Helicobacter pylori is a gram-negative bacterium that has been associated with increased risk of atrophic gastritis, peptic ulcer, and gastric cancer. Treatment of an infection usually

involves a combination of antibiotics and acid suppression medications.

4. What is the major difference between gastric and duodenal ulcers? a. Gastric ulcers can develop with low acid output, and duodenal ulcers develop with

high acid secretion. b. Gastric ulcers develop with high acid secretion, and duodenal ulcers develop with

low acid output. c. H. pylori is the primary cause of gastric ulcers. d. Gastric ulcers are treated with proton pump inhibitors, and duodenal ulcers are

treated with H2-receptor antagonists.

ANS: A

Because gastric ulcers occur most frequently along the lesser curvature of the stomach, they may develop even when acid secretion is decreased. Duodenal ulcers occur as a result of constant exposure to high acid secretion. H. pylori is involved with the development of both types of ulcers. Because the activity of both proton pump inhibitors and H2-receptor antagonists is to decrease acid secretion, either may be used in the treatment of both gastric and duodenal ulcers.

5. When a gastrectomy is performed with an accompanying vagotomy, what physiologic

changes occur? a. Antral and pyloric dysfunction, poor peristalsis, and diminished gastric acid

secretion b. Antral and pyloric dysfunction, poor peristalsis, and high gastric acid secretion c. Impaired digestion leading to the need for parenteral nutrition almost all the time d. Dysphagia because of a relaxed LES ANS: A

The vagus nerve controls the motility of the stomach, the tone of the pylorus, and the secretion of gastrin and stomach acid. Depending on the type of vagotomy, the antrum and pylorus will exhibit decreased motility and tone, resulting in delayed stomach emptying and decreased gastric acid secretion. The vagotomy is performed below the point of innervation to the lower esophageal sphincter (LES) and therefore will not affect swallowing or LES tone. Some impairments in digestion may result due to decreased acid secretion; however, these can be accommodated for by diet manipulation and do not require lifelong need for parenteral nutrition.

6. What symptoms of dumping syndrome follow the total or subtotal removal of the

stomach? a. Nausea, abdominal cramping, and diarrhea b. Elevated blood pressure, headache, and substernal pain c. Heartburn, vomiting blood, and hypoglycemia d. Decreased saliva production, steatorrhea, and bloating ANS: A

Signs and symptoms in the early stage of dumping syndrome include abdominal fullness and nausea within 10 to 20 minutes after eating, flushing, rapid heartbeat, faintness, and sweating. In the late stage, 1 to 3 hours after eating, patients experience reactive hypoglycemia, which is exhibited through sweating and feelings of anxiety, weakness, or hunger.

7. Which of the following dietary modifications minimize the problems associated with a

gastrectomy with a vagotomy? a. Increasing carbohydrate intake, particularly simple sugars, and decreasing fat and

protein b. Decreasing intake of liquids and simple sugars with meals c. Reducing the intake of fiber from fruits and vegetables d. Increasing the intake of milk at mealtimes and between meals ANS: B

Dumping syndrome is a common problem that occurs after a gastrectomy with a vagotomy. Dietary management for dumping syndrome focuses on limiting hypertonic simple sugars, which can draw fluids into the gastrointestinal system and produce the side effects of the dumping syndrome. Because of the smaller stomach capacity and impaired control of gastric emptying, the intake of fluids with meals could promote rapid gastric emptying. A high-protein, moderate-fat diet including fibrous foods and complex carbohydrates is recommended. Patients may experience lactose intolerance after these surgeries; therefore, milk and dairy portions should be limited in quantity.

8. A recommendation to a patient with gastroparesis who needs to gain weight would be a. increase the amount of dietary fiber. b. ingest liquids or pureed foods. c. eat more high-fat foods. d. eat meals and avoid snacks.

ANS: B

Patients with gastroparesis often have preserved emptying of liquids, so shifting the diet to a more pureed and liquefied form is often useful. Fiber and fat slow gastric emptying and can therefore worsen symptoms. Small, frequent meals are often helpful.

9. Which of the following is not associated with dyspepsia? a. Diet b. Abnormal gastric emptying c. Being underweight d. Upper abdominal discomfort ANS: C

Dyspepsia refers to nonspecific, persistent upper abdominal discomfort or pain. The discomfort may be related to organic causes such as esophageal reflux, gastritis, peptic ulcer, gallbladder disease, or other identifiable pathology. Diet, stress, and other lifestyle factors may contribute to the symptoms. An underlying mechanism may be altered gastric motility.

10. When an H2 blocker is used in the treatment of peptic ulcer disease, the patient may be at

risk for deficiency of which nutrient? a. Vitamin A b. Vitamin B6 c. Vitamin B12

d. Vitamin D ANS: C

An H2 blocker is used to decrease stomach acid production. This can result in the development of achlorhydria and the loss of intrinsic factor. Patients should be monitored for serum vitamin B12 level to ensure that a deficiency in this vitamin does not develop.

11. Treating esophagitis with cimetidine, a histamine H2-receptor blocking agent is effective

because it a. provides a viscous protective barrier. b. decreases gastric acid production. c. increases LES pressure. d. promotes gastric emptying.

ANS: B

Cimetidine and ranitidine are two H2-receptor blocking agents commonly used in the treatment of patients with gastrointestinal disorders. In the management of mild cases of esophageal reflux that results in esophagitis, these medications reduce gastric acid production. Sucralfate is a mucoprotective agent used in the treatment of patients with ulcer disease. Lifestyle and dietary management are used to promote LES pressure.

Prokinetic agents are used to stimulate gastric emptying.

12. Which factor has been associated with developing gastric cancer? a. Smoking b. Obesity c. A diet high in salt and fat d. All of the above ANS: D

The etiology of gastric cancer is multifactorial, but more than 80% have been attributed to H. pylori infection. In addition, diet, lifestyle, and genetic factors contribute. A Western diet, high in processed meats, fat, and salt, is associated with an increased risk of gastric cancer. Populations that eat a lot of pickled foods, cured foods, and other high-salt foods have a higher incidence. Smoking and obesity have also been linked to gastric cancer.

13. What causes the hypoglycemia that occurs after meals in patients who have had a

gastrectomy? a. Poor dietary intake b. Rapid digestion and absorption of sugars and elevation of insulin levels c. Pancreatic insufficiency d. Elevated levels of secretin and pancreozymin ANS: B

Hypoglycemia is a consequence of late dumping syndrome that results from rapid delivery and absorption of carbohydrate into the blood system, producing an exaggerated increase in insulin and then a decrease in blood glucose levels. The gut peptides glucose insulinotropic polypeptide and glucagon-like polypeptide-1 play some role in this.

Alimentary hypoglycemia is aggravated by intake of simple carbohydrates. The pancreas is functioning normally as evidenced by the secretion of insulin in response to the carbohydrate load.

14. A patient with gastroparesis may benefit by which of these drugs?

a. Metoclopramide b. Aspirin c. Acarbose d. Simethicone ANS: A

Metoclopramide is a prokinetic agent. It increases the contractility of the stomach and shortens gastric emptying time. Aspirin is an analgesic. Acarbose interferes with carbohydrate absorption. Simethicone lowers the surface tension of gas bubbles (antigas).

15. Which of the following is not one of the benefits of using pectin to manage dumping

syndrome?

a. Reduced upper gastrointestinal tract transit time b. Forms a gel with carbohydrates and fluids c. Increased glucose absorption and insulin response d. Slow carbohydrate absorption ANS: C

Pectin and guar gums form a gel with carbohydrates and fluids. When used in the treatment of patients with dumping syndrome, pectin and guar gums reduce upper GI transit time and slow down or decrease the rate of glucose absorption. A potential caution in regard to using pectin or bulk fiber sources is in regard to the development of intestinal obstructions from using large amounts.

16. Evaluation of which of the following should be included in the nutritional assessment of

patients with atrophic gastritis? a. Essential fatty acid deficiency b. Vitamin B6 status c. Vitamin B12 status d. Iron deficiency anemia ANS: C

Atrophic gastritis results in achlorhydria and decreased intrinsic factor production. Both stomach acid and intrinsic factor are necessary for the adequate absorption of vitamin B12.

If upper GI bleeding is noted, in addition, iron status should be assessed.

17. Which of the following surgeries would be used to treat a patient with GERD? a. Billroth I b. Billroth II c. Fundoplication d. Roux-en-Y procedure ANS: C

In a fundoplication surgery, the fundus of the stomach is wrapped around the lower esophagus to limit reflux. Billroth I, Billroth II, and the roux-en-Y procedure are different gastric surgeries that involve either gastrectomy or gastric partitioning.

18. Which of the following is a condition involving the cells lining the distal esophagus

becoming abnormal and premalignant? a. Gastroesophageal reflux disease b. Esophageal stricture

c. Hiatal hernia d. Barrett esophagus ANS: D

Barrett esophagus is partly responsible for the development of adenocarcinoma of the esophagus, although esophageal cancer may develop in the absence of Barrett esophagus.

GERD is also a risk factor for esophageal cancer; however, the condition does not necessarily involve the histologic changes seen in Barrett esophagus. An esophageal stricture may result from a variety of conditions that lead to decreased esophageal tone and narrowing of the esophageal lumen. Hiatal hernia involves an outpouching of the stomach through the diaphragm.

19. Which of the following is not true for diet recommendations after Nissen fundoplication? a. Start with clear liquid diet. b. Advance to full liquid diet. c. Consume multiple, small meals. d. Avoid dry, hard foods.

ANS: B

Nissen fundoplication is a surgical treatment for severe reflux esophagitis. The fundus or top portion of the stomach is wrapped 360 degrees around the lower esophagus.

Recommendations after surgery are to start with clear liquid and advance to small meals of soft, most foods. Dry, hard foods such as meat, nuts, rolls and bread, and raw fruits should be avoided initially. By 3 to 6 months most foods should be tolerated. A full liquid diet is not a recommendation.

Chapter 28: Medical Nutrition Therapy for Lower Gastrointestinal Tract Disorders Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Blind loop syndrome is a. an abnormal passage between two internal organs. b. the presence of an excessive amount of gas in the GI tract. c. a disorder of bacterial overgrowth with resulting malabsorption. d. a malabsorptive condition resulting from massive bowel resection.

ANS: C

Blind loop syndrome is characterized by a bacterial overgrowth resulting from a stasis or obstruction of the GI tract, radiation enteritis, fistula, or surgical repair. Fat and carbohydrate malabsorption result. A fistula is an abnormal passage between two internal organs. Flatulence results from excessive gas formation in the bowel. Short-bowel syndrome, which results from excessive small bowel resection, promotes the development of malabsorption.

2. Which of the following should be included in the advice given to a patient regarding eating

a high-fiber diet? a. Increase polyunsaturated fat intake. b. Make sure to get more vitamin C. c. Drink at least 2 L of water each day. d. Make sure to get more iron.

ANS: C

A high-fiber diet of up to 25 g/day for women and 38 g/day for men should be eaten with the intake of 2 L or quarts of water each day to promote effectiveness of the diet. Intake of this amount of fiber entails the consumption of whole-grain bread and cereal products, vegetables, legumes, fruits, nuts, and seeds. These foods provide additional iron and vitamin C. 3. The most common cause of antibiotic-induced diarrhea is a. Lactobacillus spp. b. Saccharomyces boulardii. c. Escherichia coli.

d. Clostridium difficile.

ANS: D

Clostridium difficile is the most common cause of antibiotic-induced diarrhea. Escherichia coli have also been implicated. Lactobacillus and Saccharomyces boulardii are used as a supplement to recolonize the colon with beneficial bacteria.

4. Which of the following statements is true regarding medium-chain triglycerides (MCTs)? a. MCTs serve as a vehicle for lipid-soluble nutrients. b. MCTs are nonabsorbable stimulants for GI tract. c. MCTs must be administered intravenously in PN. d. MCTs are contraindicated in steatorrhea and other malabsorptive conditions.

ANS: A

MCTs serve as a calorie source and as a vehicle for lipid-soluble nutrient transport when the patient has fat malabsorption (steatorrhea). MCTs can be provided to the patient in either enteral formula or through the intake of MCT oil.

5. What is the most common carbohydrate intolerance that affects people of all ages? a. Lactose intolerance b. Galactose intolerance c. Sucrose intolerance d. Maltose intolerance ANS: A

Lactose intolerance or maldigestion is the most common carbohydrate intolerance. Some carbohydrate intolerances occur in newborns as rare congenital defects. Lactose tolerance is considered to be a genetic mutation that affects peoples in Northern Europe. However, 90% of the world’s population has a low tolerance to milk.

6. What is a characteristic difference between Crohn’s disease and ulcerative colitis? a. Age at disease onset b. Segmental versus continuous distribution of the disease throughout the GI tract c. Clinical features of diarrhea, food intolerance, and dehydration d. Medical management with steroids and diet ANS: B

Whereas Crohn’s disease appears as segments of diseased bowel separated by segments of healthy bowel, in ulcerative colitis, the disease is continuous throughout the large bowel.

Both diseases occur more frequently between the ages of 15 and 30 years. Diarrhea, food intolerances, and dehydration are experienced in both diseases. The medical management for both diseases involves treatment with corticosteroids and manipulation of the diet during flare-up episodes.

7. What should patients with Crohn’s disease be monitored for when experiencing diarrhea? a. Calcium and phosphorus status b. Magnesium and iron status c. Zinc and potassium status d. Iron and selenium status ANS: C

Although maldigestion, malabsorption, and drug-nutrient interactions may contribute to

the need for overall vitamin and mineral supplementation in patients with Crohn’s disease, diarrhea experienced by the patient promotes the reduction of potassium, selenium, and zinc stores in particular.

8. What should be included in the initial treatment of diarrhea? a. Low-fat, low-fiber diet b. Replacement of lost fluids and electrolytes c. Increase of high-pectin foods d. High-fiber diet to increase stool bulk and restore normal bowel motility ANS: B

To resolve or prevent fluid and electrolyte imbalances, the first step in treating diarrhea is replacing the lost fluids and electrolytes through use of electrolyte solutions, soups, broths, vegetable juices, or other isotonic liquids. Later, starchy carbohydrates and low-fat foods may be introduced to limit the secretion of fluids into the GI tract and to prevent rapid GI transit. This could include modest amounts of pectin and fiber (<20 g).

9. Which of the following are not included in the gluten-restricted, gliadin-free diet to treat

celiac disease? a. Wheat, rye, barley, and oats b. Corn, rice, soybeans, and tapioca c. Potatoes, hydrolyzed vegetable protein, and arrowroot starch d. Wheat, rice, barley, and corn ANS: A

Wheat, rye, barley, and oat products all contain gluten peptide fractions and should be excluded from the diet. Corn, potatoes, rice, soybeans, tapioca, arrowroot, amaranth, quinoa, millet, and buckwheat are sources of grains that may be used in creating products for people with celiac disease.

10. What should be in the solution used for fluid replacement for acute diarrhea in infants and

small children? a. Vitamins, minerals, and electrolytes b. Glucose and electrolytes in water c. Chemically defined formula d. Lactose-free formula ANS: B

Oral rehydration therapy solutions for infants and children should contain 2% glucose and sodium and potassium. Additional vitamins and minerals are not included because they would increase the osmolality of the solutions and promote potential intolerance.

Chemically defined and lactose-free formulas are usually used for more complete nutrition repletion as opposed to simple rehydration.

11. Which disease is associated with advanced age? a. Crohn’s disease b. Diverticulitis c. Ulcerative colitis d. Tropical sprue

ANS: B

Diverticular disease is one of the most common medical conditions in industrialized countries and incidence increases with age. It is more common in people over 60 years.

Ulcerative colitis, Crohn’s disease, and tropical sprue generally occur earlier in life.

12. Why do renal oxalate stones form as a consequence of ileal resection? a. Inadequate intake of dietary fiber and water b. Malabsorption of fat-soluble vitamins c. Malabsorption of calcium, zinc, and magnesium d. Malabsorption of vitamin B12 and intrinsic factor complex ANS: C

The increase in renal oxalate stone formation resulting from ileal resection occurs because of impaired bile salt reabsorption. The ileum is the primary site of bile salt reabsorption, and without it, bile salts are eliminated instead of recycled. This leads to a decrease in bile secretion, which impairs lipid digestion and absorption. The resultant increase in fatty acids in the bowel can combine with divalent cations such as calcium, zinc, and magnesium to form insoluble soaps. Normally, these cations would be free to bind with oxalate to prevent colonic absorption of oxalate. However, with the divalent cations already bound as soaps, the colonic absorption of oxalate increases. is the preferred fuel for the small intestinal enterocytes and is considered

13.

important to adaption after bowel resection. a. Glucose b. Glutamine c. MCT d. Butyrate ANS: B

Glutamine is the preferred fuel for small intestinal enterocytes and thus may be valuable in enhancing adaptation. Short-chain fatty acids (e.g., butyrate) produced from microbial fermentation of carbohydrate and fibers are the major fuels of colonic epithelium.

14. Which of the following patients with small bowel resection is the least likely to need

long-term parenteral nutrition? a. 40-year-old man with a jejunal resection b. 20-year-old woman who had radiation enteritis before resection c. 60-year-old woman with an almost total ileal resection d. 50-year-old woman with the ileocecal valve removed ANS: A

Although most patients with significant bowel resection need parenteral nutrition initially to restore and maintain nutritional status, a patient with a jejunal resection adapts to enteral nutrition and oral diet more quickly after surgery because the ileum can adapt to perform the functions of the jejunum. Risk factors for dependence on long-term parenteral nutrition include elderly age, extensive removal of the ileum, loss of the ileocecal valve, and residual disease in the bowel (e.g., radiation enteritis).

15. Which of the following is a risk factor for developing colon cancer? a. Irritable bowel syndrome

b. Lactase deficiency c. Polyps d. Diverticulitis ANS: C

Colorectal polyps are considered to be precursors of colon cancer. Inflammatory bowel disease is also a risk factor. Diets high in calories, fat, and animal protein and low in fruits, vegetables, and grains are associated with increased risk of colon cancer.

16. In the MNT for inflammatory bowel disease, which of the following is least likely to be

used? a. Low-residue diet b. Parenteral nutrition

c. Lactose-free or reduced diet d. High-fiber diet ANS: D

The medical nutrition therapy for patients with inflammatory bowel disease is highly variable and individualized depending on acuteness and exacerbation of the disease.

Because of problems with flare-ups and diarrhea, low-residue and lactose-free diets may be instituted. Commonly, parenteral nutrition may be used to promote nutritional repletion or to maintain nutritional status when oral and enteral intakes are not tolerated. A high-fiber diet is least likely to be used because the presence of fiber could aggravate the affected regions of the bowel. However, investigation into the use of prebiotic foods and fibers may help control the intestinal flora associated with IBD. 17. What is the best way for lactase-deficient people to consume lactose without major

symptoms? a. Consume limited amount per day during meals. b. Drink 1 cup of fluid milk each meal. c. Drink

cup milk before each meal.

d. Lactase-deficient people cannot consume any lactose without experiencing

symptoms.

ANS: A

Most people with lactase deficiency can consume some lactose, especially if it is consumed with meals or is in the form of cheeses or fermented dairy products without experiencing symptoms. Many can ultimately adapt to consuming one whole cup of milk when it is introduced gradually and increased incrementally over the course of several weeks.

18. What type of diarrhea may be experienced by a patient with lactase deficiency? a. Exudative diarrhea b. Malabsorptive diarrhea c. Osmotic diarrhea d. Secretory diarrhea ANS: C

When a person with lactase deficiency consumes a lactose load, the presence of lactose in the bowel promotes an osmotic effect, drawing fluid into the bowel. Exudative diarrheas result from damage to the intestinal mucosa. Malabsorptive diarrheas occur when there is a

reduction to the absorptive surface area of the bowel or rapid transit of bowel contents.

Secretory diarrheas result in the loss of fluid and water into the bowel, but this is caused by bacterial toxins, viruses, or increased intestinal hormone secretions.

19. The FODMAPs diet is showing the best success for patients with which GI disorder? a. Diverticulosis b. Celiac disease c. Crohn’s disease d. Irritable bowel syndrome ANS: D

Studies have shown that patients with IBS may not be able to tolerate a specific type of carbohydrate. Foods that contain highly fermentable carbohydrates in the presence of gut bacteria can exacerbate IBS symptoms. There is emerging research that a diet low in FODMAPs (Fermentable Oligo-, Di-, and Monosaccharides and Polyols) is an effective treatment.

Chapter 29: Medical Nutrition Therapy for Hepatobiliary and Pancreatic Disorders Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Which of the following is a common sign of portal hypertension secondary to cirrhosis? a. Ascites b. Cardiac arrhythmias c. Increased gastrointestinal motility and peristalsis d. Pulmonary fibrosis ANS: A

Portal hypertension occurs secondary to cirrhosis because of obstruction of blood flow through the liver. With a decreased production of albumin by the liver, the increased pressure within the circulatory system can force fluid into the peritoneal cavity, resulting in ascites development. Cardiac arrhythmias can be affected by changes in the blood pressure, but this is not specific to portal hypertension. Pulmonary complications can result from hepatitis.

2. Which of the following is characterized by the presence of gallstones in the common bile

duct? a. Cholangitis b. Cholecystitis c. Choledocholithiasis d. Cirrhosis ANS: C

Choledocholithiasis occurs when stones slip from the gallbladder into the bile ducts.

Cholangitis or inflammation of the bile ducts can occur as a result of choledocholithiasis.

Cholecystitis is an inflammation of the gallbladder, which can also be caused by gallstones. Cirrhosis is the final stage of liver deterioration, which involves the scarring and formation of fibrous tissue that interferes with the liver’s normal structure.

3. Which of the following hepatitis viruses are primarily transmitted by blood and body

fluids? a. Hepatitis A b. Hepatitis B

c. Hepatitis E d. None of the above ANS: B

Hepatitis B and C are transmitted via blood, blood products, semen, and saliva. Hepatitis D also may be transported by blood and body fluids; however, it is rare in the United States and depends on hepatitis B virus for survival and propagation in humans. Hepatitis A and E are the infectious forms that are transmitted by the fecal-oral route.

4. A deficiency of which nutrient is associated with Wernicke encephalopathy? a. Copper b. Essential fatty acid c. Tryptophan

d. Thiamin ANS: D

Wernicke encephalopathy is a common side effect of alcoholism and involves damage to the central nervous system caused by thiamin deficiency. The classic triad of disturbances includes encephalopathy, nystagmus (constant, involuntary movement of the eyeball), and ataxia (impaired muscular movement or gait).

5. Which of the following, when eaten by a patient with cholecystitis, may cause pain? a. High-protein foods b. High-fat foods c. Complex carbohydrates d. Simple carbohydrates ANS: B

A diet limited in fat is used when a patient has cholecystitis because fat intake stimulates the contraction of the gallbladder. When this occurs, the patient experiences pain. Presence of fat in the bowel stimulates release of cholecystokinin, which triggers the release of bile acids from the gallbladder.

6. Which of the following, when consumed by a patient with chronic pancreatitis, may cause

symptoms to worsen? a. Fried foods, foods with a high sucrose content, and caffeine b. Carbohydrates, low-fat dairy products, and coffee c. Large meals, fatty foods, and alcohol d. Red meat, sweets, and coffee ANS: C

For both chronic and acute pancreatitis, the introduction of food should be done in a manner to minimize pain, nausea, and vomiting. Smaller meals with minimal fat content are better tolerated and less likely to promote symptoms. Alcohol is avoided because it is commonly associated with the development and progression of pancreatitis.

7. Which of the following symptoms appears when pancreatitis progresses to where the

ability to secrete a sufficient quantity of enzymes is impaired? a. Constipation b. Hypervitaminosis A c. Steatorrhea d. Elevated serum ammonia

ANS: C

Steatorrhea occurs as a result of inadequate production of pancreatic lipase. This results in malabsorption of fats, leading to excessive fat in the stool. Constipation may result from motility problems with the colon, but this is not affected by pancreatic function. Because vitamin A is a fat-soluble vitamin, deficiency caused by malabsorption is more likely to occur secondary to pancreatitis than a condition of hypervitaminosis. Serum ammonia levels increase as a result of impaired liver function.

8. How is serum alkaline phosphatase used to diagnose liver disease? a. It is decreased in cholestasis. b. It is increased in cholestasis.

c. It indicates prolonged bleeding time. d. It precedes jaundice.

ANS: B

Serum alkaline phosphatase is an enzyme that is widely distributed in the liver, bone, placenta, intestine, kidneys, and leukocytes. Increased levels suggest cholestasis but can also be increased with bone disorders, pregnancy, normal growth, and some malignancies.

Prothrombin time is used to assess bleeding time.

9. Which of the following foods would be recommended to be avoided by a patient with

Wilson disease, in which excretion of copper from the body becomes impaired? a. Chocolate, mushrooms, and shellfish b. Eggs, milk, and cheese c. Sweet potato, rice, and oatmeal d. Butter, cream, oil, and salad dressing ANS: A

Foods high in copper include shellfish, chocolate, and mushrooms, as well as pork, game birds, soy protein, organ meats, avocado, dried beans, wheat germ, sweet potatoes, nectarines, dried fruits, and Brewer’s yeast.

10. In liver disease, which factor(s) affect the interpretation of serum albumin values? a. Increased synthesis of albumin by the liver b. Increased synthesis of albumin by the liver and increased nitrogen retention c. Decreased synthesis of albumin by the liver and increased urinary nitrogen

excretion d. Decreased synthesis of albumin by the liver and the presence of edema and ascites ANS: D

Liver disease affects albumin in several ways. The liver produces albumin and liver disease causes a decrease in its production. As liver disease progresses to cirrhosis, alterations in the structure of the liver affect blood flow to the liver. This leads to portal hypertension. A consequence of both the increased blood pressure and the decreased albumin production is a forcing of fluid into the interstitial and third spaces.

11. Enteral nutrition is preferred over parenteral nutrition when treating patients with severe,

acute pancreatitis because a. enteral nutrition is more expensive. b. enteral nutrition can prevent hyperglycemia from developing.

c. failure to use the gastrointestinal tract exacerbates the stress response. d. it is not the preferred route of nutrition.

ANS: C

The optimal route of nutrition in acute pancreatitis has been the subject of much controversy over the years. Failure to use the GI tract in patients with acute pancreatitis may exacerbate the stress response and disease severity, leading to more complications and prolonged hospitalization; thus, enteral nutrition is preferred for nutrition therapy.

Enteral nutrition cannot prevent hyperglycemia since elevated glucose levels are primarily the result of availability and activity of insulin. However, in general, enteral nutrition is associated with lower glucose levels than parenteral nutrition.

12. Which of the following recommendations should be included in the nutrition care plan for

a patient in the acute post liver transplant phase? a. Calorie restriction b. Increased sodium c. Decreased protein d. Increased protein ANS: D

In the acute post liver transplant phase, nutrient needs are increased to promote healing, deter infection, provide energy for recovery, and replenish depleted body stores. Nitrogen requirements are elevated.

13. Increased serum aromatic amino acids and decreased serum branched-chain amino acids

are theoretically associated with a. sclerosing cholangitis. b. acute pancreatitis. c. hepatic encephalopathy. d. cholecystitis.

ANS: C

A plasma amino acid imbalance exists in end-stage liver disease in which the branched-chain amino acids are decreased and aromatic amino acids are increased. It has been hypothesized that this imbalance is responsible for hepatic encephalopathy because high levels of aromatic amino acids may limit cerebral uptake of branched-chain amino acids. It is known as the false neurotransmitter theory. Convincing evidence to support this theory is lacking.

14. Which of the following is a prognostic scoring tool for determining the mortality risk of

patients with acute pancreatitis? a. Apache II b. BISAP c. Ranson d. All of the above ANS: D

All the tools listed are used to predict severity and risk of mortality in patients with acute pancreatitis.

15. Which of the following may be provided to a patient with chronic pancreatitis to minimize

steatorrhea? a. Water-soluble form of fat-soluble vitamins b. Pancreatic enzyme replacements c. Antacids d. Proton pump inhibitors ANS: B

Pancreatic enzyme replacement therapy provides dosages of lipase that are consumed at meal times. This allows for the lipase to aid in the digestion of fat in the diet to promote improved absorption, thus reducing steatorrhea. Fat-soluble vitamins are supplemented in water-soluble form to ensure against potential deficiencies due to fat malabsorption.

Because pancreatic bicarbonate secretion is impaired, antacids and proton pump inhibitors may be provided to reduce or neutralize stomach acids to restore the optimal pH in the duodenum for digestive enzyme actions.

16. Which type of immunosuppressant drug used in the treatment of liver transplant is most

likely to promote sodium retention, hyperglycemia, and impaired absorption of calcium? a. Azathioprine b. Cyclosporine c. Glucocorticoid d. Tacrolimus ANS: C

Use of glucocorticoids has the side effects of sodium retention, hyperglycemia, hyperlipidemia, false hunger, protein wasting, and decreased absorption of calcium and phosphorus. Use of azathioprine can cause macrocytic anemia, mouth sores, nausea, vomiting, diarrhea, anorexia, sore throat, stomach pain, and decreased taste acuity.

Cyclosporine can cause sodium retention, hyperkalemia, hyperglycemia, hyperlipidemia, decreased serum magnesium, hypertension, nausea, and vomiting. Tacrolimus promotes hyperglycemia, hyperkalemia, nausea, and vomiting.

17. Which of the following herbal supplements is popular for treating liver disease? a. Milk thistle (Silybum marianum) b. Garcinia cambogia c. Ephedra (Ephedra sinica) d. Kava (Piper methysticum) ANS: A

Milk thistle is popular among those with viral hepatitis and alcoholic liver disease. The active component is silymarin. It is proposed to have anti-inflammatory, antioxidant, and antifibrotic properties. Garcinia cambogia, Ephedra, and Kava have been implicated in liver injury and there is insufficient evidence to support their use.

18. Which of the following parameters is included in Subjective Global Assessment? a. Change in weight

b. Nitrogen balance c. Fluid intake and output d. Liver enzyme levels ANS: A

Subjective Global Assessment is a reliable and valid technique for assessing a patient’s nutritional status without relying on biochemical measures or tests. The patient completes a short history regarding changes in weight, appetite, taste, intake, and gastrointestinal problems. A medical practitioner evaluates the patient physically for muscle wasting, fat stores, and the presence of edema or ascites. Then with knowledge of the patient’s medical condition, a nutritional rating is assigned to the patient regarding whether the patient is well nourished, moderately malnourished, or severely malnourished.

19. Which of the following is used in the medical treatment of ascites? a. Shunt placement b. Whipple procedure c. Paracentesis d. Shock-wave lithotripsy ANS: C

Paracentesis is a procedure used to treat ascites that involves removing fluid from the abdominal cavity with a needle. Radiologic or surgical placement of a shunt may be used to treat esophageal varices. The Whipple procedure is a surgical pancreaticoduodenectomy performed in the treatment of pancreatic cancer. Shock-wave lithotripsy is a method of breaking apart gallstones through use of sonic waves.

20. Which of the following biochemical measures is a test of the liver’s excretion? a. Serum alkaline phosphatase b. Direct serum bilirubin c. Alanine aminotransferase d. Prothrombin time ANS: B

Direct serum or conjugated bilirubin is a measure of the liver’s excretory function. Levels increase when liver function and excretion are impaired. Serum alkaline phosphatase is an indicator of cholestasis. Alanine aminotransferase is hepatocyte cytosolic enzyme. Levels of ALT increase when liver cells are damaged. Prothrombin time is a measure of the liver’s serum protein synthesis.

Chapter 30: Medical Nutrition Therapy for Diabetes Mellitus and Hypoglycemia of Nondiabetic Origin Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE

1. Which of the following criteria is appropriate for the diagnosis of diabetes mellitus? a. Fasting plasma glucose of greater than 126 mg/dl b. HbA1C of greater than 7.0% c. Postload (2 hour) plasma glucose of 200 mg/dl or greater d. All of the above ANS: D

All the above criteria are diagnostic for diabetes mellitus.

2. Which of the following is not a microvascular disease associated with hyperglycemic

patients? a. Retinopathy b. Neuropathy c. Nephropathy d. Peripheral vascular disease ANS: D

Microvascular diseases are ones that affect smaller blood vessels and nerves. Retinopathy, neuropathy, and nephropathy have been the three primary microvascular diseases that develop from uncontrolled diabetes mellitus. Peripheral vascular disease is classified as a macrovascular disease because it involves larger blood vessels.

3. Which of the following contributes to the development of type 1 DM? a. Autoantibodies that contribute to the destruction of beta-cells b. Insulin resistance and beta-cell failure c. Increase in insulin-antagonist hormone levels d. Diet and sedentary lifestyle ANS: A

Immune-mediated diabetes mellitus (DM) is the form of type 1 DM that results from autoimmune destruction of the pancreatic beta-cells. This results in the patient’s inability to produce insulin. Idiopathic type 1 DM is the other form, and it is DM that has no known

etiology. Insulin resistance and beta-cell failure are what lead to the development of type 2 DM. Diet and sedentary lifestyle can contribute to this development. Gestational diabetes mellitus develops because of an increase in the release of insulin-antagonist hormones during pregnancy. These increased hormone levels contribute to an insulin resistance in the pregnant woman.

4. Which of the following is not a potential acute complication of type 1 DM? a. Hypoglycemia b. Hyperglycemia c. Ketoacidosis d. Blood vessel damage

ANS: D

Blood vessel damage may be either microvascular or macrovascular in nature; however, this occurs because of long-term exposure of the blood vessels to the physiologic changes that commonly occur with diabetes, such as hyperglycemia, hyperlipidemia, and hypertension. Hypoglycemia, hyperglycemia, and ketoacidosis are acute complications of diabetes mellitus because each of these can occur rapidly in relation to alterations in the patient’s lifestyle, health, or use of medications.

5. In the Diabetes Control and Complications Trial (DCCT), which of the following was

demonstrated? a. Strict control of protein intake, particularly animal protein, improves glucose

control. b. Minimizing the number of meals and snacks per day decreases hyperglycemic

episodes. c. Strict control of carbohydrate intake, particularly simple sugars, improves glucose

control. d. Strict control of blood glucose reduces long-term complications of diabetes.

ANS: D

In a DCCT, subjects with type 1 diabetes mellitus were provided with either intensive treatment involving multiple insulin injections daily or conventional treatment with only one or two insulin injections daily. The subjects who monitored their blood glucose and used intensive insulin therapy experienced a reduction in the risk progression of retinopathy, nephropathy, and neuropathy. The trial did include prescribed meal plans but did not evaluate the effect of macronutrient content or number of meals on glucose control. is not a symptom of type 1 DM.

6.

a. Hyperglycemia b. Loss of thirst sensation c. Weight loss d. Polydipsia ANS: B

The common symptoms of type 1 diabetes mellitus include hyperglycemia, polyuria, polydipsia, weight loss, dehydration, electrolyte disturbance, and ketoacidosis. Type 1 DM tends to increase the thirst sensation as opposed to blocking it.

7. If a patient with type 2 DM receives a nutrition prescription for a 2000-kcal diet, which of

the following should be used? a. 50% carbohydrate, 20% protein, 30% fat b. 40% carbohydrate, 30% protein, 30% fat c. 20% carbohydrate, 40% protein, 40% fat d. A macronutrient distribution individualized based on the patient’s metabolic

profile ANS: D

Before 1994, the American Diabetes Association (ADA) attempted to define optimal percentages of macronutrients for control of metabolic complications of diabetes.

However, since then, the ADA’s focus has been on individualizing nutrition care to accommodate the patient’s lifestyle, culture, and socioeconomic status. When planning for patient diets, the RDN should maintain the acceptable macronutrient distribution ranges (AMDRs) established by the DRIs. 8. Which of the following would not result in postprandial (reactive) hypoglycemia? a. Rapid glucose absorption b. Excessive insulin secretion c. Insufficient glucagon secretion d. Excessive hepatic gluconeogenesis ANS: D

Postprandial or reactive hypoglycemia occurs within 2 to 5 hours after eating. During this period of time, the body absorbs glucose and responds to increased blood glucose levels by secreting insulin. However, during this same time, as glucose is being provided by the diet, the liver is not stimulated to produce additional glucose through gluconeogenesis. A defect in glucagon response could contribute to the hypoglycemia by not triggering gluconeogenesis.

9. What condition occurs when rebound hyperglycemia follows an episode of hypoglycemia? a. Somogyi effect b. Cushing syndrome c. Dawn phenomenon d. Hyperglycemic hyperosmolar state ANS: A

The Somogyi effect may be caused by excessive exogenous insulin administration. In response to the hypoglycemia that results, the counterregulatory hormones are secreted to promote gluconeogenesis. This results in an increase in blood glucose levels. Cushing syndrome is a rare condition involving the excessive secretion of cortisol. The dawn phenomenon involves an increase in morning blood glucose because of an increased need for insulin. The hyperglycemic hyperosmolar state is a complication in older adults with diabetes. In this condition, the patient has a very high blood glucose level but no ketones.

10. What must a patient demonstrate to be a candidate for use of oral glucose-lowering

medications?

a. Functioning alpha-cells in the pancreas b. Functioning beta-cells in the pancreas c. Functioning gastrointestinal mucosa d. Resistance to insulin at all times ANS: B

Oral glucose-lowering medications may be used in the treatment of patients with type 2 DM; therefore, the patient has to have beta-cell function for the production of insulin. The mechanisms of action for the oral glucose-lowering medications include the stimulation of pancreatic insulin secretion. Other mechanisms of action include reducing insulin resistance at muscle and adipose tissue and decreasing hepatic glucose output.

11. What is the recommendation for self-monitoring of blood glucose?

a. Every morning and every night before bed b. When there is a change in activity level or diet c. Four or more times daily for type 1 DM and one to four times for type 2 DM d. At least eight times a day for type 1 DM ANS: C

Patients with type 1 DM should perform SMBG four times or more daily, including before each meal and at bedtime. Patients with type 2 DM should perform SMBG one to four times daily to help in achieving glucose goals. Whenever they add to or modify their therapies, patients with either DM should test more often.

12. What should the person with type 1 DM do when planning to exercise? a. Strictly adhere to dietary restrictions. b. Decrease insulin dosage dependent on duration and intensity of exercise. c. Plan to exercise when the insulin is peaking. d. Take an extra injection of insulin.

ANS: B

Decreasing the amount of insulin injected is necessary to prevent hypoglycemia that can occur during exercise. Prolonged or intensive exercise may require a modest decrease of 1 to 2 U of rapid- and short-acting insulin before and possibly after exercise. As an alternative, the person with type 1 DM may ingest carbohydrate before or after exercise to prevent hypoglycemia. Exercising at the time of insulin peak action and providing extra insulin can increase the likelihood of hypoglycemia.

13. What does insulin promote in regard to the metabolism of lipids? a. Lipolysis in the liver b. An increase in serum free fatty acids c. Lipogenesis in the liver d. The breakdown of fat stores in adipose tissue ANS: C

In regard to lipids, insulin stimulates the conversion of pyruvate to fatty acids in the liver as part of the process of lipogenesis. Insulin’s anticatabolic activities in relation to lipids include the inhibition of lipolysis and the prevention of excessive ketone production.

Insulin’s transport activity includes the activation of lipoprotein lipase to facilitate the transport of triglycerides into adipose tissue.

14. How do sulfonylureas and meglitinides help to lower blood glucose levels?

a. Promoting beta-cell secretion of insulin b. Decreasing the insulin sensitivity of the receptor cell c. Increasing glucose formation from liver glycogen d. Decreasing deamination of protein ANS: A

Sulfonylureas and meglitinides are oral glucose-lowering medications that act as insulin secretagogues. Their action is to stimulate the pancreatic secretion of insulin. Biguanides and thiazolidinediones are insulin-sensitizing medications that lower insulin resistance and decrease hepatic glucose production from glycogenolysis and gluconeogenesis.

15. Which insulin peaks in activity 2 to 3 hours after injection?

a. Lispro (Humalog) b. Detemir (Levemir) c. NPH d. Regular ANS: D

Regular insulin is short-acting insulin that peaks within 2 to 3 hours of injection. Lispro is rapid-acting insulin that peaks within 30 minutes to 2.5 hours. NPH is intermediate-acting insulin that peaks between 4 and 10 hours after injection. Detemir is long-acting insulin that stays in the blood system from 18 to 24 hours without a “peak” time of activity.

Patients receiving detemir should be monitored 10 to 12 hours after injection for effects of the insulin.

16. Which of the following is not true about amylin? a. It is a glucoregulatory hormone. b. It is produced in pancreatic beta-cells. c. It counteracts the effects of insulin. d. Deficiency is associated with TIDM. ANS: C

Amylin, a glucoregulatory hormone, is also produced in the beta-cells of the pancreas and is co-secreted with insulin. It works in concert with insulin to regulate postprandial serum glucose levels and suppresses glucagon secretion.

17. Which of the following is the primary goal of MNT for all people with diabetes? a. Promote weight loss. b. Achieve blood glucose control. c. Limit dietary cholesterol. d. Limit intake of simple carbohydrates.

ANS: B

The first MNT goal for all people with diabetes is to achieve and maintain normal blood glucose levels. Managing lipid and lipoprotein profiles and blood pressure levels that reduce the risk for vascular disease is one of the goals. MNT goals also include preventing or slowing the progression of chronic complications of diabetes mellitus, addressing the individual’s nutritional needs, and limiting food choices only based on evidence while maintaining the pleasure of eating. Diabetes may affect children and pregnant women, and weight loss is not important to maintaining health in these population groups. Research evidence does not substantiate a recommendation to limit simple carbohydrate intake in

the treatment of diabetes.

18. Which of the following statements about glycemic index (GI) is true? a. Consuming low-GI meals (<70) improves overall glycemic control. b. Specific carbohydrate foods can have a variable GI. c. When compared with an equal amount of starch, sucrose promotes a greater

glycemic response. d. The GI of glucose is lower than the GI of white bread.

ANS: B

The difficulty of working with the GI concept is that the GI of an individual food may vary. This is part of the reason that the ADA has not fully adopted GI and glycemic load as approaches to meal planning. Low-GI foods are those with a GI of less than 55. Selection of low-GI foods may help in fine-tuning postprandial glycemic response, but research presents inconsistent results in relation to overall glycemic control. Equal amounts of starch and sucrose result in identical glycemic responses. The GI of glucose is 100. The GI of white bread is 70.

19. Screening for gestational diabetes should occur a. when assessment of pregnancy is first established. b. at 24 to 28 weeks’ gestation. c. 38 to 40 weeks after conception. d. by the end of the first trimester.

ANS: B

The need for insulin increases during the second and third trimesters of pregnancy because these are the periods during which much of the growth of tissue in both the mother and fetus occurs. Screening for GDM occurs between 24 and 28 weeks’ gestation to monitor the maternal insulin response. Toward the end of pregnancy, 38 to 40 weeks, insulin needs and levels peak at two to three times the prepregnancy levels.

Chapter 31: Medical Nutrition Therapy for Thyroid, Adrenal, and Other Endocrine Disorders Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE

1. Iodine deficiency is often a culprit in thyroid disorders. However, in which of these

thyroid conditions may supplementing with iodine exacerbate the condition? a. Adrenal insufficiency b. Hashimoto thyroiditis c. Polycystic ovary syndrome (PCOS) d. Graves’ disease ANS: B

In autoimmune Hashimoto thyroiditis, supplementing with iodine may exacerbate the condition. Because iodine stimulates production of TPO, this in turn increases the levels of TPO antibodies (TPO Abs) dramatically, indicating an autoimmune flare-up. Some people develop symptoms of an overactive thyroid, but others have no symptoms despite tests showing an elevated level of TPO Abs. Therefore, one must be cautious regarding the use of iodine. Furthermore, although iodine deficiency is the most common cause of hypothyroidism for most of the world’s population, in the United States and other westernized countries, Hashimoto thyroiditis accounts for the majority of cases.

2. Selenium deficiency, inadequate protein, excess carbohydrates, chronic illness, and stress

(high cortisol levels) can all impact what thyroid metabolic process? a. Thyroid-stimulating hormone (TSH) production b. Organification of iodide c. Thyroid-binding globulin (TBG) T4 transport d. 5-Deiodinase conversion of T4 to T3 ANS: D

Changes in 5-deiodination occur in a number of situations, such as stress, poor nutrition, illness, selenium deficiency, and drug therapy. Toxic metals such as cadmium, mercury, and lead have been associated with impaired hepatic 5-deiodination in animal models.

Free radicals are also involved in inhibition of 5-deiodinase activity.

3. Low energy, cold hands and feet, fatigue, hypercholesterolemia, muscle pain, depression,

and a positive test result for thyroid peroxidase antibodies could all be indicative of what condition? a. Diabetes mellitus b. Graves’ disease c. Hashimoto thyroiditis d. Polycystic ovary syndrome (PCOS) ANS: C

Hashimoto thyroiditis is an autoimmune disorder in which the immune system attacks and destroys the thyroid gland. It is the most common form of hypothyroidism. The TPO Abs test is the most important because TPO is the enzyme responsible for the production of thyroid hormones and the most frequent target of attack in Hashimoto thyroiditis.

4. Eating an excessive amount of some plant foods (especially when raw) such as

cauliflower, broccoli, and cabbage, exert antithyroid activity through what mechanism? a. Binding iodine species b. Inhibiting thyroid peroxidase c. Increasing thyroglobulin antibodies d. Stimulating cortisol ANS: B

Cyanogenic plant foods (cauliflower, broccoli, cabbage, Brussels sprouts, mustard seed, turnip, radish, bamboo shoot, and cassava) exert antithyroid activity through inhibition of thyroid peroxidase (TPO). The hydrolysis of some glucosinolates found in cruciferous vegetables (e.g., progoitrin) may yield goitrin, a compound known to interfere with thyroid hormone synthesis. Cooking the foods and having good iodine and selenium status will help prevent this from happening.

5. Before 1960, reports surfaced that soy formula-fed infants were developing

hypothyroidism. The addition of what supplement to these formulas ameliorated this problem? a. Iodine b. Selenium c. Iron d. Tyrosine ANS: A

Soybean, an important source of protein in many developing countries, has goitrogenic properties when iodine intake is limited. The isoflavones, genistein and daidzein, inhibit the activity of TPO and can lower thyroid hormone synthesis. Furthermore, soybean interrupts the enterohepatic cycle of thyroid hormone metabolism. Since the addition of iodine to soy-based formulas in the 1960s, there have been no further reports of hypothyroidism developing in soy formula-fed infants.

6. Graves’ disease is an autoimmune disease in which the thyroid is diffusely enlarged

(goiter) and overactive, producing an excessive amount of thyroid hormones. It is the most common cause of hyperthyroidism (overactive thyroid) in the United States. What is the primary target of circulating autoantibodies in this disease? a. Insulin receptors b. Thyroid-stimulating hormone (TSH) receptors c. Thyrotropin-releasing hormone (TRH) receptors

d. Cortisol receptors ANS: C

In Graves’ disease, the TRH receptor itself is the primary autoantigen and is responsible for the manifestation of hyperthyroidism. The thyroid gland is under continuous stimulation by circulating autoantibodies against the TRH receptor, and pituitary TSH secretion is suppressed because of the increased production of thyroid hormones. These thyroid-stimulating antibodies cause release of thyroid hormone and Tg and stimulate iodine uptake, protein synthesis, and thyroid gland growth.

7. Dietary intervention is a key therapeutic tool in managing patients with thyroid disease. In

the absence of nutritional deficiencies, what is the main goal of nutritional support? a. Maintaining vitamin sufficiency

b. Decreasing oxidative stress c. Increasing iodine concentrations d. Reducing antithyroidal antibodies ANS: D

A variety of food antigens could induce antibodies that cross-react with the thyroid gland.

A food elimination diet using gluten-free grains and possible elimination of casein, the predominant milk protein, might be considered for patients with hypothyroidism of unexplained origin.

8. Maintaining thyroid hormone function throughout the aging process appears to be an

important hallmark of healthy aging. What characteristic is an indicator of thyroid health in centenarians? a. Decreased free T4 and rT3 levels b. An increased libido c. Constant cortisol production d. The absence of circulating thyroid autoantibodies ANS: D

Because unhealthy aging is associated with a progressively increasing prevalence of organ-specific and nonorgan-specific autoantibodies, the absence of these antibodies may represent a significantly reduced risk for cardiovascular disease and other chronic age-related disorders.

9. A rare primary adrenal insufficiency in which insufficient levels of steroid hormones are

produced despite adequate levels of the hormone ACTH is known as a. adrenal fatigue. b. Addison disease. c. Cushing syndrome. d. euthyroid sick syndrome.

ANS: B

Addison disease is primary adrenal insufficiency and insufficient levels of steroid hormones are produced despite adequate levels of ACTH. In Cushing syndrome, too much cortisol remains in the bloodstream over a long period of time. Adrenal fatigue is a syndrome caused by the decreased ability of the adrenal glands to respond to stress and is almost always secondary to something else. Euthyroid sick syndrome is hypothyroidism associated with a severe systemic illness.

10. Which of these is not a product of the thyroid? a. Thyroxine (T4) b. Calcitonin c. Reverse T3 (rT3) d. Triiodothyronine (T3) ANS: C

Reverse T3 (rT3) is derived from T4 through the action of deiodinase. It is an isomer of T3 but is not itself produced by the thyroid.

11. A severe systemic illness that causes decreased peripheral conversion of T4 to T3, an

increased conversion of T3 to the inactive rT3, and decreased binding of thyroid hormones is known as a. Hashimoto thyroiditis. b. Graves’ disease. c. euthyroid sick syndrome. d. Addison disease.

ANS: C

Euthyroid sick syndrome is hypothyroidism associated with malnutrition, surgical trauma, myocardial infarction, chronic renal failure, diabetic ketoacidosis, anorexia nervosa, cirrhosis, thermal injury, or sepsis. After the underlying cause is treated, the condition is usually resolved.

12. Characteristics of chronic adrenal stress do not include a. decrease thyroid-binding protein activity. b. decreased conversion of T4 to active forms of T3. c. weakened immune barriers of the digestive tract, lungs, and brain. d. increased sensitivity to thyroid hormones.

ANS: D

Chronic adrenal stress results in decreased sensitivity to thyroid hormones. Chronic adrenal stress, marked by an increase in cortisol, can decrease thyroid binding protein activity, decrease conversion of T4 to T3, and weaken the immune system.

13. Polycystic ovary syndrome (PCOS) is characterized by which of the following

biochemical and endocrine abnormalities? a. Elevated testosterone, insulin resistance, and impaired glucose tolerance b. Thyrotoxicosis, iodine deficiency, and elevated estrogen c. Impaired glucose tolerance, increased T4 conversion, and hypertension d. Low blood calcium, thyroid receptor hypersensitivity, and elevated cortisol ANS: A

Biochemical and endocrine abnormalities in people with PCOS include elevated levels of androgens (dehydroepiandrosterone, testosterone, and androstenedione), hyperinsulinemia (which results from insulin resistance), impaired glucose tolerance, and hyperlipidemia.

Hyperandrogenism is responsible for many of the symptoms of PCOS, such as reproductive and menstrual abnormalities, hirsutism, and acne.

14. Botanical preparations have been found in animal studies to influence thyroid activity.

Commiphora mukul (guggulsterones from guggul extract) has strong thyroid stimulatory action, demonstrated by a. increasing lipid peroxidation. b. decreasing iodine uptake by the thyroid. c. increasing TPO activity. d. decreasing peripheral serum generation of T3.

ANS: C

Administration of 1 mg of Commiphora mukul/100 g body weight increases iodine uptake by the thyroid, increases TPO activity, and decreases lipid peroxidation, suggesting that increased peripheral generation of T3 might be mediated by this plant’s antioxidant effects.

15. Although some T3 is produced in the thyroid, approximately 80% to 85% is generated

outside the thyroid in which organs? a. Nervous system and adrenal glands b. Liver and kidneys c. Pancreas and gastrointestinal tract d. Hypothalamus and pituitary gland ANS: B

T3 is primarily produced by conversion of T4 in the liver and kidneys. The pituitary and nervous system are capable of converting T4 to T3, so they are not reliant on T3 produced in the liver or kidney.

16. In some cases, especially if autoimmune disease is present, thyroid health has been shown

to be impacted by the elimination of which foods? a. Seafood b. Gluten c. Mushrooms d. Barley ANS: B

A variety of food antigens could induce antibodies that cross-react with the thyroid gland.

Eliminating gluten-containing grains has been suggested for treatment of hypothyroidism of unknown origin. Selenium has been shown to enhance thyroid function; mushrooms, barley, and seafood are good sources of selenium.

17. More than 90% of people with autoimmune thyroid disease have a genetic defect affecting

their ability to metabolize what? a. Vitamin D b. Flavonoids c. Selenium d. Tyrosine ANS: A

Vitamin D is considered a prohormone with antiproliferative, differentiating, and

immunosuppressive activities. Vitamin D also appears to work with other nutritional factors to help regulate immune sensitivity and may protect against development of autoantibodies.

18. Which of these is not required for the production of thyroxine (T4) and triiodothyronine

(T3)? a. Thyroid peroxidase (TPO) b. Tyrosine c. Thyroid-binding globulin (TBG) d. Iodide ANS: C

The synthesis of T3 and T4 requires tyrosine, a key amino acid involved in the production of thyroid hormone, and the trace mineral iodine. Two additional molecules of iodine bind to the tyrosyl ring in a reaction that involves thyroid peroxidase (TPO), an enzyme. When T4 is released from the thyroid, it is primarily in a bound form with thyroid-binding globulin (TBG), a protein that transports thyroid hormones through the bloodstream but is not required for production.

19. Thyroid health in some adults can be improved by increasing the conversion of T4 to T3.

This can be accomplished by a. supplementing with tyrosine. b. correcting zinc deficiencies with zinc glycinate or zinc citrate. c. increasing naturally occurring flavonoids in the diet. d. cautiously supplementing with lipoic acid.

ANS: B

Nutritional agents that help support proper deiodination by the type 1 5-deiodinase enzyme include selenomethionine (as L-selenomethionine) and zinc (as zinc glycinate or zinc citrate). Human studies have repeatedly demonstrated consequent reduced concentrations of thyroid hormones when a zinc deficiency is present. Supplementation with tyrosine does not appear to have a beneficial effect on elevating thyroid hormones.

Synthetic flavonoid derivatives can decrease serum T4 concentrations and inhibit both the conversion of T4 to T3 and the metabolic clearance of rT3 by the selenium-dependent 5-deiodinase. Naturally occurring flavonoids appear to have a similar inhibitory effect.

Lipoic acid reduces the conversion of T4 to T3.

20. Cushing syndrome is characterized by weight gain, easy bruising, depression, muscle loss,

and weakness. It is caused by a. an increased concentration of endocrine autoantibodies. b. thiocyanate ions, which can compete with iodine for uptake by the thyroid gland. c. too much cortisol remaining in the bloodstream over a long period. d. thyroid hormone deficiency during pregnancy.

ANS: C

In Cushing syndrome, too much cortisol remains in the bloodstream over a long period.

The exogenous form occurs when individuals take steroids or other similar medications and ceases when the medication is stopped. Endogenous Cushing syndrome is rare and occurs as the result of a tumor on the adrenal or pituitary gland.

Chapter 32: Medical Nutrition Therapy for Anemia Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Which of the following enhances the absorption of dietary iron and iron supplements? a. Calcium-containing foods b. Carbohydrates c. Vitamin C d. Magnesium ANS: C

Factors in food related to improved bioavailability of iron include heme form, MFP factor, and vitamin C. Factors in food that may decrease bioavailability of iron include chelators such as phytate, oxalate, carbonate, and phosphate, which are often found in fibrous foods; tannins in tea and coffee; phosvitin in egg yolk; and possible competition with other minerals.

2. Which of the following food groupings has the highest iron content? a. Milk, raisins, and spinach b. Broccoli, rice krispies, and black beans c. Kidney beans, pistachio nuts, and eggs d. Tuna, beef tenderloin steak, and chicken liver ANS: D

Heme iron is the organic form in meat, fish, and poultry. It is much better absorbed than nonheme iron.

3. Which of the following may reduce the absorption of iron when consumed in large

amounts? a. Coffee or tea with meals b. Leavened bread c. Pork d. Fish ANS: A

Taken with meals, coffee and tea can reduce the absorption of iron by 50% because of their tannin content. Unleavened breads tend to be higher in phytates, which can chelate

iron. The iron in pork and fish tends to be heme iron, and MFP factor in these foods promotes improved absorption of the iron.

4. Which of the following foods provide significant amounts of folate in the diet? a. Fish and seafood b. Milk products c. Fresh fruit and vegetables d. Eggs and poultry ANS: C

Fresh, uncooked fruits and vegetables are good sources of folate, as are legumes, tofu, and organ meats. Folate is easily destroyed by heat. Poultry, fish, eggs, meat, and dairy products provide small amounts of folate but not as much as fruits and vegetables. Because of fortification, grain products are also significant sources of folate in the United States.

5. How does pernicious anemia differ from folate deficiency? a. Pernicious anemia is easily treated by dietary alterations. b. Pernicious anemia affects the central and peripheral nervous systems. c. Pernicious anemia is reversible with treatment. d. Pernicious anemia results in microcytic, hypochromic red blood cells.

ANS: B

Pernicious anemia differs from folate deficiency because it affects the central and peripheral nervous systems. Pernicious anemia results in macrocytic anemia caused by a vitamin B12 deficiency commonly resulting from a lack of intrinsic factor. By providing supplementation, both pernicious and folate deficiency anemia are reversible. Including animal protein products in the diet will treat pernicious anemia, and including green leafy vegetables and fortified grains in the diet will treat folate deficiency.

6. Foods high in

should be avoided by individuals with sickle cell anemia.

a. protein b. folate c. iron d. vitamin A ANS: C

Sickle cell anemia is a hemolytic anemia that results in increased iron stores in the liver.

When a patient has received multiple blood transfusions, this could promote iron overload.

Diet should focus on inclusion of sources of iron that have poor absorbability to limit the likelihood of development of iron overload.

7. Which nutrient deficiency is most likely to cause an anemia that appears microcytic and

hypochromic? a. Folic acid b. Pyridoxine c. Iron d. Vitamin B12 ANS: C

Microcytic hypochromic anemia results from iron deficiency. This occurs because the body produces small red blood cells and has decreased circulation of hemoglobin. Folic acid, pyridoxine, and vitamin B12 deficiencies result in macrocytic anemias caused by the release of immature red blood cells from the bone marrow.

8. Restless legs syndrome is associated with deficiency of what nutrient? a. Iron b. Folic acid c. Vitamin B12 d. Vitamin C ANS: A

Restless legs syndrome with leg pain or discomfort may result from a lack of iron in the brain, which alters dopamine production and movement. In addition to iron deficiency, kidney failure, Parkinson disease, diabetes, and rheumatoid arthritis are implicated in this disorder.

9. What does the quantity plasma ferritin value reflect when iron status is evaluated? a. Supply of iron delivered to developing red blood cells b. The most sensitive indicator of negative iron balance c. Total iron-binding capacity d. Iron supply to the tissues ANS: B

Plasma ferritin levels reflect total iron stores. Transferrin saturation is a measure of the iron supply available for the tissues of the body and in use for developing red blood cells.

Total iron-binding capacity is a measure of the capacity of transferrin to take on and become saturated with iron.

10. Which of the following may be useful in treating sickle cell anemia? a. Iron b. Ascorbic acid c. Zinc d. Copper ANS: C

Zinc can increase the oxygen affinity of both normal and sickle-shaped erythrocytes. Thus, zinc supplements may be beneficial in managing sickle cell disease, especially because decreased plasma zinc is common in children with sickle cell disease and is associated with decreased linear and skeletal growth, muscle mass, and sexual maturation. Iron and ascorbic acid are contraindicated.

11. What causes pernicious anemia? a. Problem with vitamin B12 intake or absorption b. A loss of blood through the gastrointestinal tract c. A lack of iron from both heme and nonheme iron sources d. Insufficient availability of pyridoxine ANS: A

Pernicious anemia results from vitamin B12 deficiency, usually resulting from a lack of intrinsic factor to ensure adequate absorption. GI blood loss and inadequate iron intake are

more likely to be associated with an iron deficiency anemia. Sideroblastic anemia results from an impairment in heme synthesis, which depends on adequate pyridoxine availability.

12. After absorption, iron is transported by a. hemoglobin. b. serum albumin. c. plasma transferrin. d. protoporphyrin.

ANS: C

Transferrin is the primary transport protein for iron from the gut to other tissues.

Hemoglobin is the oxygen-carrying pigment of red blood cells that relies on iron as a functional component. Serum albumin is a common transport protein of minerals through the blood. Protoporphyrin is the iron-containing portion of the respiratory pigments that combines with protein to form hemoglobin and myoglobin.

13. Although severe microcytic hypochromic anemia is present, which of the following is also

a characteristic of sideroblastic anemia? a. Iron overload b. Low serum iron levels c. High serum iron and low tissue iron levels d. Low tissue iron levels ANS: A

Sideroblastic anemia presents with iron overload as an impairment in heme formation resulting in a sequestering of iron in immature red blood cells. High serum and tissue iron levels are a characteristic of sideroblastic anemia.

14. Which nutrient deficiency is associated with the development of hemolytic anemia? a. Iron b. Vitamin B6 c. Vitamin E d. Folate ANS: C

Vitamin E is involved in protecting cell membranes against oxidation damage, and one of the signs of vitamin E deficiency is the hemolysis of red blood cells. The cells become fragile and break open. Iron and vitamin B6 deficiencies result in smaller than normal red blood cells. Folate deficiency is evidenced by large, immature red blood cells.

15. Which biochemical measure is useful in evaluating the body’s folate stores? a. Serum folate level b. Red blood cell folate level c. Urinary formiminoglutamic acid (FIGLU) d. Serum homocysteine level ANS: B

The level of folate in red blood cells measures the actual folate stores and is the first, best indicator of folate depletion. Serum folate level may initially reflect a negative balance of

folate at the time of the blood draw. Urinary FIGLU and serum homocysteine levels increase when folate deficiency occurs because folate is necessary for the conversion of histidine to glutamic acid, in the case of the former, and in homocysteine to methionine.

16. Which form of folate is the one that becomes “trapped” when vitamin B12 deficiency

occurs? a. Folate b. THFA c. 5-Methyl THFA d. 5,10-Methyl THFA ANS: C

Vitamin B12 is necessary for the removal of the 5-methyl unit from 5-methyl tetrahydrofolate to transfer it to homocysteine to produce methionine. Folate is the typical form consumed in foods and is converted to THFA in the enterocyte. 5,10-Methyl THFA is the precursor form that leads to DNA synthesis.

17. Which protein is most responsible for the transport of vitamin B12 to target cells in the

body? a. Haptocorrin b. Intrinsic factor c. Holotranscobalamin I d. Holotranscobalamin II ANS: D

Holotranscobalamin II protein is important in the delivery of vitamin B12 to all cells needing it. Although only 25% of the vitamin B12 is bound to TC II, lack of TC II develops into megaloblastic anemia. Haptocorrin, or TC I, binds about 75% of the circulating vitamin B12. Intrinsic factor is involved with the transport and absorption of vitamin B12 in the GI tract.

18. A low holo-TCII is an early sign of which type of anemia? a. Pernicious b. Iron deficiency c. Hemolytic d. Medication induced ANS: A

A low holo-TCII is an early sign of vitamin B12 deficiency, pernicious anemia. Holo-TCII is required for transport of vitamin B12 from the intestinal lumen into the portal venous blood.

19. Soluble serum transferrin receptors (STRs) are high in what anemia? a. Iron deficiency b. Chronic disease or inflammation c. Iron overload d. Sports ANS: A

Serum transferrin receptors are generated on the surface of the red blood cells when iron is needed. As iron deficiency progresses to stages III and IV, STR levels are very high. STR

levels are within normal limits in anemia of chronic illness and inflammation which makes it a useful tool to differentiate between anemia of chronic illness and iron deficiency anemia. Patients with iron overload have low levels of STRs. Sports anemia is a hemodilution effect with initiation of vigorous training and not a deficiency in iron; therefore, STR levels will be within normal.

20. Hepcidin, a peptide synthesized in the liver, is associated with what function? a. Absorption of vitamin B12 b. Iron saturation of myoglobin c. Increasing iron absorption d. Systemic iron homeostasis

ANS: D

Hepcidin regulates iron transport from iron-exporting tissues into plasma.

Chapter 33: Medical Nutrition Therapy for Cardiovascular Disease Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. CVD is the leading cause of death in the United States in a. men only. b. women only. c. African American women but not White women. d. men and women.

ANS: D

CVD remains the number one killer of both men and women in the United States; one of every three deaths is attributed to CVD. The incidence of heart disease is 12.1% in Whites older than 18 years of age. In African Americans, the incidence is 10.2% for the same age group.

2. Which of the following lipoproteins is considered to be triglyceride rich? a. VLDL b. IDL c. LDL d. HDL ANS: A

Very low-density lipoproteins (VLDLs) are triglyceride rich because they are the transport proteins created by the liver to take triglycerides to the various tissues.

Intermediate-density lipoproteins, also known as VLDL remnants, are the remaining portion of the VLDL after triglycerides have been hydrolyzed by lipoprotein lipase at adipose cells. Low-density lipoprotein is cholesterol rich and the most atherogenic of the lipoproteins. High-density lipoprotein is high in protein and functions in reverse cholesterol transport.

3. Which of the following lipoproteins is the primary cholesterol carrier in blood? a. Chylomicrons b. VLDL c. LDL d. HDL

ANS: C

LDL is the primary cholesterol carrier in blood, formed by the breakdown of VLDL. 4. Which of the following lipoproteins normally returns most of the cholesterol to the liver

for disposal via reverse transport? a. Chylomicrons b. VLDL c. LDL d. HDL ANS: D

High-density lipoprotein, through the action of apolipoprotein A-I, removes cholesterol from arterial walls and transports it back to the liver. Low-density lipoprotein transports cholesterol from the liver to the cells, increasing the risk of atherosclerosis.

5. Which of the following lipoproteins is considered to be the most atherogenic? a. Chylomicrons b. VLDL c. LDL d. HDL ANS: C

Low-density lipoprotein is the primary transporter of cholesterol in the body, and formation of plaques within arterial walls begins with the incorporation of LDL cholesterol that has been taken up by macrophages to become foam cells. Chylomicrons and VLDLs are usually not considered to be atherogenic. IDLs produced from VLDL, however, are atherogenic because they are often repackaged as LDL. HDL reduces the likelihood of developing atherosclerosis.

6. Which of the following is not one of the recommendations of the ACC/AHA diet

guidelines to reduce cardiovascular disease risk? a. Reduction of dietary cholesterol b. Reduction of saturated fat, especially from red meat c. Increase in dietary fiber d. Appropriate calories ANS: A

The ACC/AHA guidelines of 2017 eliminated any restriction on dietary cholesterol. They recommend a diet high in fruits, vegetables, legumes, whole grains, fish, low-fat dairy, and monounsaturated fats like olive oil and nuts. They recommend limiting red meat and saturated fat.

7. Which class of drugs reduces LDL levels by inhibiting the synthesis of cholesterol? a. Bile acid sequestrants b. Nicotinic acid c. HMG-CoA reductase inhibitors d. Fibric acid derivatives ANS: C

HMG-CoA reductase inhibitors or statins inhibit the rate-limiting enzyme in cholesterol

synthesis. Bile acid sequestrants trap bile acids in the bowel, causing their elimination, and promote a decrease in serum cholesterol by rerouting cholesterol for bile synthesis.

Nicotinic acid and fibric acid derivatives are beneficial in regard to reduction of triglyceride synthesis.

8. Which medical procedure used to treat patients with asymptomatic ischemia or angina

involves a balloon? a. Cardiac catheterization b. Percutaneous coronary intervention c. Coronary stent d. CABG

ANS: B

PCI was previously known as percutaneous transluminal coronary angioplasty (PTCA) and involves the insertion of a catheter with a balloon that is inflated within a partially blocked artery. The inflation of the balloon breaks up the plaque formation and opens up the lumen of the artery. Cardiac catheterization or angiography involves the injection of dye into the arteries to produce radiographic images of the heart. A coronary stent is a wire mesh device inserted into an artery to hold the lumen open. Coronary artery bypass graft involves the surgical placement of an artery onto the heart to redirect blood flow.

9. Which of the following decreases in heart failure? a. Beta-natriuretic peptide b. Ejection fraction c. Cardiac remodeling d. Interleukin-1 ANS: B

The ejection fraction is the percent of the blood pumped from the ventricles when the heart beats, and as HF progresses, ejection fraction decreases. Beta-natriuretic peptide is secreted by the ventricles in response to pressure and is predictive of the severity of HF. Cardiac remodeling occurs as a result of left ventricular hypertrophy to maintain the pumping activity of the heart. Interleukin-I and other proinflammatory cytokines are secreted to regulate cardiac remodeling.

10. Which of the following is a modifiable risk factor for cardiovascular disease? a. Tobacco addiction b. Family history of heart disease c. Familiar hypercholesterolemia d. Female 50 years or older ANS: A

Smoking cessation counseling can enable an individual to reduce dependence on tobacco and to quit smoking. Family history, genetically transmitted disease, and age are not modifiable risk factors.

11. Which of the following promotes homeostatic control of blood pressure in the short term? a. Kidney control of fluid levels b. Sympathetic nervous system secretion of norepinephrine c. Secretion of renin from the nephrons

d. Activation of the renin-angiotensin system ANS: B

As a short-term control of blood pressure, the sympathetic nervous system releases norepinephrine, which acts as a vasoconstrictor on small arteries and arterioles, increasing peripheral resistance. Long-term control of blood pressure is regulated by the kidneys, which control the extracellular fluid volume and activate the renin-angiotensin system by secreting renin.

12. What condition of severe heart failure is characterized by a state of severe malnutrition? a. Anorexia nervosa b. Cardiac cachexia c. Hypoalbuminemia

d. Tissue hypoxia ANS: B

Cardiac cachexia is defined as involuntary weight loss of at least 6% non-edematous body weight over a 6-month period that occurs in patients with heart failure. Unlike normal starvation, this weight loss is characterized by loss of lean body tissue and heart muscle. A number of factors contribute to the development of cardiac cachexia, including a proinflammatory, catabolic state.

13. How many milligrams (mg) of sodium are in 3700 mg sodium chloride? a. 370 mg b. 1062 mg c. 1454 mg d. 1730 mg ANS: C

Sodium chloride is 39.3% sodium. 3700 mg NaCl  0.393 = 1454 mg sodium.

14. Which mineral has not been suggested as a way to improve (lower) blood pressure when

consumed in adequate amounts? a. Calcium b. Magnesium c. Potassium d. Chloride ANS: D

Higher potassium intakes are associated with a decrease in blood pressure. Dairy calcium intake has been recommended as part of a low-fat dairy intake for prevention and management of hypertension. Magnesium is a vasodilator, and higher magnesium intakes have resulted in reduced blood pressure. Chloride accompanies sodium intake through table salt, and excessive intakes have been associated with hypertension.

15. Which of the following is not associated with lowering blood pressure? a. Hawthorn berry b. Mint c. Garlic d. Coenzyme Q10 ANS: B

Coenzyme Q10 decreased blood pressure via a direct effect on the vascular endothelium.

Garlic reduces blood pressure in those with hypertension via vasodilation, and hawthorn berry exerts a mild, gradual blood pressure-lowering effect, but the mechanism is unclear.

Mint is not considered complementary therapy for lowering blood pressure.

16. Which of the following causes blood pressure to increase? a. Vasodilation b. Decreased cardiac output c. Decreased vascular resistance d. Increased peripheral resistance ANS: D

Blood pressure is a function of cardiac output multiplied by peripheral resistance.

Peripheral or vascular resistance may be increased by the narrowing of the diameter of the blood vessel, either through vasoconstriction or blockage. Cardiac output may increase because of an increase in intravascular blood volume. When either of these occurs, blood pressure increases.

17. Which of the following is not a proinflammatory marker that increases when endothelial

dysfunction leads to unstable plaque formation in atherosclerosis? a. Interleukin-6 b. Fibrinogen c. Nitric oxide d. C-reactive protein ANS: C

Nitric oxide is a vasodilator that is produced by epithelial cells and normally prevents LDL oxidation. However, in endothelial dysfunction, less nitric oxide is produced.

Interleukin-6, tumor necrosis factor-alpha, CRP, and fibrinogen are proinflammatory proteins that increase in relation to atherothrombosis.

18. Diuretics work to lower blood pressure by a. promoting vasodilation. b. inhibiting the renin-angiotensin system. c. decreasing blood volume. d. increasing sodium retention.

ANS: C

Diuretics lower blood pressure by promoting the excretion of fluid and sodium from the body. Vasodilators are medications that promote an increase in blood vessel diameters.

ACE inhibitors are medications that inhibit the release of angiotensin-converting enzyme, an important component in the function of the renin-angiotensin system. Diuretics promote the excretion of sodium.

Chapter 34: Medical Nutrition Therapy for Cardiovascular Disease Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. How can supplemental phosphorus and calcium be provided to an infant with

bronchopulmonary dysplasia? a. Increase calcium and phosphorus in parenteral nutrition formula. b. Provide supplemental minerals outside of nutrition infusions. c. Increase calcium and phosphorus in enteral nutrition formula. d. Additional calcium and phosphorus are rarely indicated.

ANS: B

Infants with BPD have decreased bone mineralization. Calcium losses occur with corticosteroids and diuretics. It is recommended to supplement calcium with phosphorus and vitamin D. Parenteral nutrition has very limited capacity to increase calcium and phosphorus because of solubility restrictions. An enteral formula is limited to the amount in the formula and additions increase potential risk of contamination and product stability.

A separate enteral, oral or parenteral supplement of calcium, phosphorus and vitamin D is recommended.

2. Long-term pulmonary improvement requires special monitoring of what in the infant with

BPD? a. Fluid and electrolytes b. Lipid intake c. Head circumference d. Serum albumin ANS: A

Most infants are managed with a modest fluid restriction of 140 to 150 ml/kg/day. Though diuretic therapy may improve short-term pulmonary status, there is no evidence that it improves clinical outcomes. Use of diuretics leads to serum electrolyte abnormalities like hyponatremia and hypokalemia. Though lipids remain a vital component in providing essential fatty acids and meeting energy goals, the role of lipid administration remains controversial.

3. What is the effect of pulmonary disease on a patient’s energy requirements?

a. Decreased need for energy because of loss of lean body mass b. Increased need for energy because of increased work of breathing c. Decreased need for energy because of a lack of physical activity d. Decreased need for energy because of starvation ANS: B

Pulmonary disease promotes an increase in energy requirements caused by increased muscular work to promote breathing, possible chronic infection, and medical treatments.

Malnutrition in relation to pulmonary disease can contribute to a loss of lean body mass and decreased capacity to perform physical activity. Additionally, malnutrition could impair immune function and contribute to the likelihood of infection.

4. Which of the following recommendations should be made to the parents of an infant who

has both BPD and esophageal reflux? a. Thicken formula with baby cereal. b. Thin formula with a glucose solution. c. Feed the infant positioned in the supine position. d. Delay introduction of baby food until 9 months of age.

ANS: A

Gastroesophageal reflux can exacerbate BPD by promoting possible aspiration. Parents of infants who have these conditions can minimize the risk of aspiration by thickening the infant’s formula with infant cereal and placing the infant in an upright sitting position.

Introducing solid foods should not be delayed because formula and breastmilk alone do not provide adequate nutrition and calories after 6 months of age.

5. Which of the following is true regarding pancreatic enzyme replacement therapy? a. It is needed to treat all patients with CF. b. It is needed to treat CF patients with malabsorption. c. It is provided in approximately the same dosages for all CF patients. d. It is not used to treat CF patients.

ANS: B

About 85% to 90% of patients with cystic fibrosis have pancreatic insufficiency. When this occurs, mucus plugs reduce pancreatic enzyme secretion into the small intestine, and maldigestion and malabsorption result. If a patient develops malabsorption of fat (steatorrhea), pancreatic enzymes should be started. A fecal fat test may be necessary to determine if the amount of enzyme replacement is adequate to reduce fat malabsorption.

6. Which of the following is a dietary modification needed for treatment of cystic fibrosis? a. Increased sodium intake b. Reduction of fat to less than 20% of calories c. Decreased carbohydrate intake d. Supplemental probiotics ANS: A

Individuals with CF require sodium supplementation to compensate for excessive losses of sodium through sweat. Pancreatic enzymes are given to increase fat absorption. Although patients can develop CF-related diabetes, carbohydrate should not be restricted. Fat and carbohydrates are needed to provide sufficient kcal to meet increased energy and micronutrient needs and should not be limited. There is insufficient evidence to

supplement probiotics in CF patients.

7. Which of the following is true about chronic obstructive pulmonary disease? a. COPD is most often caused by genetic polymorphisms. b. COPD can progress to cor pulmonale. c. COPD leads to chylothorax. d. COPD is not seen in obese patients.

ANS: B

Cor pulmonale is a type of heart failure involving right ventricular enlargement that can develop late in the course of COPD. COPD patients who develop chronic bronchitis are normal weight or overweight. COPD is most often caused by smoking. Genetic factors are sometimes involved in its development. Development of a chylothorax, a pleural effusion, is unrelated to COPD and results from trauma or nontrauma causes.

8. Which of the following is not true of pulse oximetry? a. It is a pulmonary function test. b. It gives information on lung volume. c. It uses light waves to measure oxygen saturation of arterial blood. d. It measures the ability of the respiratory system to exchange O2 and CO2.

ANS: B

Spirometry is a pulmonary function test that gives information on lung volume. Pulse oximetry is also a pulmonary function test. It uses light waves to measure oxygen saturation in arterial blood.

9. Which vitamins are most likely to be deficient in a child with cystic fibrosis? a. Vitamins A, E, and C b. Water-soluble vitamins and K c. Vitamins A, D, E, and K d. Fat-soluble vitamins and B12 ANS: C

Even with pancreatic enzyme replacement therapy, fat-soluble vitamin absorption is still impaired. Water-soluble versions of the vitamins A, D, E, and K are often needed to prevent deficiencies.

10. Which results from a sweat test indicate that a patient may have CF? a. Elevated levels of chloride b. Decreased levels of chloride c. Elevated levels of potassium d. Decreased levels of sodium ANS: A

Elevated levels of chloride greater than 60 mEq/L in collected sweat samples are used to diagnose CF. This is performed in combination with evaluation for chronic lung disease, failure to thrive and malnutrition, and family history of CF.

11. What vitamin supplementation may be necessary for patients with tuberculosis? a. Vitamin C b. Folate c. Vitamin B6 d. Thiamin ANS: C

Isoniazid is a first-line drug used in the treatment of patients with tuberculosis. Isoniazid depletes vitamin B6 (or pyridoxine) Patients with tuberculosis should be provided with adequate vitamin B6 (25 mg/d) prevent potential deficiency.

12. Which of the following explains why nutritional wasting is commonly seen in patients

with COPD? a. Increased energy expenditure, decreased energy intake, and impaired oxygenation b. Decreased oxygen consumption and increased energy expenditure c. Decreased energy expenditure and decreased oxygen consumption d. Increased oxygen consumption and increased energy intake ANS: A

Patients with COPD may experience nutritional wasting because of a combination of factors. Increased energy expenditure occurs because of the increased work undertaken by the respiratory system to breathe. This increase results from the obstruction of airflow. On the other side of the cause is decreased food intake. This is brought on by fatigue and confusion caused by lack of oxygen and the buildup of carbon dioxide in the blood.

13. What pulmonary condition is a common complication of critical illness including severe

COVID-19 infection? a. Cor pulmonale b. Emphysema c. Pneumonia d. Acute respiratory distress syndrome ANS: D

Acute respiratory distress syndrome is a pulmonary condition that is characterized by severe hypoxia, bilateral pulmonary fluid infiltration, and decreased lung compliance. This may be caused by trauma, surgery, medical conditions associated with critical illness and severe COVID-19 infection. Cor pulmonale is heart failure associated with right ventricular hypertrophy. Emphysema is caused by smoking or environmental pollution and genetic susceptibility. Pneumonia occurs as a result of a nosocomial infection or as a consequence of aspirating food, fluid, or secretions into the lung.

14. Which of the following is recommended to reduce the risk of aspiration of enteral tube

feedings? a. Add blood dye to enteral formula. b. Provide bolus enteral feedings. c. Check gastric residual volumes every 4 hours. d. Elevate the head of the bed 30 to 45 degrees.

ANS: D

Recommendations to reduce aspiration risk with tube feedings include feeding directly into the small bowel, providing continuous feeds (not bolus), elevating the head of the bed 30 to 45 degrees, using prokinetic agents, minimizing sedation, and providing oral hygiene. The addition of dye to the feeding had been used to help detect the presence of aspiration but has been found to be ineffective and potentially toxic. Gastric residual volumes do not correlate to the incidence of aspiration and should not be done.

15. What is the recommendation for determining energy needs for patients with COPD? a. Provide 30 to 35 kcal/kg of body weight. b. Provide 130% to 150% of the BEE. c. Use indirect calorimetry. d. Harris-Benedict equation.

ANS: C

In COPD, adequate calories must be provided to meet energy needs for maintaining visceral and somatic proteins, physical activity, and possibly nutritional repletion. The preferred means for determining energy needs is through indirect calorimetry. Use of energy equations for predicting energy needs varies. In addition to providing adequate energy, care must be taken to prevent overfeeding because this could exacerbate the pulmonary condition.

16. Which of the following is a disease of bronchial hyperresponsiveness? a. Cystic fibrosis b. Emphysema c. Tuberculosis d. Asthma ANS: D

Asthma is a disease of bronchial hyperresponsiveness and airway inflammation. It results from complex interactions among genetic, immunologic, and environmental factors.

Emphysema results from destruction of the alveoli. Cystic fibrosis is a genetic disorder that is characterized by abnormal secretions in the respiratory tract. Tuberculosis is a bacterial disease.

17. Fluid in the pleural space with a milky appearance is a symptom of a. chylothorax. b. respiratory distress syndrome. c. acute respiratory distress syndrome. d. asthma.

ANS: A

Chylothorax is a rare cause of pleural effusion. It is caused by the disruption or obstruction of the thoracic duct, which results in the leakage of chyle (lymphatic fluid of intestinal origin) into the pleural space. The fluid typically has a milky appearance. A pleural fluid triglyceride concentration of more than 110 mg/dl strongly supports the diagnosis of a chylothorax.

18. What is the concern about giving supplemental iron to patients with tuberculosis? a. Risk of iron overload b. Risk of infection c. No response to iron supplementation

d. Interference with medications ANS: B

Iron is an essential nutrient for humans and is also essential for bacteria. Giving iron or a blood transfusion has the potential to worsen or increase risk of infection in patients with bacterial infections. TB is a bacterial infection and is dependent on the host’s supply of iron. TB patients are at risk of iron deficiency anemia and its related risk of death. Giving iron is controversial but when iron deficiency anemia is diagnosed, iron is generally given.

19. Which of the following is(are) synthesized in the lungs? a. Angiotensin I b. Arachidonic acid c. Prostaglandins

d. Hemoglobin ANS: B

Arachidonic acid is synthesized in the lungs from precursor fatty acids. The arachidonic acid ultimately is converted to prostaglandins and leukotrienes. Angiotensin I is converted to angiotensin II in the lungs. It is synthesized in blood plasma. Hemoglobin is produced in the bone marrow.

20. What term refers to rapid breathing? a. Dyspnea b. Hemoptysis c. Tachypnea d. Aspiration ANS: C

Tachypnea is the medical term for rapid breathing. Dyspnea is shortness of breath or difficulty in breathing. Hemoptysis is vomiting of blood. Aspiration is inhalation of foreign substances into the lungs.

Chapter 35: Medical Therapy for Renal Disorders Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. A reduction in which of the following parameters is the first alteration that leads to the

development of chronic renal failure or end-stage renal disease? a. Blood pressure b. Left ventricular ejection c. Blood volume d. Glomerular filtration rate ANS: D

As chronic renal failure progresses, the glomerular filtration rate (GFR) decreases. The kidneys adapt to the decrease in GFR as a means of preserving function; however, in the long run, it results in an increased loss of nephrons. Blood pressure may be affected by these adaptations, but because blood pressure may be affected by heart and blood vessel function as well as water and electrolyte alterations, it is not specific to impaired kidney function. Left ventricular ejection reflects the strength and structure of the heart. Blood volume is not affected until the end stages of renal failure.

2. Renal adaptations that permit “normal” function eventually fail, causing a progression

toward ESRD because of a. loss of nephrons. b. uremia. c. increases in blood pressure. d. imbalances between glomerular and tubular functions.

ANS: A

As ESRD progresses, the GFR declines because of a continuing loss of nephrons. As nephron number decreases, there is less functional capacity within the kidney to filter blood and promote the excretion of metabolic end products. Uremia results from the inability to excrete nitrogenous waste products. Blood pressure increases as both sodium and water are retained, contributing to an increased blood volume. The filtration and exchange activities that occur within the glomerulus and tubules of the nephron continue in the functioning nephrons, but as the number declines, the dependence upon fewer nephrons places increased stress and wear on those remaining, continuing to promote the

decline in nephron number.

3. Intake of which of the following nutrients is generally not decreased in the nutrition

therapy of patients with ESRD? a. Sodium b. Phosphorus c. Calcium d. Potassium ANS: C

Dietary calcium is usually not decreased to prevent the development of renal osteopenia.

In ESRD, sodium, phosphorus, and potassium are all retained in the blood. Increases in blood phosphorus levels in relation to blood calcium levels can stimulate the release of parathyroid hormone. PTH promotes the resorption of calcium from bone to increase blood calcium levels in proportion to the phosphorus. The only time calcium may be restricted is in the case of a patient demonstrating hypercalcemia while taking calcium supplementation.

4. At least how much protein should be provided by the diet of a patient who receives

hemodialysis three times per week? a. 0.6 g/kg of body weight b. 1 g/kg of body weight c. 1.2 g/kg of body weight d. 1.5 g/kg of body weight ANS: C

Dialysis processes promote protein loss, and therefore, daily protein intake needs to be increased to compensate for this. For patients on hemodialysis, the recommendation is to consume 1.2 g protein per kg of body weight. Patients using peritoneal dialysis should consume 1.2 to 1.5 g protein per kg of body weight.

5. The most common renal stones contain calcium precipitates of a. oxalate. b. phosphate. c. phytate. d. struvite.

ANS: A

Oxalate stones account for 60% of recurrent stone formation. Calcium phosphate stones account for 10% of cases. Dietary phytate inhibits the crystallization of calcium oxalate and calcium phosphate. Struvite stones contain magnesium ammonium phosphate and carbonate apatite and are only formed in the presence of urease-containing bacteria. These only account for 5% to 10% of cases.

6. The rennin-angiotensin mechanism a. regulates calcium and phosphorus balance. b. regulates blood pressure. c. is the first function of the kidney to deteriorate in AFI.

d. is responsible for the production of EPO. ANS: B

The renin-angiotensin mechanism is a major control for blood pressure. It works in concert with vasopressin, which is secreted by the pituitary.

7. Which of the following guidelines should be followed by a patient who has a history of

kidney stones? a. Decrease fluid intake to keep urine output to less than 1 L/day. b. Decrease intake of magnesium-containing antacids. c. Increase fluid intake to maintain urinary output at or above 2 L/day. d. Use sodium bicarbonate to alkalize urine.

ANS: C

Low urine volume is the most common abnormality noted with patients who develop kidney stones. Increasing fluid intake by 2.5 to 3 L/day can increase urine output to 2 to 2.5 L/d to prevent stone formation. This helps by both increasing urine volume and decreasing renal solute load. Magnesium potassium citrate can decrease the development of renal stones. Acidity of urine contributes to stone formation.

8. Which of the following increases the excretion of urinary calcium and uric acid? a. Animal protein b. Carbohydrate c. Fat d. Increased water intake ANS: A

High animal protein intake promotes the excretion of urinary calcium and uric acid, increasing the risk of development of calcium oxalate or uric acid stones. Carbohydrates contribute phytates to the diet, which have been observed to be associated with decreased kidney stone formation. Omega-3 fatty acids in fish oil supplements lower urinary calcium excretion, partly because of less arachidonic acid production, which can increase hypercalciuria. Increased fluid intake decreases the risk of stone formation.

9. In children with CKD, a primary goal of MNT is a. to control hypertension. b. fluid balance. c. normal growth and development. d. adherence to protein restriction.

ANS: C

The major concern in all children is to promote growth and development. Gastrostomy tube feedings are often needed to insure adequate intake of kcal and nutrients. Protein is generally not restricted since the potential protective effect on kidney function increases the risk of malnutrition. The minimum protein given is the DRI for age. The diet is as liberal as possible to promote an adequate intake for growth and development.

10. Which of the following can minimize the resorption effects of increased parathyroid

hormone on bone calcium that occurs in renal disease? a. Eliminating carbonated beverages to decrease phosphates b. Using thiazide diuretics to eliminate calcium

c. Ensuring optimal vitamin D and calcium d. Decreasing protein products high in phosphate ANS: C

The supplementation of calcium early in kidney disease is provided to reduce the imbalances in serum calcium and serum phosphorus levels that occur. Parathormone secretion is stimulated by increased serum phosphorus levels. PTH promotes bone resorption to elevate serum calcium levels. Calcium supplementation can help increase serum calcium levels and prevent phosphorus absorption from the gut. This is preferred over the increase of calcium-containing foods such as dairy because these foods provide calcium but also phosphorus. Carbonated beverages increase urinary acidity and contribute to calcium excretion. Thiazide diuretics cause potassium losses.

11. The primary cause of anemia that presents in chronic renal failure is a. lack of heme and nonheme iron intake. b. loss of iron through the diseased kidney. c. deficiency of the hormone erythropoietin. d. loss of blood through dialysis.

ANS: C

The kidneys produce the hormone erythropoietin, which is involved in the production of red blood cells. The anemia that results in kidney failure is because of EPO deficiency. IV iron provides adequate iron for hemoglobin formation when synthetic EPO is given to patients with renal failure. The kidneys are not the primary route of iron excretion, so their failure does not promote iron loss. Dialysis involves minimal blood loss.

12. Which of the following foods does not potentially increase the acidity of urine? a. Carrots b. Cranberries c. Chicken d. Beef ANS: A

Fruits and vegetables contribute alkaline “ash” to urine, increasing alkalinity. However, cranberries increase urinary acidity. Animal protein foods, such as meats, eggs, and cheeses, and bread and grain products contribute the most acid ash.

13. A patient on hemodialysis has 600 mL of urine output per day. What is the patient’s

recommended fluid intake per day? a. 1100 mL b. 1500 mL c. 2000 mL d. Fluid is not restricted on hemodialysis.

ANS: A

500 mL plus the amount equal to urine output is the amount of fluid recommended per day. 500 + 600 = 1100.

14. When acute kidney injury (AKI) is caused by urinary tract infection, it is classified as

AKI. a. secondary b. prerenal

c. intrinsic d. postrenal ANS: D

Urinary tract infection is an example of postrenal acute kidney injury because the cause is obstructive in nature. Prerenal causes of AKI include dehydration and circulatory collapse that result in inadequate renal perfusion. AKI resulting from diseases within the renal parenchyma, such as glomerulonephritis, is considered to be intrinsic AKI. 15. During which stage of chronic kidney disease does the National Kidney Foundation (NKF)

recommend that a protein intake of 0.6 g/kg/day be initiated? a. For acute kidney injury

b. When HD is started c. When the GFR falls below 25 ml/min d. Protein should never be as low as 0.6 g/kg/day ANS: C

When the patient’s GFR falls below 25 ml/min and they are not receiving dialysis treatment, the NKF recommends a restriction of protein of 0.6 g/kg/day. Protein intake should be increased to 1.2 g/kg/day when HD is initiated. Protein intake for AKI is variable and depends on the underlying cause.

16. Which of the following blood parameters is associated with uremia? a. Sodium greater than 145 mEq/L b. Blood urea nitrogen greater than 100 mg/dl c. Creatinine level between 0.6 and 1.5 mg/dl d. eKt/V greater than 1.2 ANS: B

Uremia is a clinical syndrome of malaise, weakness, nausea and vomiting, muscle cramps, itching, and a metallic taste brought on by high levels of nitrogenous wastes in the body.

BUN greater than 100 mg/dl is commonly associated with the condition. Sodium levels above normal are usually associated with dehydration. Normal creatinine levels run between 0.6 and 1.5 mg/dl; uremia is associated with creatinine levels of 10 to 12 mg/dl.

Equilibrated kinetic modeling (eKt/V) is a measure of dialysis efficiency, and levels of 1.2 or higher indicate that urea is effectively being cleared.

17. A concern of parenteral nutrition with ESRD is a. energy needs cannot be met with PN. b. additional vitamin A requirements with ESRD. c. inability to adjust electrolytes in PN. d. specific vitamin needs of ESRD patients.

ANS: D

Concern about PN and ESRD is that there is no renal specific multivitamin infusion. The standard MVI product contains vitamin A which may be elevated with ESRD. PN can be concentrated to meet energy needs and electrolytes can be individualized within compatibility limits to meet fluid and electrolyte needs of patients with ESRD. 18. Which type of dialysis treatment is usually done at night? a. Continuous ambulatory peritoneal dialysis

b. Automated peritoneal dialysis c. Hemodialysis d. Intermittent dialysis ANS: B

Automated peritoneal dialysis involves continuous dialysate exchanges that are machine driven while the patient is sleeping at night. Continuous ambulatory peritoneal dialysis involves the patient manually performing the exchanges throughout the day. Hemodialysis requires that the patient have his or her blood filtered for metabolic end products over a period of several hours, either daily or every other day. Hemodialysis is essentially an intermittent process of performing dialysis.

19. The type of renal therapy that requires the patient to restrict fluid intake is a. impaired renal function. b. hemodialysis. c. APD. d. CCPD. ANS: B

When a patient is on hemodialysis, kidney function usually results in oliguria. Most patients receiving hemodialysis undergo the procedure on an every-other-day basis.

Because of the inability to urinate, the patient needs to be careful not to drink excessive fluids between dialysis treatments. During impaired renal function, as long as urination is still possible, the patient can consume fluids. During peritoneal dialysis, because treatments are occurring daily, there is little risk of the patient becoming fluid overloaded.

20. What is the recommended interdialytic weight gain for a patient on hemodialysis? a. 10% b. 7% c. 4% d. 2% ANS: C

In patients on maintenance hemodialysis, sodium and fluid intake are regulated to allow a 4% weight gain from fluid between dialysis treatments to help support cardiac function.

Chapter 36: Medical Nutrition Therapy for Cancer Prevention, Treatment, and Survivorship Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE

1. Chemoprevention is the a. pharmacologic use of nutrients to reduce risk of cancer. b. pharmacologic use of medications to treat cancer. c. use of complementary and integrative (CIM) therapy to prevent or treat cancer. d. reduction of carcinogenic growth factors in the blood.

ANS: A

Cancer chemoprevention involves the use of drugs, vitamins and other agents, such as beta-carotene, selenium, and vitamin E, to reduce the risk of developing, delay the development of, or reduce the recurrence of cancer. Chemotherapy is the pharmacologic use of medications to treat cancer after it develops. Patients may use complementary and integrative therapies as additional means of preventing or treating cancer. Immunotherapy stimulates the body’s immune system to suppress the growth of cancer cells.

2. Which of the following presents with the symptoms of progressive weight loss, anorexia,

generalized wasting and weakness, altered basal metabolism, and immunosuppression? a. Radiation-induced enteritis b. Xerostomia c. Graft-versus-host disease d. Cancer cachexia ANS: D

Cancer cachexia is a secondary diagnosis in patients with advanced cancer that is similar to protein-energy malnutrition. The patient exhibits progressive weight loss, anorexia, wasting, immunosuppression, altered basal metabolism, and electrolyte and fluid abnormalities. Radiation-induced enteritis is an inflammation of the intestinal tract that can lead to malabsorption. Xerostomia is the sensation of dry mouth, and it can result from chemotherapy, radiation therapy, or surgery involving the mouth. Graft-versus-host disease (GVHD) is a potential consequence of stem cell transplant, which is associated with multiple complications.

3. Which of the following is a protein that affects fat stores during cancer and induces a state

of anorexia? a. Insulin b. Cannabis c. Tumor necrosis factor d. Glucagon ANS: C

Tumor necrosis factor is a cytokine protein that promotes breakdown of both protein and fat stores to provide adequate energy for tumor cells. At the same time, an insulin resistance occurs because of the excessive fatty acid oxidation. Glucose levels increase, but the glucose and amino acids made available from protein breakdown are preferentially used by the cancer cells. Cannabis has been investigated as a potential treatment to reduce pain, nausea and anxiety in an effort to promote weight gain in cancer patients who have lost weight. High levels of glucose suppress the secretion of glucagon.

4. Epidemiologic studies have demonstrated most often an association between body weight

or BMI and which site-specific cancers? a. Bladder and lung b. Breast and prostate c. Colon, pancreas, and thyroid d. Esophagus, endometrium, gallbladder, and kidney ANS: D

The most common site-specific cancers that have been positively associated with increased body weight and BMI include the esophagus, endometrium, kidney, and gallbladder.

5. Common side effects of radiation-induced enteritis combined with small bowel resection

include a. sore throat, mucositis, and severe dental and gum destruction. b. nausea, vomiting, and diarrhea. c. maldigestion, malabsorption, dehydration, and malnutrition. d. edema, ascites, and weight gain.

ANS: C

Short bowel syndrome is a result of radiation-induced enteritis and small bowel resection.

Because of the decreased length of the bowel, maldigestion, malabsorption, dehydration, and malnutrition are common side effects. When radiation therapy is used to treat head and neck cancer, sore throat, mucositis, and dental and gum destruction can occur. Nausea, vomiting, and diarrhea are common consequences of a variety of cancer treatments.

Chemotherapy treatments that affect fluid retention and excretion can promote edema, ascites, and weight gain.

6. Which of the following is recommended in the medical nutrition therapy for a patient

undergoing surgical treatment of esophageal tumors? a. Placement of a feeding tube at the time of surgery

b. Oral liquid diet with supplements c. Regular diet with multivitamin supplementation d. Total parenteral nutrition ANS: A

Because surgical treatment of esophageal cancer involves partial or total removal of the esophagus, placement of a feeding tube at the time of surgery allows early postsurgical feedings to promote healing. During the surgery, part of the stomach is used for esophageal reconstruction. Provision of oral liquids or solids may not be tolerated immediately after surgery. Parenteral nutrition should only be used if the distal bowel is incapable of performing its regular digestion and absorption functions.

7. For which of the following problems associated with cancer treatment should a

high-calorie diet supplemented with calorically dense foods be provided? a. Constipation b. Xerostomia c. Anorexia d. Neutropenia ANS: C

Anorexia with early satiety may result from many cancer treatments. Because the patient may report early satiety because of diminished stomach capacity or pressure on the stomach, use of high-calorie supplements or calorically dense foods will ensure that the patient will receive adequate calories while consuming smaller amounts of food.

Constipation treatment would include increased fluid intake, activity, and increased fiber for stimulation of the bowel. Xerostomia would be treated by providing liquids and foods that are moist. Neutropenia results in an increased susceptibility to infection; therefore, food safety guidelines must be strictly followed in preparation and handling of foods for the patient.

8. Parenteral nutrition support should be routinely considered a. for all cancer patients. b. after hematopoietic cell transplantation (HCT). c. for well-nourished cancer patients in whom oral intake is about 50% of the desired

goal. d. for patients with advanced cancer whose disease is unresponsive to chemotherapy

or radiation.

ANS: B

HCT can significantly affect nutrition status. The acute toxicities of immunosuppression include nausea, vomiting, anorexia, and mucositis. Individuals typically have little or no oral intake, and parenteral nutrition has become a standard component of care.

Well-nourished patients may be fed orally or enterally. Patients with nonresponsive cancers are more likely to be in the terminal stages of the cancer. In these instances, parenteral nutrition is ineffective. If palliative care is implemented, nutrition would be provided as tolerated and desired.

9. People will often avoid intake of which type of foods after cancer therapy as the result of

alteration in taste sensation? a. Sweets

b. Salty foods c. Meats d. Dairy products ANS: C

Meat aversions can result from chemotherapy or radiation therapy that affects oral or mouth cancers. Meat aversions may be acquired because of changes in taste acuity. Taste thresholds for sweet and salty sensations may alter, and the effect on intake varies depending on whether taste acuity increases or decreases. Although the fats in dairy products have been associated with the development of several cancers, alterations in taste sensation after treatment have not been reported.

10. According to the evidence from current research, what role does drinking regular amounts

of coffee or tea have on cancer development? a. There is a strong causal relationship between coffee intake and cancer. b. There is a suggested causal relationship between coffee intake and cancer. c. Coffee may have an anticancer effect. d. There is a strong causal relationship for tea but not for coffee.

ANS: C

Coffee contains various antioxidants and phenolic compounds, some of which have been shown to have anticancer properties. Tea is also a good source of antioxidants.

11. The goal of nutrition therapy during palliative care is to a. replenish nutrient stores. b. promote weight gain. c. improve albumin status. d. alleviate symptoms.

ANS: D

Palliative care focuses on promoting optimal quality of life and does not continue to address curative measures. Nutrition therapy during palliative care should alleviate symptoms that affect quality of life. Examples of these include pain, weakness, loss of appetite, early satiety, constipation, weakness, dry mouth, and dyspnea. Curative measures associated with nutrition therapy focus on goals such as replenishing nutrient stores, promoting weight gain, and alleviating symptoms.

12. An autologous hematopoietic stem cell transplant is one involving a. stem cells donated by a sibling or parent. b. stem cells donated by a twin. c. stem cells previously taken from the patient. d. stem cells from an unrelated donor or cadaver.

ANS: C

Autologous hematopoietic stem cell transplant is a treatment for leukemias and lymphomas that involves replacing a patient’s stem cells after harvesting and treating them with chemotherapy or radiation therapy. The patient also undergoes chemotherapy or radiation therapy to ablate the bone marrow, and then previously harvested stem cells are reinfused to replace the bone marrow. When the stem cells come from a sibling or parent, unrelated donor, or cadaver, the transplant is called allogenic. If the stem cells come from

a twin, the transplant is syngeneic.

13. For

cancer, epidemiologic studies indicated that alcohol consumption increases the

risk of development. a. ovarian b. prostate c. mouth d. lung ANS: C

Alcohol consumption increases the risk of mouth, pharynx, larynx, esophagus, stomach, pancreas, colon, rectum, liver, and breast cancers.

14. In carcinogenesis, which step does not necessarily occur in tumor development? a. Initiation b. Promotion c. Progression d. Metastasis ANS: D

Metastasis is the process involving the spread of tumor cells to tissues and organs distant from the initial site of development. Not all cancers metastasize, and the discovery of the cancer early in its development can prevent metastasis. Initiation, promotion, and progression are all necessary steps in tumor development.

15. Which diagnostic mechanism is used to determine tumor size? a. Staging b. Tumor biopsy c. Tumor markers d. Cytokines ANS: A

A staging classification, such as the tumor-node-metastases staging system, identifies attributes of tumor growth, including size, node involvement, and metastases. Tumor biopsy is used to examine the cytology of the tumor. Tumor markers, which may include cytokines, are chemicals in the blood that are used to identify the presence and type of cancer.

16. Which dietary modification would be used when a patient has neutropenia? a. Provide bland liquids and soft solids. b. Avoid strong flavors and acidic or spicy foods. c. Provide special handling of raw meats. d. Provide sauces and gravies with foods.

ANS: C

Neutropenia is a decrease in white blood cells that could increase the patient’s risk of developing infections. Because of this, food safety is of paramount importance. Special handling of raw meats, game, poultry, and eggs should be followed. This includes careful attention to countertops, utensils, and cutting boards. In the past, centers have prescribed a low-microbial diet, but there is now clear evidence to support this practice. Patients who develop mucositis, mouth pain, or xerostomia in response to cancer treatments may tolerate oral intake better when bland liquids and soft solids are provided, strong flavors

and acidic or spicy foods are avoided, and sauces and gravies are provided with food.

17. Which type of cancer treatment is systemic therapy? a. Chemotherapy b. Surgery c. Radiation therapy d. None of the above ANS: A

Chemotherapy involves the provision of medications to treat cancer. These medications, however, do not only affect cancer cells because when they are administered, they become distributed throughout the body and are therefore capable of affecting other body cells and systems. Surgery and radiation therapy are generally localized in the treatment of tumors.

18. Graft-versus-host disease (GVHD) a. should never be treated with parenteral nutrition. b. always occurs immediately after transplant. c. is a minor complication of chemotherapy. d. is a major complication seen primarily after allogenic transplants.

ANS: D

GVHD is a major complication seen after allogenic transplants, in which the donated stem cells react against the tissues of the transplant recipient. It can occur within the first 100 days after transplantation. Symptoms can be severe and include gastroenteritis, abdominal pain, nausea, and vomiting. Parenteral nutrition is often used as Phase I treatment to rest the bowel.

Chapter 37: Medical Nutrition Therapy for Infectious Diseases Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. In the 19th century, what type of disease was a leading public health concern? a. Cardiovascular disease b. Infectious disease c. Obesity d. Diabetes ANS: B

Infectious diseases including pneumonia, tuberculosis and diarrheal diseases were the leading public health concern up until the middle of the 20th century. At this time, antimicrobials were developed and became more available. Cardiovascular disease, obesity and diabetes became a health concern after the epidemiological transition, lower rates of malnutrition and access to fat and sugar became more available. In lower and middle income countries, infectious diseases remained a problem for a longer time.

2. What is a hallmark of an emerging infectious diseases? a. Strong virulence b. Rapid spread c. High mortality rates d. All of the above ANS: D

Emerging infectious diseases can be new or previously known diseases. They are characterized by being virulent, spreading rapidly and having high mortality rates. Among the most notable are viral outbreaks including: Zika (2015 to 2016), Ebola (2014 to 2021), Avian influenza (H1N1 [2009 to 2010]; H5N1 [2003-], H7N9 [2013-]), Middle East respiratory syndrome coronavirus (MERS-CoV) (2012 to 2018), severe acute respiratory syndrome (SARS) (2003 to 2004), and most recently, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), responsible for the COVID-19 disease.

3. What is true about the relationship between malnutrition and infectious disease? a. Malnutrition can increase risk of infectious disease and infectious disease can

increase risk of malnutrition.

b. Malnutrition can decrease risk of infectious disease and infectious disease can

increase risk of malnutrition. c. Malnutrition can increase risk of infectious disease and infectious disease can

decrease risk of malnutrition. d. Malnutrition and infectious disease are not strongly correlated.

ANS: A

Malnutrition can increase risk of infectious disease due to a reduction in nutrients needed for immune competence. Infectious diseases can cause malnutrition due to loss of appetite, increased nutrient losses and increased catabolism of lean body mass.

4. All of the following are pathogens except: a. Viruses

b. Prions c. Eosinophils d. Protozoa ANS: C

Viruses, prions, protozoa (as well as bacteria and fungi) are considered infectious pathogens. Eosinophils are a type of white blood cell that is part of the innate immune system.

5. Which of the following is true regarding the innate immune system? a. It is one of three major subsystems of the immune system. b. It is made up of white blood cells including macrophages and natural killer cells. c. It is made up of B cells, T cells and antibodies. d. It functions independently of the complement system.

ANS: B

The innate immune system is one of two major subsystems of the immune system. It is made up of specialized white blood cells including macrophages and NK cells that are first on the scene when an infection occurs. They help activate the complement system and clear foreign substances from the body. The innate immune system also sends antigen presenting cells to B cells to activate the adaptive immune system (including T cells) and make antibodies.

6. Which of the following is not cell or tissue directly involved in the immune system? a. Kidney b. Spleen c. Thymus d. Skin ANS: A

The spleen is an organ of the lymphatic system that helps enrich and increase immune cells. The thymus is an organ on the upper chest that helps mature T cells. The skin is part of the first line of defense acting as a barrier. It also produces some anti-microbial proteins. The kidney is not a direct part of the immune system.

7. Which of the following is true about phagocytic cells? a. They help reduce oxidative stress. b. They can directly kill a pathogen. c. They are produced in the spleen.

d. They circulate in small numbers and increase when needed.

ANS: B

Phagocytic cells such as neutrophils and macrophages use oxidative bursts (ROS), as well as encasement to directly kill a pathogen. They are produced in the bone marrow, not the spleen and circulate in relatively large numbers.

8. Which of the following is true of the adaptive immune system? a. It is nonspecific and does not respond to specific pathogens. b. It is specific and responds to specific pathogens. c. It is made up of specialized white blood cells. d. It is made up of specialized proteins called the complement system.

ANS: B

The adaptive immune system is specific and responds to specific pathogens. It consists of B lymphocytes (B cells) that secrete antibodies and T lymphocytes (T cells that are programmed to kill specific pathogens). The inn ate immune system is nonspecific and made up of specialized while blood cells. The complement system is made up of specialized proteins that assist the innate immune system by direct killing or by helping to recruit other cells in the immune system.

9. An antigen can be defined as a. a specialized white blood cell that directly kills a pathogen. b. a Y shaped protein that triggers the adaptive immune system. c. any substance that triggers an immune response. d. a substance that circulates in the blood in an inactive form until activated.

ANS: C

An antigen is any substance that can trigger an immune response. Antibodies are Y shaped proteins that triggers the adaptive immune response. Specialized white blood cells such as macrophages and natural killer cells are part of the innate immune system. Complement proteins are substances that circulate in the blood in an inactive form until activated and complement the antibody system to help kill pathogens.

10. What medical intervention helps safely and preemptively expose a person to a pathogen so

they can build an immune response? a. Vaccine b. Antigen c. Cytokine d. Virus ANS: A

Vaccines are medical interventions that help safely and preemptively expose a person to a pathogen so they can build an immune response. Antigens and viruses are pathogens and are not given as a medical intervention unless they are made less virulent. Cytokines are substances released by immune cells to enhance the immune response.

11. What vitamin or mineral below is not directly important as a catalyst and co-factor in the

immune response? a. Vitamin C b. B vitamins

c. Vitamin K d. Zinc ANS: C

Vitamin C, B vitamins and zinc are all directly important for immune competence and act as cofactors in the immune response. Vitamin K is important for bone health and blood clotting and is not a principle nutrient in the immune system.

12. What is the primary influence of vitamins C, E, polyunsaturated fatty acids and selenium

in the immune response? a. Help reduce inflammation and oxidative stress. b. Help support gut barrier and the microbiome. c. Help increase energy supply to cells and tissues.

d. All of the above.

ANS: A

Vitamins C, E, polyunsaturated fatty acids and selenium are all part of natural antioxidant systems and help reduce inflammation and oxidative stress. Protein and PUFA as well as a fiber rich diet is important for the gut lining and microbiome. Macronutrients, especially carbohydrates and fats supply energy to the cells.

13. What percentage of the immune system is in the gut? a. 20% b. 35% c. 50% d. 65% ANS: D

65% of the immune system is found within the digestive tract and is made up of the gut-associated lymphoid tissue (GALT). The GALT includes Peyer’s patches (areas with high concentrations of macrophages and lymphocytes) and M cells that help with immune surveillance.

14. How would you define the “double burden of disease”? a. The convergence of poverty and malnutrition exacerbating infectious disease b. The convergence of obesity and malnutrition exacerbating infectious disease c. The convergence of multiple infectious disease infections leading to severe

malnutrition d. The convergence of poverty and infectious diseases leading to increased risk of

infection ANS: B

The double burden of disease refers to obesity as a form of malnutrition—due to overnutrition. This is something that affects both developed and lesser developed countries. The link between poverty and malnutrition is well established as well as the risk of multiple infectious diseases leading to malnutrition and increasing risk of infection (co-infection).

15. What is a nosocomial infection? a. Occurs during co-infection. b. Transmitted through the skin. c. Occurs in a hospital setting.

d. Transmitted via respiratory droplets.

ANS: C

Nosocomial infections are infections incurred in a hospital or clinical setting such as ventilator associated pneumonia, bacterial or fungal infections and surgical site infections.

16. All of the following are ways that obesity and metabolic syndrome is related to infectious

disease including COVID-19 except: a. Increases incidence of infectious disease. b. Increases morbidity and mortality. c. Decreases B and T cell production. d. Decreases inflammation and oxidative stress.

ANS: D

Obesity and metabolic syndrome increase inflammation and oxidative stress which is associated with a decrease in immune function. Studies from animals and humans show that obesity and metabolic syndrome increases the incidence of infectious disease, increases the risk of morbidity and mortality associated with infectious disease and decreases the proliferation and activity of the adaptive immune cells (B cells and T cells).

17. When evaluating risk for poor outcomes with COVID-19 infection in hospitals in New

York City, which of the following is the most common characteristic? a. People with more than one comorbidity b. People with one or less comorbidity c. People with diabetes d. People with obesity ANS: A

People with more than one comorbidity had the highest risk of a poor outcome with COVID-19 infection based on a study of 5,700 patients in the New York City area. Of those comorbidities, hypertension, obesity, diabetes and cardiovascular disease were the most risky.

18. Many infections cause direct nutrient losses though the gut. What is the name of the

specific type of malnutrition that is caused by intestinal infections? a. Nosocomial infection b. Protein losing enteropathy c. Gut associated lymphoid tissue d. Protein energy malnutrition ANS: B

Protein losing enteropathy (PLE) is the specific type of malnutrition caused by intestinal infections and is associated with nutrient losses and blood loss. Nosocomial infections are incurred in a hospital or clinical setting. Gut associated lymphoid tissue is the name of the gut associated immune system and protein energy malnutrition is a more general term for malnutrition that can have multiple causes.

19. Which mineral is essential throughout the immune system, acts as an antioxidant nutrient,

enhances the killing power of NK cells and is promotes immune tolerance? a. Magnesium b. Selenium

c. Zinc d. Iron ANS: C

Zinc is essential throughout the immune system, acts as an antioxidant nutrient, enhances the killing power of NK cells and is promotes immune tolerance. Deficiency of zinc causes impairments in both the innate and adaptive immune system. Selenium is important for antioxidant defense including glutathione production. Magnesium plays a more peripheral role in immune response including regulation of inflammation, innate cell proliferation and antibody production. Iron is needed for growth of cells and creation of oxidative bursts.

20. What infectious disease is caused by rotavirus, Escherichia coli, Shigella, Vibrio cholerae,

Salmonella, and Entamoeba histolytica? a. Diarrheal disease b. Acute lower respiratory infections c. Malaria d. Measles ANS: A

Rotavirus, Escherichia coli, Shigella, Vibrio cholerae, Salmonella, and Entamoeba histolytica are all pathogens that infect the digestive tract and cause diarrheal disease. This can be deadly for infants and children under 5 years of age. Acute lower respiratory diseases are often caused by Haemophilus influenzae. Malaria is caused by plasmodium parasite passed on by Anopheles mosquitos. Measles is caused by morbillivirus.

Chapter 38: Medical Nutrition Therapy for HIV and AIDS Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. What factor contributes to CVD in an individual with HIV? a. HIV virus b. ART c. Elevated C-reactive protein d. All the above ANS: D

Inflammation plays a role in CVD. Chronic immune activation and inflammation from the virus itself as well as the effects of ART on the lipid profile contribute to the increased risk of CVD in individuals with HIV. HIV is associated with an increase in the markers of inflammation, such as CRP and IL-6. The low level chronic activation of the immune system may adversely affect endothelial cells and promote a prothrombotic environment for atherosclerosis.

2. It is important to talk with patients about body shape and fat redistribution to combat what

aspect of HIV disease? a. Food-medication interaction b. Opportunistic infections c. Peripheral neuropathy d. HIV-associated lipodystrophy syndrome (HALS) ANS: D

Patients with HIV are aware of changes in their body shape and are instrumental in identifying these changes. Health care professionals should remember to ask patients about body shape changes every 3 to 6 months. Changes in body shape and fat redistribution can be monitored by anthropometric measurements. Unintentional weight changes should be monitored closely because they can indicate progression of HIV disease. There is no consensus on the clinical definition of HALS, and the manifestations vary greatly from patient to patient.

3. What condition can result from malabsorption, altered metabolism, gut infection, and

altered gut barrier function?

a. HALS b. Opportunistic infections c. Micronutrient deficiencies d. Low protein intake ANS: C

Micronutrient deficiencies are common in people with HIV as a result of malabsorption.

Adequate micronutrient intake through consumption of a balanced, healthy diet should be encouraged. However, diet alone may not be sufficient in people with HIV, and supplementation may be required. HALS is associated with lipid redistribution and is related to ARV use.

4. What is the most valuable indicator of nutritional status in HIV-infected children?

a. Energy levels b. Viral load c. CD4 levels d. Growth ANS: D

Poor growth may be an early indicator of HIV progression. Growth failure can result from HIV infection itself or associated opportunistic infections. The weight and height of HIV-infected children usually lag behind those of uninfected children of the same age.

5. What is the primary adverse effect of some kinds of integrative and functional nutrition

(IFN)? a. Drug-nutrient interactions b. Increase in side effects and disease progression c. Decreased adherence d. Micronutrient malabsorption ANS: A

Potential interactions with ART medications should be addressed when interacting with patients practicing integrative and functional nutrition. IFN is most often practiced in an attempt to alleviate side effects and slow disease progression.

6. Individuals are more susceptible to developing signs and symptoms of HIV infection when

the CD4+ cell count falls below a. 200 cells/mm3. b. 500 cells/mm3. c. 1000 cells/mm3. d. CD4+ cell concentrations do not relate to signs and symptoms of HIV. ANS: B

HIV progression slowly breaks down the immune system, making it incapable of fighting the virus. Persistent fever, chronic diarrhea, unexplained weight loss, and recurrent fungal or bacterial infections are all indicative of HIV infection and occur more frequently when CD4+ cell counts fall below 500 cells/mm3. The CDC classifies AIDS cases as positive laboratory confirmation of HIV infection in persons with CD4+ cell count less than 200 cells/mm3.

7. Which cells become infected by the human immunodeficiency virus that causes AIDS? a. All lymphocytes

b. All immature lymphocytes c. CD4+ or mature T-helper lymphocytes d. T8 lymphocytes ANS: C

HIV virus infects CD4+ or mature T-helper lymphocytes. Helper T-cells are also known as T4 lymphocytes. These are the primary cells that stimulate the cell-mediated immune response. T8 lymphocytes are the cytotoxic T-cells.

8. What should a pregnant woman who is HIV positive be advised in regard to feeding her

baby? a. Breastfeed her baby.

b. Do not breastfeed her baby. c. Breastfeed her baby only if she is asymptomatic. d. Breastfeed her baby only if her disease is in its early stage.

ANS: B

In the United States, breastfeeding is not recommended for women who are HIV positive, including those on ART or where safe, affordable and feasible alternatives are available and culturally appropriate.

9. Protein intake for individuals with HIV is a. increased with opportunistic infections. b. the same as the DRI for healthy individuals. c. less than the DRI for healthy individuals. d. decreased with CD4 count >500.

ANS: A

There is limited evidence-based research addressing protein needs with HIV. The Association of Nutrition Services provided the educated guess of 1 to 1.4 g/kg/d with weight maintenance and 1.5 to 2 g/kg/d for repletion of LBM. There does appear to be an increased protein need with a CD4 count <500 and a 10% increase with opportunistic infections.

10. Which herbal supplement decreases the efficacy of ART? a. Echinacea b. Fish oil c. Curcumin d. St. John’s wort ANS: D

St. John’s wort decreases blood levels of ART medication, decreasing the efficacy of ART and potentially leading to drug resistance. Echinacea and curcumin and are herbal supplements not associated with decreasing efficiency of ART. The same is true for fish oil.

11. For HIV-infected individuals with high triglyceride levels, what kind of supplementation

might be helpful? a. Vitamin A b. Fish oil c. Zinc

d. Garlic ANS: B

Omega-3 fatty acids, found in fish oil, have been shown to significantly lower triglyceride levels in some patients with HIV. Vitamin A and zinc supplementation have not been shown to help triglyceride levels. Megadoses of vitamin A and zinc can result in adverse outcomes. Garlic has been shown to negatively interact with some HIV medications and should be monitored in patients’ diets.

12. Low levels of literacy, cognitive impairment, homelessness, stigma, and active substance

abuse can have significant effects on what aspect of HIV disease? a. Coinfection

b. Drug resistance c. Increased nutrition needs d. Increased transmission rates ANS: B

Drug resistance increases because of decreased adherence to a regular drug therapy schedule. Coinfection and transmission rates have not been shown to be tied to the factors above, although they may be correlated. Nutrition needs should be monitored more closely for HIV patients with the factors above, but these factors do not indicate the need for increased nutrition.

13. Which of the following is true concerning probiotics from foods and supplements? a. They may help reduce HIV associated diarrhea and improve CD4 count. b. Prebiotics should not be taken with probiotics. c. Most probiotics are not well tolerated. d. All probiotic supplements sold at health food stores are of good quality.

ANS: A

While more research is needed, multiple studies demonstrate probiotic safety and efficacy for reducing diarrhea and improving CD4 counts. Probiotics function optimally when given with prebiotics which feed the probiotics. Lactobacillus is a beneficial probiotic.

Commercial supplements of probiotics and prebiotics have variable quality, so it is best to look for third party certification.

14. Hepatitis C virus coinfection with HIV is highly correlated with a. men who have sex with men. b. injection drug use. c. poverty. d. low literacy rates.

ANS: B

Injection drug use is strongly linked with transmission of bloodborne infections such as HIV, hepatitis B virus, and hepatitis C virus (HCV), especially if needles are reused or shared. About 50% to 90% of HIV-infected injection drug users are also infected with HCV. Other demographic features listed do not have a significant correlation with HCV coinfection.

15. Which area of the world has the highest prevalence of HIV infection? a. North America

b. Latin America c. South and Southeast Asia d. Sub-Saharan Africa ANS: D

Sub-Saharan Africa accounts for 64% of new HIV infections and 42% of AIDS-related deaths.

16. What opportunistic infection manifests as lesions on the skin and mucous membranes? a. Candidiasis b. Cryptosporidiosis c. Kaposi sarcoma

d. Hepatitis C ANS: C

Kaposi sarcoma is a malignant disease of abnormal tissue growth under the skin that causes lesions on the skin and in the oral cavity, esophagus, and intestines. Candidiasis, or thrush, appears as white plaques in the mouth. Cryptosporidiosis is an intestinal infection caused by a parasite. Hepatitis C, an inflammation of the liver, is not considered an opportunistic infection.

17. Obesity in people with HIV should be treated with a. altered antiviral medications. b. decreased protein intake. c. supplementation and complementary medicine. d. physical activity and balanced diet to achieve healthy weight.

ANS: D

Interventions for populations infected with HIV should be similar to those of healthy obese individuals. The goal is to achieve and maintain a healthy weight with a balanced diet and physical activity (aerobic exercise and resistance training).

18. What period of disease progression does acute HIV infection make up? a. The period from transmission to up to 10 years after infection b. The period from transmission of HIV to the production of detectable antibodies c. The period between normal and less than 500 CD4+ cells/mm3 d. The period when CD4 decrease falls to even lower levels and the infection

becomes symptomatic and progresses to AIDS ANS: B

Acute HIV infection is the time from transmission of HIV to the host until the production of detectable antibodies against the virus occurs. This is also known as seroconversion. A period of clinical latency follows.

Chapter 39: Medical Nutrition Therapy in Critical Care Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Which of the following occurs during the ebb phase of injury? a. Hypovolemic shock b. Release of catecholamines c. Increased metabolic rate d. Hyperglycemia ANS: A

During the ebb phase of hypermetabolic response, hypovolemia, shock, and tissue hypoxia occur immediately after injury. The acute response of the flow phase to these physiologic changes includes release of catecholamines and other hormones that promote an increase in metabolic rate and hyperglycemia.

2. Which of the following should be the first emphasis of nutrition care immediately after a

major burn injury? a. Promote weight gain. b. Increase lean body mass and strength. c. Establish fluid and electrolyte balance. d. Promote a positive nitrogen balance.

ANS: C

The first 24 to 48 hours of care for thermal injury is devoted to fluid resuscitation.

Stabilization of weight and lean body mass cannot occur until the patient reaches the adaptive response of the flow phase. At this time, which may occur days or weeks after the initial injury, hormonal responses decrease, and anabolism can begin. However, enteral feedings should be started as soon as the patient is hemodynamically stable.

3. In contrast to stress, which of the following is a characteristic of starvation? a. Increased resting energy expenditure b. Decreased energy expenditure c. Increased gluconeogenesis d. Increased nitrogen excretion ANS: B

During the adaptation to starvation, the body decreases its energy expenditure as a means of preservation of body function. During starvation, to maintain glucose production for tissues depending on glucose for energy, protein degradation occurs to promote gluconeogenesis. However, as lean tissue is lost, this results in a lower REE. This progression of loss of lean tissue is slowed down by the decrease in energy expenditure, allowing for the person to live longer without food.

4. Which of the following may have a role in supporting tight junctions between the

intraepithelial cells in the gut? a. Parenteral nutrition b. Positive nitrogen balance c. Gut rest

d. Enteral feedings ANS: D

Enteral nutrition may have a role in maintaining tight junctions between the intraepithelial cells, stimulating blood flow and inducing the release of trophic factors. Lack of nutrition or parenteral nutrition may be contributing factors to loss of the tight junctions.

5. The preferred method for estimating energy needs in a hypermetabolic patient is a. 25 to 30 kcal/kg. b. indirect calorimetry. c. the DRIs. d. nitrogen balance.

ANS: B

Indirect calorimetry measures energy expenditure and is the preferred method for determining energy needs in severely injured patients. Indirect calorimetry should not be used in patients with acidosis or chest tubes or who are dependent on supplemental oxygen. Calculating energy needs using 25 to 30 kcal/kg depends on body weight, which may be affected by fluid imbalance, and could lead to potential underfeeding or overfeeding of the patient. Nitrogen balance is used to monitor protein metabolism.

6. What type of nutrition should be avoided in a critically ill patient? a. Soluble fiber b. Insoluble fiber c. Omega-3 fat d. Polymeric ANS: B

Standard polymeric enteral formulas are tolerated by most patients. While insoluble fiber should be avoided, soluble fiber may be beneficial in the hemodynamically stable ICU patient with diarrhea.

7. How does the gut hypothesis explain the development of systemic inflammatory response

syndrome? a. Injury or disruption of the gut barrier function allows translocation of bacteria. b. Active feeding of the gut promotes the migration of gut-associated lymphoid

tissue. c. Bypassing feeding of the gut via parenteral nutrition promotes infection through

open access to the blood system.

d. Foodborne illness promotes absorption of foodborne pathogens, increasing

infection.

ANS: A

Systemic inflammatory response syndrome (SIRS) is a widespread inflammation that can occur in response to infection, burns, trauma, or hemorrhagic shock. The gut hypothesis suggests that the trigger is injury or disruption of the GI barrier function with corresponding translocation of enteric bacteria into the mesentery lymph nodes, liver, and other organs. Unique gut-derived factors carried in the intestinal lymph but not the portal vein lead to acute injury- and shock-induced SIRS. 8. Which of the following statements is not true about cortisol?

a. It is released from the adrenal cortex. b. It accelerates skeletal muscle catabolism. c. It promotes acute-phase protein synthesis. d. It promotes hypoglycemia.

ANS: D

Cortisol, which is released from the adrenal cortex in response to stimulation by adrenocorticotropic hormone secreted by the anterior pituitary, enhances skeletal muscle catabolism and promotes hepatic use of amino acids for gluconeogenesis, glycogenolysis, and acute-phase protein synthesis. Hyperglycemia is generally observed during stress.

9. The adequacy of energy and protein intake after burn injury is best evaluated by a. monitoring weight. b. using indirect calorimetry. c. monitoring wound healing and graft take. d. monitoring albumin level.

ANS: C

The adequacy of energy and protein intake is best evaluated by monitoring healing, graft take, and some nutrition assessment parameters such as weight. The problem with using weight on its own is that it can be difficult to obtain accurate weights because of fluid shifts, edema, and wound dressings. Indirect calorimetry is used to measure energy expenditure. Serum albumin is representative of the acute phase response and should not be used to monitor nutritional status.

10. What are interleukin-1, interleukin-6, and tumor necrosis factor examples of? a. Catecholamines b. Acute phase proteins c. Cytokines d. Antiinflammatory proteins ANS: C

Cytokines are proinflammatory proteins that are released in response to injury.

Interleukin-1, interleukin-6, and tumor necrosis factor stimulate metabolic responses and the production of acute-phase proteins. The catecholamines epinephrine and norepinephrine are two of the hormones that are secreted during the hypermetabolic response.

11. Multiple organ dysfunction syndrome (MODS) generally begins with

a. coagulopathy. b. lung failure. c. liver failure. d. intestinal failure.

ANS: B

MODS is a complication of SIRS and generally begins with lung failure. The lung failure is followed by failure, in no particular order, of the liver, intestines, and kidneys.

12. In surgical patients, what factor is the strongest predictor of postoperative mortality? a. Extent of the primary disease and operation performed b. Nutritional status

c. BMI d. Age ANS: A

Surgical morbidity correlates best with the extent of the primary disease and the nature of the operation performed. Age, BMI, and nutritional status can impact surgical risk but are not the strongest predictors of post-op mortality.

13. Which mineral may be lost and need replacement in burn patients being treated with silver

nitrate soaks? a. Calcium b. Phosphorus c. Magnesium d. Zinc ANS: A

Silver nitrate soaks are used in wound management to reduce heat losses from the body and to prevent infection. However, these soaks draw sodium and calcium out of the wound and cause loss of these minerals. Calcium supplementation may be necessary to prevent hypocalcemia. Hypophosphatemia occurs in burn patients during the refeeding syndrome.

Magnesium may also be lost through the wound. Serum zinc levels have been reported as decreased in burn patients, but the evidence is not clear as to whether this is a reflection of depressed total body zinc or of hypoalbuminemia.

14. Nutrition support cannot replete lean body mass a. in starvation-related malnutrition. b. in patients with MODS and SIRS. c. in chronic disease-related malnutrition. d. after GI surgery.

ANS: B

Adequate provision of nutrition support therapy cannot replete lean body mass in patients experiencing SIRS and MODS. The loss of fat-free mass is caused by a heightened cytokine response. Providing additional kcal to promote weight gain results in overfeeding current metabolic needs. Overfeeding during critical illness can lead to difficulty weaning from the ventilator, fatty liver, azotemia, and hyperglycemia. Repletion can be addressed when the metabolic aberrations of critical illness subside.

15. Low albumin in a critically ill patient is caused by

a. inadequate protein intake. b. illness, injury, and inflammation. c. inadequate calorie intake. d. inadequate fluid intake.

ANS: B

Hypoalbuminemia reflects severe illness, injury, and inflammation; thus, serum albumin should not be used as a marker of nutritional status in critically ill patients.

16. In critically ill patients, what is the recommended range for maintaining serum glucose? a. 120 to 150 mg/dl b. 150 to 200 mg/dl

c. 80 to 110 mg/dl d. 140 to 180 mg/dl ANS: D

Glycemic control and its relationship to improved outcomes in critically ill patients has been the focus of extensive study. It is now recommended that blood glucose be controlled with moderate levels of 140 to 180 mg/dl.

17. A patient would be given enteral nutrition if the patient had a. fistula output >500 mL/d. b. MAP <50 mm Hg. c. high doses of catecholamine agents. d. GI surgery.

ANS: D

Enteral nutrition is generally the preferred route of nutrition support for critically ill patients. Some contraindications to enteral feeding include high-output fistulas (>500 mL/d) and patients who are hemodynamically unstable with a mean arterial pressure (MAP) <50 mm Hg or receiving high doses of catecholamine agents.

18. Which hormone promotes the synthesis of acute-phase proteins? a. Glucagon b. Cortisol c. Epinephrine d. ACTH ANS: B

Cortisol is the counterregulatory hormone released in response to stimulation by adrenocorticotropic hormone (ACTH). Cortisol increases muscle catabolism and promotes hepatic use of amino acids in gluconeogenesis and acute-phase protein synthesis.

Glucagon and epinephrine also stimulate gluconeogenesis and glycogenolysis to increase glucose availability during stress.

19. Which of the following is a criterion in the diagnosis of SIRS? a. Shock b. Ileus c. Elevated heart rate d. Decreased heart rate ANS: C

Systemic inflammatory response syndrome (SIRS) describes widespread inflammation that is usually present in areas remote from primary site of injury. Diagnosis of SIRS requires the presence of two of the following criteria: body temperature above 38°C or below 36°C; heart rate greater than 90 beats/min; respiratory rate greater than 20 breaths/min; white blood cell count above 12,000 or less than 4000; or >10% immature bands. Shock and ileus can contribute to the development of SIRS.

Chapter 40: Medical Nutrition Therapy for Rheumatic and Musculoskeletal Disease Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Current research suggests that which of the following play a role in the inflammatory

process? a. Polyunsaturated fatty acids b. Monounsaturated fatty acids c. Omega-3 and omega-6 fatty acids d. Medium-chain triglycerides ANS: C

Omega-6 fatty acids promote production of arachidonic acid which is the most potent proinflammatory eicosanoid. Substituting omega-6 fatty acids with omega-3 fatty acids (DHA and EPA) increases production of antiinflammatory mediators. DHA and EPA are converted to specialized protein-resolving mediators which promote resolution of inflammation. MCTs have not been investigated in regard to a role in inflammation.

2. Nonsteroidal antiinflammatory drugs (NSAIDs) a. include the drug Tylenol. b. work by inhibiting the COX-1 enzyme. c. work by blocking interleukin. d. have significant catabolic effects.

ANS: B

NSAIDs include ibuprofen and naproxen and work by inhibiting COX-1 enzyme activity.

Tylenol is an analgesic pain reliever. There is a group of drugs aimed at interleukin; one is anakinra. Corticosteroids, also used to decrease inflammation, have significant catabolic effects.

3. What should be a primary nutritional goal for patients with osteoarthritis? a. Achieve and maintain a desirable body weight. b. Increase fiber intake to prevent constipation. c. Provide antioxidant supplementation. d. Decrease sodium intake to reduce edema.

ANS: A

Because osteoarthritis (OA) mostly affects the weight-bearing joints of the body, reduction of excessive weight places less stress on these joints. When combined with moderate exercise, diet-induced weight loss has been shown to be an effective treatment for OA. An additional benefit of weight loss is a decrease in fat mass, and this could promote a decrease in inflammatory mediators from adipose tissue. If constipation were to occur in OA, it would be as a consequence of medication use. There is insufficient evidence demonstrating benefit from antioxidant supplementation.

4. Which of the following dietary recommendations assists in the management of patients

with gout? a. Avoidance of dairy, coffee and chocolate b. Limit intake of animal foods, alcohol, and simple CHO

c. High-fat, low-CHO diet d. Low-pyrimidine diet with decreased CHO ANS: B

Although two-thirds of the daily purine load comes from cellular turnover, a low-purine diet that limits intake of meats, and alcohol is usually advised. Fructose and simple CHO increase risk of hyperuricemia. Black coffee without sugar may be protective for gout. A diet with liberal intake of plant proteins, nuts, vegetables, legumes, whole grains, and plant oils is recommended. Up to 2 servings per day of low-fat dairy products is recommended.

5. Which of the following foods has a protective effective for gout? a. Simple CHO b. Red meat c. Red wine d. Coffee ANS: D

Black coffee without sugar is associated with low levels of serum urate and may be protective for gout. Fructose and simple CHO predispose patients to insulin resistance and metabolic syndrome, increasing risk of hyperuricemia. Animal protein is high in purines.

Alcohol including red wine can increase serum urate and increases the risk of gout.

6. Which of the following is an important component in the nutritional assessment of patients

with rheumatoid arthritis? a. ADLs b. Degree of malabsorption c. Blood glucose control d. Nitrogen balance ANS: A

Because rheumatoid arthritis (RA) can affect mobility, activities of daily living (ADLs) should be assessed. An inability to perform basic self-care skills can have a negative impact on the patient’s ability to self-feed. Support in the form of caregivers or adaptive equipment may be needed to ensure nutritional adequacy. Malabsorption is not a consequence of RA. Blood glucose control depends on the presence of diabetes and other lifestyle factors. Nitrogen balance can be used to monitor protein metabolism, but it can be a challenge to obtain an accurate collection for analysis. The patient’s weight aids in the assessment of the patient’s nutritional status.

7. Which of the following provides abundant omega-3 fatty acids such as DHA and EPA? a. Flaxseed and walnuts b. Soy and canola oils c. Salmon and sardines d. Lard ANS: C

The primary omega-3 fatty acids that have been demonstrated as having various beneficial effects in humans have been docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). Through the diet, these two omega-3 fatty acids are primarily provided by fatty fish such as salmon and sardines. Alpha linoleic acid, which also has an omega-3 bond, is found in flaxseed, walnuts, soy, and canola oils. Lard provides saturated fatty acids.

8. With what do the plasma copper levels seen in patients with rheumatoid arthritis correlate? a. Dietary intake of copper b. Type of medication c. Degree of joint inflammation d. Degree of malabsorption and diarrhea ANS: C

Plasma copper levels correlate with the degree of joint inflammation. As plasma copper levels decrease, the inflammation diminishes. Elevated plasma levels of ceruloplasmin, a carrier protein for copper, may have a protective role because of its antioxidant activity.

9. What drug(s) is(are) the first line of therapy for controlling the inflammatory process seen

in arthritis? a. Corticosteroids b. Salicylates c. Gold salts d. Methotrexate ANS: B

For the control of pain and inflammation in rheumatoid arthritis, salicylates and nonsteroidal antiinflammatory drugs are first used. Methotrexate is a secondary medication used, but it is a folate antagonist and could contribute to neutropenia and hyperhomocysteinemia. Corticosteroids have extensive catabolic effects when used continuously. Use of gold salts can promote proteinuria.

10. Which of the following is characteristic of Sjögren syndrome? a. Excessive sweating and salivation b. Temporomandibular joint symptoms c. Diminished production of tears and saliva d. Diminished production of hydrochloric acid ANS: C

Sjögren syndrome is an autoimmune disorder that affects exocrine glands—tear and salivary glands. These tissues are attacked by the immune system, and destruction of the glands leads to decreased production of tears and saliva. Temporomandibular joint symptoms occur in the jaw.

11. Which of the following complementary and integrative therapies has shown beneficial

effects in the treatment of rheumatoid arthritis? a. Copper bracelets b. Echinacea c. Borage and evening primrose oil d. Thunder god vine ANS: C

Gamma-linolenic acid is an omega-6 fatty acid found in the oils of borage and primrose oil that can be converted to the antiinflammatory PGE-1. Further studies are needed to determine dosage and duration of therapy. Copper bracelets, echinacea therapy, thunder god vine have not shown benefit.

12. Which of the following may have a beneficial effect in the treatment of patients with

Sjögren syndrome? a. Increase frequency of meals. b. Moisten foods with sauces or gravies. c. Limit fiber. d. Increase citrus fruits.

ANS: B

Sjögren syndrome is a chronic autoimmune inflammatory disease that affects the exocrine glands, particularly the salivary and the lacrimal glands, leading to dryness of the mouth (xerostomia) and of the eyes (xerophthalmia). Modification of dietary habits to cope with oral symptoms, particularly to improve biting (cutting fruits, vegetables, and meats in small pieces), chewing (making foods softer by preparing them as soups, broths, casseroles, or as tender cooked vegetables and meats), and swallowing (moistening foods with sauces, gravies, yogurts, or salad dressings) often helps. Foods that worsen oral symptoms should be limited, like citrus fruits, as well as irritant, hot, or spicy foods.

13. Which of the following is an autoimmune disorder that presents with severe fatigue,

painful or swollen joints, and skin rashes? a. Chronic fatigue syndrome b. Systemic lupus erythematosus c. Raynaud syndrome d. Systemic sclerosis ANS: B

Systemic lupus erythematosus (SLE) involves inflammation, resulting in extreme fatigue, arthritis, unexplained fever, skin rashes, and kidney problems. SLE has a genetic predisposition for the overproduction of type 1 interferon and other cytotoxic cells that can affect all organ systems. Chronic fatigue syndrome is characterized by extreme fatigue that does not improve with rest. Raynaud syndrome is an ischemia or coldness in the fingers that makes it difficult to perform fine motor functions. Raynaud syndrome may be one of the symptoms that happen in systemic sclerosis, which is a progressive disorder that involves the deposition of fibrous connective tissue in the skin and visceral organs.

14. Which feature associated with the joint of a person affected with gout is different from the

joint of a person affected with rheumatoid arthritis? a. Bone erosion b. Inflamed synovium

c. Bone spurs d. Presence of tophi ANS: D

Tophi are deposits of uric acid that crystallize on the bone and cartilage, leading to damage of the joint. In rheumatoid arthritis, inflammation of the synovial fluid damages the cartilage and bone, leading to bone erosion and loss. Osteoarthritis is characterized by the presence of bone spurs in the joint.

15. Which spices are included in an antiinflammatory diet? a. Thyme, cayenne, and cloves b. Oregano, lemon peel, and thyme c. Ginger, curry, turmeric, and rosemary

d. All of the above ANS: D

Nearly all culinary spices and herbs have antiinflammatory effects and are included in an anti-inflammatory diet.

16. Which of the following conditions is characterized by hardening of the skin and visceral

organs? a. Gout b. Systemic sclerosis c. Fibromyalgia d. Sjögren syndrome ANS: B

Systemic sclerosis is a chronic, systemic sclerosis or hardening of the skin and visceral organs characterized by deposition of fibrous connective tissue.

17. A group of self-reacting antibodies found in the sera of rheumatic patients a. include CRP. b. are known to suppress the immune system. c. are known as rheumatoid factor. d. are known as eicosanoids.

ANS: C

The term rheumatic factor is used to refer to a group of self-reacting antibodies found in the sera of rheumatic patients. It is used to screen for and monitor rheumatic disease along with CRP. Eicosanoids are modulators of the inflammation process that include prostaglandins.

18. Which of the following conditions is not a disease of autoimmune origin? a. OA b. RA c. SLE d. Systemic sclerosis ANS: A

Osteoarthritis is not autoimmune in origin. Rheumatoid arthritis, systemic lupus erythematosus, and systemic sclerosis are all conditions with autoimmune origins.

19. Which of the following is true about extra virgin olive oil?

a. It is not part of the anti-inflammatory diet. b. It contains omega-3 fatty acids. c. It modulates immune-inflammatory processes. d. It contains MCT. ANS: C

Extra virgin olive oil is a component of the anti-inflammatory diet and the Mediterranean diet. Studies show that EVOO and its components have a positive modulating effect on the inflammatory process and is beneficial in the prevention and management of inflammatory diseases. It has a beneficial fatty acid profile and contains phenolic compounds which protect against oxidative damage. EVOO contains monounsaturated fatty acids.

Chapter 41: Medical Nutrition Therapy for Neurologic Disorders Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Which of the following foods is easiest to swallow for patients experiencing difficulty

swallowing? a. Thin liquids b. Room temperature cream soups c. Lukewarm cooked cereals diluted with milk d. Cool, soft textured foods with sauce or gravy ANS: D

Swallowing is improved by improving the taste, texture, and temperature of the food. Thin liquids cannot be controlled during the swallowing process. By providing texture and adding sauce or gravy, foods can form a bolus, which is easier to control during swallowing. Additionally, cool and cold items are better tolerated in regard to swallowing.

2. What is dysphagia? a. Inhalation of a foreign object into the lungs b. Impaired taste c. Difficulty swallowing d. Impairment of the tongue or other muscles essential to speech ANS: C

Dysphagia is a difficulty in swallowing that may be caused by various neuromuscular conditions. Inhalation of a foreign object into the lungs results in aspiration. Dysgeusia is an alteration or impairment in taste. Dysarthria is an impairment of the tongue or other muscles essential to speech that results in a person’s having difficulty speaking.

3. The Frazier free water protocol can be used for patients with a. Wernicke-Korsakoff syndrome. b. brain trauma. c. multiple sclerosis. d. dysphagia.

ANS: D

The Frazier free water protocol allows patients with swallowing impairment (dysphagia) to

safely drink unthickened water between meals. Water is the least likely liquid to cause aspiration pneumonia when provided in the atmosphere of good oral hygiene.

Wernicke-Korsakoff, brain trauma, and multiple sclerosis patients would only use the Frazier free water protocol if they also had dysphagia.

4. Damage to which of the following cranial nerves will likely affect the ability to eat food? a. Olfactory (I) nerve b. Abducens (VI) nerve c. Glossopharyngeal (IX) nerve d. Vagus (X) nerve ANS: C

The glossopharyngeal or IX cranial nerve controls swallowing and the gag reflex, and it is involved with palatal, glossal, and oral sensations. The olfactory nerve affects the sensation of smell but has no control of motor function in relation to eating. The abducens nerve affects eye movement. The vagus nerve controls gastrointestinal (GI) activity and sensation of taste on the posterior third of the tongue; however, stimulation of GI activity depends on eating.

5. Which of the following requires the greatest coordination and control in order to swallow? a. Solid foods b. Liquids of thin consistency c. Soft foods with high water content d. Thick, viscous liquids ANS: B

Impairments in swallowing make the intake of thin liquids dangerous because the swallowing of these cannot be controlled. Aspiration of liquids may result. To improve swallowing of liquids, thickening agents are added to provide consistency that is easier to control. Solid foods or soft foods with high water content are easier to control than liquids; however, this ease depends on factors such as texture and the ability to form a bolus.

6. Which of the following can occur with impaired swallowing? a. Aspiration pneumonia b. Hemiparesis c. Dysgeusia d. Demyelination ANS: A

Aspiration pneumonia is a concern in regard to dysphagia because poor control of swallowing can allow food or liquid to pass into the trachea and end up in the lungs.

Hemiparesis is weakness on one side of the body, which is common in patients who have had a stroke. Hemiparesis can contribute to the possibility of aspiration. Dysgeusia is a loss of or impaired taste that can be neurologic in origin or can be affected by medication use. Demyelination is destruction of the myelin sheath covering and protecting nerve axons.

7. Because of potential drug-nutrient interactions, it would be more beneficial to provide the

majority of their dietary protein to patients with Parkinson disease a. during breakfast.

b. at the noon meal. c. evenly throughout the day. d. with the evening meal.

ANS: D

L-Dopa is given to patients with Parkinson disease to help control the tremors, rigidity, and bradykinesia associated with the disease. However, large neutral amino acids compete with L-dopa for absorption, and this is thought to alter the rate of entry of L-dopa into the circulation and its uptake into the brain. To reduce the presence of symptoms during the day when the patient is most active, dietary protein should be minimized at breakfast and lunch and added with the evening meal. This improves mobility of the patient during the day.

8. How may phenobarbital, used for anticonvulsant therapy, interfere with the intestinal

absorption of calcium? a. It increases metabolism of vitamin D in the liver. b. It prevents absorption of vitamin D in the intestinal mucosa. c. It induces diarrhea and loss of electrolytes. d. It damages the mucosal cells lining the intestinal wall.

ANS: A

Phenytoin, phenobarbital, and valproates interfere with the metabolism of vitamin D in the kidneys. The result is that dietary calcium intestinal absorption is impaired. Long-term use of the medications places children at risk for rickets and adults at risk for osteomalacia. To prevent this, vitamin D supplementation is recommended.

9. The guideline for use of a percutaneous endoscopic gastrostomy (PEG) in patients with

neurologic disease or disorders is to use a. whenever there is a risk of aspiration pneumonia. b. with patients whose swallowing function will not ensure adequate nutritional

intake. c. with patients who refuse a central line for parenteral nutrition. d. with patients who are expected to resume oral diet intake within 7 days.

ANS: B

In patients with neurologic conditions, PEG placement is reserved for those whose swallowing is so affected that adequate nutritional intake cannot occur. Dysphagia places patients at risk for aspiration, so use of enteral nutrition is usually a temporary means of providing adequate nutrition while swallowing ability is reestablished. This may take several weeks to months to occur. However, because PEG feeding provides enteral formula to the stomach, appropriate positioning of the patient is necessary to prevent potential reflux and aspiration.

10. Which of the following can result from thiamin deficiency? a. Pernicious anemia b. Wernicke-Korsakoff syndrome c. Pellagra d. Adrenomyeloleukodystrophy ANS: B

Thiamin deficiency is the primary cause of Wernicke-Korsakoff syndrome. This is a

potential side effect of alcoholism, and the syndrome manifests with encephalopathy, involuntary movement of the eyeballs, and impaired gait. Pernicious anemia is associated with vitamin B12 deficiency and manifests with general weakness and tingling in the hands and feet. Pellagra results from niacin deficiency and is associated with dementia.

Adrenomyeloleukodystrophy is a congenital enzyme deficiency that results in the accumulation of very-long-chain fatty acids. This disorder manifests with dementia, aphasia, apraxia, dysarthria, and blindness.

11. A patient with amyotrophic lateral sclerosis (ALS) has a rating of 3 or 4 on the swallowing

severity scale. Which of the following interventions would be recommended in the medical nutrition therapy plan? a. A regular diet with small, frequent feedings b. Modification of dietary consistency and texture

c. Supplemental tube feedings d. Nothing by mouth (NPO) ANS: C

Patients with amyotrophic lateral sclerosis who rate 3 or 4 on the swallowing severity scale need supplemental tube feedings because intake by oral means is not adequate. An ALS swallowing score of 10 is associated with normal swallowing ability. A swallowing score of 7 calls for an adjustment to small, frequent feedings. Scores of 5 and 6 indicate that the patient should be provided with a liquefied diet and a soft diet, respectively. A score of 2 or less indicates that the patient should be provided no oral intake.

12. What is the guideline for accepted weight adjusted for tetraplegia? a. Ideal body weight (IBW) as determined by the Hamwi formula b. 10 to 15 lb less than IBW as determined by the Hamwi formula c. 10 to 15 lb less than ideal body weight determined by BMI d. 15 to 20 lb less than ideal body weight determined by BMI ANS: D

Loss of muscle tone caused by skeletal muscle paralysis below the point of spinal cord injury leads to decreased metabolic activity. An initial weight loss is expected; however, this weight level should be maintained to prevent further complications such as osteoporosis or obesity. For people with tetraplegia, the recommended guideline is to aim for maintaining weight 15 to 20 lb less than the ideal weight as dictated by BMI standards.

The Hamwi formula does not account for levels of IBW associated with overall health and disease risk.

13. Curcumin is being researched for treatment of a. Parkinson’s disease. b. traumatic brain injury. c. dementia. d. All the above.

ANS: D

Phenolic compounds such as resveratrol, curcumin, and epigallocatechin are being investigated for benefit of their anti-inflammatory and neuroprotective effects in Parkinson’s disease, TBI, and dementia.

14. Which of the following is not true of head-injured patients? a. They have profound urinary nitrogen loss.

b. Their energy needs are related to the Glasgow Coma Scale. c. They are hypermetabolic. d. They have decreased energy needs.

ANS: D

Head injury results in hypermetabolism evidenced by increased energy expenditure and profound urinary nitrogen loss. Correlations between the severity of brain injury as measured by the Glasgow Coma Scale and energy requirements have been shown.

15. For which condition might a ketogenic diet be used in treatment? a. Myasthenia gravis b. Dysphagia

c. Epilepsy d. Guillain-Barré syndrome (GBS) ANS: C

The ketogenic diet, which is set up to create and maintain a state of ketosis, has been used to effectively control seizure activity in children with epilepsy. The diet originally provided a ratio of 4:1 or 3:1 grams of fat to nonfat. Less restrictive version provides a lower ratio of 1:1 or 2:1. For myasthenia gravis, nutrition therapy is focused on ensuring adequate intake despite chewing and swallowing difficulties. Dysphagia diets are texture modified according to an individual’s ability to swallow. A ketogenic diet would be used if the patient with dysphagia also had epilepsy. For patients who develop GBS, high calorie and protein intakes are necessary to counter the hypercatabolism associated with the condition.

16. Which of the following is the inability to perform purposeful, complex movements,

although no sensory or motor impairment is evident? a. Apraxia b. Aphasia c. Anosmia d. Paresthesia ANS: A

Lesions in the central portion of the frontal lobe may present with apraxia, the inability to execute purposeful movements. Aphasia is an impaired or absent comprehension of language because of a lesion near the junction of the left temporal, parietal, and frontal lobes. Anosmia is the loss or impairment of smell caused by a lesion near the base of the brain. Paresthesia is spontaneously occurring tingling sensation, sometimes described as “pins and needles.”

17. Which of the following is characterized by a cholesterol plaque within an artery that

ruptures and promotes platelet aggregation to clog an already narrowed artery? a. Intracranial hemorrhage b. Embolic stroke c. Thrombotic stroke d. Transient ischemic attack ANS: C

The thrombotic stroke involves platelet aggregation leading to occlusion of an artery.

Intracranial hemorrhage accounts for about 13% of all strokes and results from a blood

vessel rupturing inside the brain. An embolic stroke happens when a cholesterol plaque is dislodged from a proximal vessel and travels to the brain to block an artery. Transient ischemic attacks are brief attacks of cerebral dysfunction that are of vascular origin with no persistent neurologic defect.

18. During which phase of swallowing does bolus formation occur? a. Oral phase b. Early pharyngeal phase c. Middle pharyngeal phase d. Esophageal phase ANS: A

During the oral phase, food is formed into a bolus by the tongue. In the pharyngeal phase, the bolus is propelled past the faucial arches and then propelled down the pharynx. When the bolus passes the epiglottis, the bolus enters the esophageal phase of swallowing.

19. According to the IDDSI Framework for dysphagia diet texture standardization, which is

true about Level 3? a. Food can be molded on the plate. b. Food contains lumps, fibers, or particles. c. Food requires no chewing. d. Food can be eaten with a fork.

ANS: C

Level 3 is liquidized/moderately thick foods and liquids. The food can be drunk from a cup although it will take some effort to consume through a straw. Food cannot be molded on the plate and cannot be eaten with a fork. The food will not contain lumps, fiber, or particles. The food requires no chewing.

20. What is the preferred additive for thickening liquids? a. Dry milk powder b. Xanthan gum c. Tapioca d. Mashed potatoes ANS: B

Xanthan gum is a commercial product that is tasteless, holds the thickness over time, and is easy to mix. It is the preferred thickener. Dry milk powder alters the taste of the food and can provide too much protein for children, especially with the decreased free water.

Tapioca and modified food starches add extra kcal and continue to thicken over time, making it difficult to be accurate in level of thickness. Mashed potatoes are not used for thickening liquids with dysphagia. They would add kcal, could add particles, lumps and fiber while not provide a consistent degree of thickening.

Chapter 42: Medical Nutrition Therapy for Psychiatric and Cognitive Disorders Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. The brain is

% fat.

a. 80 b. 50 c. 100 d. 20 ANS: A

The brain is approximately 80% fat.

2. Wernicke encephalopathy can be treated with what nutrient(s)? a. EPA and DHA b. Vitamin C c. Thiamin d. Zinc ANS: C

Wernicke encephalopathy is a potentially reversible, yet serious disorder caused by thiamin deficiency. It is commonly associated with heavy alcohol consumption. It can also be seen after bariatric surgery. Although EPA and DHA are important to brain health, they are not used to treat this disorder.

3. MTHFR mutations are associated with what psychiatric disorder? a. Alzheimer disease b. Anxiety disorder c. Schizophrenia d. Addiction ANS: C

A genetic methylation mutation of MTHFR is involved in the activation of catecholamine neurotransmitters and is implicated in schizophrenia, OCD, ADHD and depression as well as vascular disease, thrombotic stroke, homocystinuria, and homocysteinemia.

4. Fluctuations in blood glucose can amplify which condition/disease?

a. Depression b. Schizophrenia c. Anxiety d. All of the above ANS: D

Excessive sugar intake can cause wide fluctuations in blood glucose that can amplify aberrant moods and behavior. Both high and low blood glucose have been found to have a strong association with a myriad of psychiatric conditions including anxiety, depression, and schizophrenia.

5. Which of the following are sources of alpha linoleic acid?

a. Cod b. Spinach c. Walnuts d. Oysters ANS: C

ALA is found in the oil of seeds and some nuts. Walnuts are the best source.

6. Vitamin D deficiency has been associated with a. bipolar disorder. b. delusional disorder. c. mood disorders. d. generalized anxiety.

ANS: C

Vitamin D affects hundreds of genes in the human body and is recognized as an important nutrient in brain health. Vitamin D has a crucial role in proliferation, differentiation, neurotrophism, neuroprotection, neurotransmission, and neuroplasticity of cells. The brain has vitamin D receptors which protect against, and even aid in the reversal of, in cognitive decline. Clinical research has associated vitamin D deficiency with the presence of mood disorders, dementia, and depression.

7. Which food is a good source of vitamin D? a. Butter b. Flax seed c. Egg yolk d. Steel cut oat ANS: C

The best sources of vitamin D are exposure of a large amount of skin to sunlight or foods such as oily fish, egg yolks, and vitamin D fortified foods such as cow’s milk and soy milk. Cereals are only a good source if they are fortified.

8. Which of the following groups is at high risk for deficiency of DHA? a. Formula-fed infants b. Pregnant women c. Weight lifters d. Adolescent girls ANS: B

Experts have suggested that a daily intake of at least 200 to 300 mg of DHA during pregnancy may be necessary for optimal development of infant nervous system. Starting in 2002, DHA has been supplemented to infant formulas to ensure adequate fatty acid intake for brain development. The risk of deficiency of omega-3 fatty acids has not been identified in weight lifters or adolescent females.

9. Folic acid supplementation in the methylated form is useful in some psychiatric disorders

because of its role in a. production of serotonin and dopamine. b. macrocytic anemia. c. histamine metabolism.

d. preventing neural tube defects.

ANS: A

Clients with genetic single nucleotide polymorphisms may require folate supplementation in methylated (5-MTHF) form. This is because of folate’s role in the production and function of dopamine and serotonin.

10. Which of the following conditions may be improved by supplementation of long-chain

omega-3 fatty acids? a. Bipolar disorder b. Dementia c. Depression d. All the above ANS: C

Adequate intake of long-chain omega-3 fatty acids is recommended for patients with bipolar disorder, dementia, and depression. Omega-3 fatty acids are also recommended for postpartum depression, schizophrenia, and alcoholism.

11. What is the recommendation of the International Society for the Study of Fatty Acids and

Lipids (ISSFAL) for the daily intake of DHA and EPA? a. 200 mg of each daily b. 500 mg combined daily c. 1100 mg combined daily d. 1600 mg combined daily ANS: B

The ISSFAL makes a general recommendation for a daily minimum intake of 500 mg combined of EPA and DHA. However, this recommendation does not clarify whether this is for populations with significant or limited fish intake.

12. Which of the following is not a neurotransmitter? a. Dopamine b. Epinephrine c. Glutamine d. Acetylcholine ANS: C

Glutamine is an amino acid required for production of neurotransmitters.

13. Flavonoid-rich foods include a. peaches, apricots, and sweet potatoes. b. fish and seafood. c. kale, broccoli, and spinach. d. oranges, berries, and green tea.

ANS: D

Evidence indicates that plant-based foods, especially foods with flavonoids, have nutritional and possibly pharmacologic effects in the brain. These foods include berries, citrus fruits, and green tea.

14. An excess of which nutrient has been associated with bipolar disorder?

a. Chromium b. Potassium c. Iron d. Vitamin C ANS: C

Iron excess is associated with increased risk of bipolar disorder, so screening some ferritin is warranted. Chromium, potassium, and vitamin C excess have not been associated with bipolar disorder.

15. A non-modifiable risk factor for Alzheimer’s disease is a. malnutrition. b. cardiovascular disease. c. hypertension. d. advanced age.

ANS: D

Advanced age is the most proven and nonmodifiable risk factor for Alzheimer’s disease.

Cardiovascular disease and hypertension are modifiable risk factors. Malnutrition is a result of the disease rather than a cause.

16. Chronic fatigue syndrome and fibromyalgia are associated with dysfunction of the a. pituitary gland. b. cerebral cortex. c. hypothalamus. d. glucose metabolism.

ANS: C

The hypothalamus controls sleep, temperature regulation, and hormonal and autonomic systems. It has high energy needs for its size. Dysfunction has been associated with chronic fatigue syndrome and fibromyalgia.

Chapter 43: Medical Nutrition Therapy for Low-Birth Weight Infants Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. Which of the following is a fluid loss that is preventable in the care of low birthweight

(LBW) infants? a. Insensible water loss caused by increased permeability of the skin b. Insensible water loss caused by radiant warmers c. Sensible water loss caused by an inability to concentrate urine d. Insensible water loss caused by a larger surface area relative to body weight ANS: B

Insensible water losses occur through the skin of premature infants because of increased permeability of the skin to water and larger body surface area relative to weight. However, these insensible losses can be increased or decreased depending upon how the infant is kept warm. Radiant warmers and phototherapy lights can increase insensible water losses and increase need for fluids. Heat shields, thermal blankets, and humidified incubators can decrease insensible water losses.

2. How much fluid should be provided to an LBW infant during the first day of life? a. 40 to 85 ml/kg b. 50 to 100 ml/kg c. 60 to 100 ml/kg d. 1000 ml total ANS: C

Usually 60 to 100 ml fluid/kg of body weight is provided to a premature infant to meet insensible fluid losses and renal output on the first day of life. After fluid needs are evaluated, fluids should increase by 10 to 20 ml/kg/day. By the end of the second week of life, the preterm infant may need to receive 140 to 160 ml fluid/kg/day to ensure adequate hydration status.

3. Which of the following may contribute to dehydration in a premature infant? a. Hypoglycemia b. Hypercholesterolemia c. Hyperglycemia

d. Hypovolemia ANS: C

High blood glucose can promote dehydration in a premature infant because it can promote diuresis. The high concentration of glucose in the blood draws fluid from the cells and increases the blood volume. Increased renal perfusion stimulates the excretion of glucose and water through the kidneys, increasing the likelihood that the infant will develop dehydration. High cholesterol does not affect hydration status. Hypovolemia is a decrease in volume of circulating blood.

4. The energy needs of a premature infant fed parenterally differ from those of a premature

infant fed enterally because parenterally fed infants a. require less energy per kilogram of body weight.

b. require an equal amount of energy per kilogram of body weight. c. require more energy per kilogram of body weight. d. have very erratic energy requirements.

ANS: A

Because parenteral nutrition bypasses the gastrointestinal tract, no loss of energy occurs because of energy cost of digestion and absorption and the inefficiency of absorption. As a result, infants receiving parenteral nutrition require less energy intake than those being fed enterally. Enterally fed premature infants need 105 to 130 kcal/kg, and parenterally fed premature infants need 90 to 100 kcal/kg.

5. Gastric residuals should be checked when feeding an LBW infant by bolus gavage feeding a. 1 hour after each feeding. b. before each feeding. c. once each day at the same time. d. when abdominal distension is suspected.

ANS: B

Because premature infants have stomachs with very limited capacity, residual checks are necessary when feeding these infants through a tube to ensure that an obstruction has not occurred. When providing bolus gavage feeding, aspiration of stomach contents for gastric residuals should be performed before the feeding starts. If residuals are found, depending on the volume in relation to the last time of feeding, continued feedings may need to be held. When providing feedings via continuous drip, intermittent checks for gastric residuals should be performed to ensure that gastric emptying is occurring.

6. Compared with term infants, preterm infants have an increased need for vitamin a. A. b. C. c. D. d. E. ANS: A

Preterm infants need more vitamin A compared with term infants. The reasons for this are increased need for facilitating tissue repair and because preterm infants have low vitamin A stores. Vitamin A is suggested for the prevention of bronchopulmonary dysplasia.

7. Because of a preterm infant’s decreased ability to concentrate urine, in which of the

following should sodium concentration be monitored regularly?

a. Serum b. Urine c. Stool and urine d. Saliva ANS: A

Hyponatremia is a potential risk in premature infants because of their immature kidneys.

The inability to concentrate urine could cause these infants to excrete excessive amounts of sodium. To safeguard against this, serum sodium levels should be monitored. Sodium may be lost in the stool if these infants experience diarrhea.

8. Which of the following procedures should be used in the transition from parenteral to

enteral feedings with an LBW infant? a. Advance to enteral feeding as quickly as possible. b. Begin full-volume enteral feeding. c. Stop parenteral feeding until enteral feeding is well established. d. Maintain parenteral feeding until enteral feeding is well established.

ANS: D

Transitioning of feedings must be performed slowly to accommodate the LBW infant’s ability to tolerate enteral feeding. If parenteral nutrition is the primary source of nutrition for the infant, parenteral nutrition must be maintained until the infant tolerates an adequate volume of enteral formula to maintain nutritional status. For VLBW infants, the transition process may take 7 to 10 days. Stable infants may be able to tolerate enteral feeding advances of 20 to 30 ml/kg/day. Enteral feeding is never started at full volume because prior disuse of the gastrointestinal tract leaves it unprepared for mature digestion and absorption. Abruptly stopping parenteral nutrition may result in fluid and electrolyte imbalances and hypoglycemia.

9. Which of the following must be supplemented to preterm infants fed parenterally or fed

human milk to prevent the development of osteopenia? a. Protein b. Calcium and phosphorus c. Vitamins A and D d. All fat-soluble vitamins ANS: B

Osteopenia of prematurity results from early birth because two-thirds of the calcium and phosphorus body content is accumulated in term infants during the last trimester of pregnancy. Prematurity results in lower calcium and phosphorus stores. Although both parenteral nutrition and human milk provide calcium and phosphorus, the amount of these nutrients is not enough to build up the stores in the infant. Parenteral nutrition cannot provide increased calcium and phosphorus because, at high levels, these can precipitate out into crystals that make the minerals unavailable to the infant and can result in crystal deposition in soft tissue. Human milk needs to be fortified to provide the additional calcium and phosphorus needed by premature infants.

10. The total of IV lipid in an LBW infant is generally a. 25% to 40% of nonprotein calories.

b. 10 g/kg/day. c. 10% to 15% of nonprotein calories. d. 60% of nonprotein calories.

ANS: A

For preterm infants the total lipid load is usually 25% to 40% according to the American Academy of Pediatrics. This can be given in amounts up to 3 g/kg/day. In preterm infants, the use of 20% lipid emulsions is preferred as this promotes lower plasma triglyceride, cholesterol, and phospholipid levels than does 10% emulsion.

11. Which of the following is not adequately provided to preterm infants through the use of

human milk fortifiers? a. Zinc

b. Calcium c. Phosphorus d. Iron ANS: D

Human milk fortifiers are supplements of protein, carbohydrates, fat, mineral, and vitamins that can be added to breastmilk to better meet the nutritional needs of preterm infants. However, iron is not always included as one of the nutrients in human milk fortifiers. Normally, the bioavailability of iron from breastmilk is high compared with formula, but preterm infants need more iron because of incomplete development of iron stores. Iron supplementation is needed.

12. Human milk a. has a different composition in the mothers of preterm infants. b. has zinc and iron that is more readily absorbed. c. has hormones. d. All of the above.

ANS: D

Human milk is the most ideal food for the preterm infant as well as the full-term infant.

The milk of mothers is different for the first month after the birth of a preterm infant.

Premature infants grow more rapidly when fed their own mother’s milk. Human milk contains antimicrobial factors, hormones, and enzymes.

13. Low birth weight is defined as birth weight a. less than 1000 g. b. less than 1500 g. c. less than 2500 g. d. for age less than the 10th percentile.

ANS: C

An infant who weighs less than 2500 g (5.5 lb) at birth is classified as having low birth weight. Infants who weigh less than 1000 g (2.25 lb) at birth are classified as being extremely low birth weight. Infants who weigh less than 1500 g (3.30 lb) at birth are classified as being very low birth weight. An infant born with a weight for age less than the 10th percentile is classified as being small for gestational age.

14. An infant has a birth weight below the 10th percentile, but her linear growth and head

growth are between the 10th and 90th percentiles. This infant would be classified as

a. AGA. b. SGA with asymmetric IUGR. c. SGA with symmetric IUGR. d. only SGA. ANS: B

A small-for-gestational age (SGA) infant has a birth weight below the 10th percentile.

When this is combined with linear and head growth between the 10th and 90th percentiles, then the infant has SGA with asymmetric intrauterine growth restriction. An SGA infant whose linear growth and head growth are below the 10th percentile as well is classified as being SGA with symmetric IUGR. An appropriate-for-gestational age infant has a birth weight between the 10th and 90th percentiles.

15. Which of the following helps promote better feeding of a premature infant after being

discharged from the hospital? a. Attracting the infant’s attention with toys b. Playing with the infant at feeding time c. Supporting the infant’s body during feeding d. Feeding while playing age-appropriate music ANS: C

Preterm infants are easily distracted and can be easily overstimulated. In addition, preterm infants tire easily and may have poor muscle tone. Because of these traits, a preterm infant needs to be supported in a position to properly align the head and neck to allow for adequate feeding. Also, distractions and stimulation can tire the infant and draw focus away from feeding. To help provide adequate feeding, the environment should be quiet and free of distractions.

16. An infant born at 32 weeks’ gestation is now 6 months old. Her adjusted age is

months. a. 6 b. 4 c. 3 d. 2 ANS: B

An infant born at 32 weeks’ gestation is premature. Therefore, her chronologic age should be adjusted for prematurity. 40 weeks term – 32 weeks’ gestation = 8 weeks premature.

Eight weeks is equal to 2 months. Therefore, her chronologic age of 6 months minus her correction factor of 2 months equals an adjusted age of 4 months.

17. Infants begin to gain weight above their birth weight a. by the end of the first day postpartum. b. within 48 to 72 hours postpartum. c. by the end of the first week postpartum. d. by 2 to 3 weeks postpartum.

ANS: D

All infants lose weight after birth, and preterm infants lose more relative weight than term infants because they are born with more extracellular water. By 2 to 3 weeks postpartum, infants usually regain their birth weight, and with adequate nutrition, they begin to grow

and exceed their birth weight.

18. Which of the following is not one of the characteristics that make premature infant

formula different from standard infant formula? a. Premature infant formula may provide 24 kcal/oz. b. Premature infant formula provides more casein than whey protein. c. Premature infant formula provides MCT oil. d. Premature infant formula provides more sodium.

ANS: B

Preterm infants require more nutrients and more calories than term infants to facilitate growth and help develop the nutrient stores that they lack. To allow for this, some premature formulas provide 24 kcal/oz to facilitate growth at intrauterine rates. MCT oil is one of the types of fat included in premature formula to help increase the calorie concentration of the formula. Also, to prevent potential hyponatremia, additional sodium is provided in premature formula. In regard to the protein content of premature formula, although more total protein is provided, premature formula provides a whey:casein ratio of 60:40, which is similar to that of standard formula.

19. After discharge, most preterm infants need approximately

ml/kg/day of

breastmilk or standard infant formula. a. 124 b. 120 c. 180 d. 250 ANS: C

After discharge, most preterm infants need approximately 180 ml/kg/day of breastmilk or standard infant formula containing 20 kcal/oz.

20. The basal metabolic needs of the premature newborn is

kcal/kg/day.

a. 30 b. 50 c. 90 d. 105 ANS: B

Preterm infants have basal metabolic needs of 50 kcal/kg/day. Because premature newborns have little to no fat or carbohydrate energy reserves, without additional energy provision, catabolism of the newborn’s protein stores will occur to provide energy. This will limit the survival time of the newborn. Provision of 40 to 60 kcal/kg/d and 1.5 g pro/kg/day is recommended to promote nitrogen balance in VLBW infants during the first 3 days postpartum. If fed enterally, a premature infant may grow by consuming at least 105 kcal/kg/day, but a parenterally fed premature infant will experience growth by receiving at least 90 kcal/kg/day.

Chapter 44: Medical Nutrition Therapy for Genetic Metabolic Disorders Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE 1. An appropriate description of a metabolic disorder is an autosomal recessive disorder that a. involves amino acids. b. results in the reduced activity or absence of a specific enzyme. c. occurs because the body cannot use dietary amino acids, fatty acids, or

monosaccharides. d. results in the buildup of metabolites in the blood, urine, or both.

ANS: B

Genetic metabolic disorders are mostly autosomal recessive inherited disorders that affect metabolic processes in the body through the absence or reduced activity of specific enzymes. In these metabolic disorders, body functions may become impaired by buildup of certain proteins that did not undergo conversion because of deficiency of the enzyme or lack of the end product of metabolism because of the missing enzyme.

2. Which of the following is not one of the nutritional treatments that would be provided to

patients with metabolic disorders? a. Restrict the amount of a specific substrate (nutrient) in the diet. b. Supplement the diet with a greater amount of a “safe” product of metabolism. c. Replace the defective enzyme through the diet. d. Supplement the defective enzyme cofactor.

ANS: C

Nutritional treatment of metabolic disorders focuses on trying to make up for the missing or inactive enzyme. Ways that this could be done include restricting the dietary intake of the specific substrate that would normally be altered by the missing enzyme, supplementing the diet with the underproduced end product of the enzyme’s metabolism, and supplementing the defective enzyme cofactor. Combinations of these approaches could also be used. Provision of the defective enzyme through the diet may not be effective because the digestive process will affect the enzyme as it would any other protein.

3. Which of the following will not result in the development of phenylketonuria?

a. Deficiency in phenylalanine hydroxylase b. Deficiency in dihydropteridine reductase c. Insufficient synthesis of biopterin d. Insufficiency of dietary tyrosine ANS: D

Phenylketonuria (PKU) is characterized by phenylalanine not being converted to tyrosine.

As tyrosine is an end product of the metabolic process, insufficiency of tyrosine does not lead to PKU development. PKU may develop through the lack of three different enzymes.

The classic PKU involves a deficiency of phenylalanine hydroxylase and prevents the conversion of phenylalanine to tyrosine. A deficiency of dihydropteridine reductase prevents the conversion of quinonoid (qBH4) to tetrahydrobiopterin (BH4), which is the cofactor in the phenylalanine to tyrosine conversion. BH4 is produced from biopterin precursor. Biopterin may be limited because of deficiency of a biopterin synthetase.

4. Which of the following metabolic disorders is not classified as an organic acidemia? a. Methylmalonic metabolic disorder b. Propionic metabolic disorder c. Isovaleric metabolic disorder d. Argininosuccinic aciduria ANS: D

Argininosuccinic aciduria is a urea cycle disorder that results in arginine deficiency.

Methylmalonic metabolic disorder and propionic disorder promote the development of metabolic acidosis through the accumulation of organic acids. Isovaleric disorder is also an organic acidemia; however, this disorder can produce metabolic ketoacidosis.

5. Which of the following metabolic disorders is not a disorder of carbohydrate metabolism? a. Hereditary glucose intolerance b. Glycogen storage disease c. Galactosemia d. Hereditary fructose intolerance ANS: A

Hereditary glucose intolerance is not a known metabolic disorder. Carbohydrate metabolism disorders include hereditary fructose intolerance, galactosemia and the various glycogen storage diseases.

6. Which of the following is reduced in the diet in the treatment of maple syrup urine disease

(MSUD)? a. Fructose b. Aromatic amino acids c. Branched-chain amino acids d. Sulfur-containing amino acids

ANS: C

MSUD is also known as branched-chain ketoaciduria, and this results from a defect in the branched-chain alpha-ketoacid dehydrogenase complex. The branched-chain amino acids—leucine, isoleucine, and valine—cannot be metabolized; therefore, affected persons require the use of specialty formulas that lack BCAAs. The BCAAs are slowly introduced into the diet when plasma leucine levels are decreased as they are necessary for growth to occur. However, dietary manipulation must occur so that enough BCAAs are available to support growth but not too high to increase plasma levels of the BCAAs. 7. Which of the following is not one of the enzyme deficiencies associated with urea cycle

disorders? a. Ornithine transcarbamylase

b. HMG-CoA reductase c. Carbamyl-phosphate synthetase d. Arginase ANS: B

HMG-CoA reductase is an enzyme necessary for cholesterol synthesis, and it is not involved with the urea cycle. The five enzyme deficiencies involved with urea cycle disorders include carbamoyl-phosphate synthetase, ornithine transcarbamylase, argininosuccinate synthetase, argininosuccinate lyase, and argininosuccinic acid synthetase.

8. Which of the following is the deficient enzyme in glycogen storage disease Ia (GSD Ia)? a. Glucose-1,6-phosphatase b. Fructose-1,6-diphosphatase c. Fructose-1-phosphate aldolase d. Hexokinase ANS: A

GSD Ia involves a defect in the enzyme glucose-1,6-phosphatase. This defect results in impairments in gluconeogenesis and glycogenolysis, which can result in severe hypoglycemia. Fructose-1,6-diphosphatase deficiency is a rare fructose metabolism disorder that promotes metabolic acidosis when fructose is consumed, but fructose levels do not increase in the blood or urine. Hereditary fructose intolerance is associated with a defect in fructose-1-phosphate aldolase that causes a depletion of inorganic phosphate and adenosine triphosphate. This disorder can result in renal and liver damage. Metabolic disorders involving hexokinase have not been identified.

9. The desirable range for blood phenylalanine in a child with PKU is

mg/dl.

a. 2 to 6 b. 6 to 10 c. 8 to 12 d. 10 to 20 ANS: A

Regular checking of blood phenylalanine levels is necessary to monitor for excessive phenylalanine intake and to prevent development of intellectual disability. The desirable range for blood phenylalanine concentration is 2 to 6 mg/dl. Subtle deficits in higher cognitive function may persist at blood phenylalanine levels of 6 to 10 mg/dl.

Phenylalanine levels greater than 20 mg/dl are the best predictor of IQ loss.

10. The metabolic result that occurs in all of the urea cycle disorders is an accumulation of

in the blood. a. ammonia b. purines c. ketones d. ketoacid ANS: A

Urea cycle disorders are named as such because the lack of particular enzymes in the cycle impairs the production of urea. Urea production is the means for eliminating ammonia resulting from amino acid metabolism. If ammonia cannot be packaged into urea, ammonia levels increase in the blood and can cause neurologic damage, seizures, coma, and death. Ketoacid residues from amino acid metabolism may be reused for production of other amino acids or for substrate in energy metabolism. Ketone production occurs when regular fatty acid metabolism is limited from continuing into the Krebs cycle.

11. Which of the following conversions is defective in galactosemia? a. Glucose to galactose b. Galactose to glucose c. Lactose to galactose d. Galactose to lactose ANS: B

In galactosemia, a buildup of galactose in the blood results from the inability to convert galactose into glucose. This is characterized by either galactokinase deficiency or galactose-1-phosphate uridyl transferase deficiency. Lactase deficiency would result in the inability to break down lactose to galactose and glucose.

12. Which of the following is used in the nutritional management of patients with glycogen

storage disease? a. Oral intake of cornstarch b. Small, frequent high-protein meals c. Severe restriction of all carbohydrates d. Three well-balanced meals a day ANS: A

Because patients with glycogen storage disease develop no provisional carbohydrate stores, they run the risk of developing hypoglycemia. Therefore, the provision of a high-carbohydrate, low-fat diet with intake of raw cornstarch at regular intervals throughout the day is used to prevent hypoglycemia. Carbohydrate feedings must occur throughout the day and should not be distributed to only three eating episodes or restricted.

13. The current preferred method for screening for inborn errors of metabolism is a. microarray technology. b. tandem mass spectrometry. c. Guthrie bacterial inhibition assay.

d. enzyme-linked immunosorbent assay.

ANS: B

Tandem mass spectrometry was developed in the 1990s and can screen for 30 or more disorders that affect newborns. Microarray technology is used to measure gene expression, which is useful in nutrigenomics but is too costly to use as a widespread screening methodology. The Guthrie bacterial inhibition assay was developed in the 1960s and became the basis for newborn screening. ELISA is used in immunologic testing.

14. For infants and children younger than 10 years of age with PKU, which amino acid has to

be supplemented in the diet? a. Cysteine b. Methionine

c. Phenylalanine d. Tyrosine ANS: D

In PKU, as the conversion of phenylalanine to tyrosine is blocked, infants and children have to receive supplemental tyrosine to ensure adequate growth. Usually, the extra tyrosine is provided in specialty formula products that have no phenylalanine. Cysteine and methionine are the sulfur-containing amino acids, and intake needs of each depend on the intake and metabolism of the other.

15. Which of the following foods would be allowed in the diet of a child with PKU? a. Peanut butter and jelly sandwich b. Sugar-free gum c. Potato chips d. Spaghetti and meatballs ANS: C

Children with PKU should be provided with foods with low-protein content because these also have low phenylalanine content. Potato chips provide relatively no phenylalanine.

High-protein foods such as dairy foods, meats, and peanut butter provide too much phenylalanine. Also, regular breads, pastas, and baked goods may be too high in phenylalanine. Low-protein versions of these foods are available from specialty sources.

Aspartame is the sweetener that is commonly used in sugar-free and diet products; however, because aspartame contains phenylalanine, these foods should be avoided in the diet of a child with PKU. 16. Which of the following is not one of the possible infant outcomes of PKU mothers with

elevated phenylalanine levels? a. Liver dysfunction b. Microcephaly c. Congenital heart disease d. Low birth weight ANS: A

The most common abnormalities in infants born to mothers with PKU and elevated phenylalanine levels are intellectual disability, microcephaly, heart defects, and restricted growth. The function of the liver has not been shown to be affected by fetal exposure to high levels of phenylalanine.

17. Which of the following metabolic disorders is not treated with a low-protein diet? a. Argininemia b. Methylmalonic acidemia c. Ketone use disorder d. Galactosemia ANS: D

Galactosemia is a disorder of carbohydrate metabolism, and although galactose is only available in the diet through dairy products, these are the only protein sources that need to be avoided. Argininemia is a urea cycle disorder, and as with all urea cycle disorders, a protein-restricted diet is necessary in treatment. Methylmalonic acidemia and ketone use disorder are both organic acidemia disorders. Patients with these disorders are treated with protein restriction because protein contributes more acids to the body than carbohydrates and fats.

18. Which of the following is part of the medical nutrition therapy for fatty acid oxidation

disorder? a. Fasting b. High carbohydrate c. High fat d. Vitamin B12 supplementation ANS: B

Patients with fatty acid oxidation disorders are generally treated with low-fat, high-carbohydrate diet with regularly spaced meals and snacks. The diet is particularly low in the type of fatty acid involved. Additionally, fasting is limited so as not to stimulate increased mobilization of fatty acids from adipose stores. B12 supplements are used in the treatment of methylmalonic acidemia.

19. Which of the following fruits and vegetables would be allowed in the diet of a person with

galactosemia? a. Bell peppers b. Watermelon c. Raisins d. Tomatoes ANS: C

Bell peppers, watermelon, tomatoes, dates, papayas, and persimmons are all fruits and vegetables that provide greater than 10 mg galactose per 100 g fresh weight. These are foods that should be avoided by patients with galactosemia. Raisins are not a concentrated source of galactose and can be consumed.

20. Which metabolic disorder, in addition to fatty acid oxidation disorders, is treated with

supplemental carnitine? a. Isovaleric acidemia

b. Ketone utilization disorder c. Ornithine transcarbamylase deficiency d. Tyrosinemia ANS: B

Ketone utilization disorder affects the metabolism of ketones; however, the provision of carnitine can help promote transport of fatty acids into the mitochondria and thus promote a decrease in ketone production. Patients with isovaleric acidemia, ornithine transcarbamylase deficiency, and tyrosinemia are treated with protein restriction. In the case of tyrosinemia, the restriction would focus on tyrosine.

Chapter 45: Medical Nutrition Therapy for Intellectual and Developmental Disabilities Raymond: Krause and Mahan’s Food and the Nutrition Care Process, 16th Edition

MULTIPLE CHOICE

1. Which of the following is not one of the qualifications of developmental disabilities as

established by law? a. Manifests before the age of 22 years b. Attributable to malnutrition that causes mental or physical impairment c. Results in substantial functional limitations in three or more areas of major life

activity d. Expected to continue through life indefinitely ANS: B

The Developmental Disabilities Assistance and Bill of Rights Act does not specify the etiology of mental and physical impairments. The impairments are what evidence the disability. Usually, developmental disabilities appear in infancy or childhood and continue to affect the person for a lifetime. Disabilities tend to promote functional limitations in various life activities such as self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, and economic self-sufficiency.

2. The most common developmental disability is a. autism. b. cerebral palsy. c. Down syndrome. d. intellectual disability.

ANS: D

Intellectual disability is the most common developmental disability, and it is associated with significantly below average intelligence. Intellectual disability can be associated with other developmental disabilities, including autism and Down syndrome. Cerebral palsy is a disorder of motor control or coordination resulting from injury to the brain during its early development.

3. Which type of cerebral palsy is characterized by constant contraction of muscles, making

limbs still, rigid, and resistant to relaxing?

a. Nonspastic b. Athetoid c. Dystonic d. Spastic ANS: D

Spastic cerebral palsy (CP) is characterized by increased muscle tone. Muscles constantly contract and resist relaxing. Nonspastic CP affects coordination of movements and balance. Dystonic CP affects trunk muscles and results in fixed, twisted posture. Athetoid CP includes involuntary movement, especially in legs, arms, and hands.

4. The child that would have the lowest energy needs is a a. healthy child.

b. child with mild cerebral palsy. c. child with spina bifida. d. child with Down syndrome.

ANS: C

Because spina bifida can result in weakness in the lower extremities, paralysis, and nonambulation, the decrease in physical activity associated with these may place the affected child at risk for developing obesity. Therefore, to maintain weight, children with spina bifida should receive only 9 to 11 kcal/cm height compared with healthy children who should consume 16 kcal/cm. Children with mild cerebral palsy also have some limitations in regard to their mobility; however, in most cases, involuntary movements or muscle tension contribute to energy needs. Children with mild CP should receive about 14 kcal/cm to prevent potential weight loss. Children with Down syndrome run the risk of developing obesity; however, because they tend to be of shorter stature than healthy children, their energy needs are comparable to maintain weight: 14.3 kcal/cm for girls and 16.1 kcal/cm for boys.

5. Which developmental disability is associated with problems with childhood growth

failure? a. Prader-Willi syndrome b. Spina bifida c. Cerebral palsy d. Down syndrome ANS: C

Lack of muscle coordination associated with CP can promote feeding problems while the child uses energy to support involuntary movements and muscle tension. Combined, these two factors could lead to inadequate nutrient intake and promote failure to thrive. Children with Prader-Willi syndrome, spina bifida, and Down syndrome tend to run the risk of developing obesity because of limited or, in the case of Down syndrome, delayed gross motor ability.

6. Which of the following is not required for a child with a disability to receive a modified or

special diet at school? a. Payment of additional cost for the special diet b. Identification of the medical condition requiring modification of diet c. List of foods to be omitted from the child’s diet d. List of food substitutions to use in the child’s diet

ANS: A

By law, schools must offer special diets at no additional cost for children whose disabilities restrict their diets. In the language of the law, this actually includes modifications for children with diabetes and heart problems. For a referral to be made, a statement signed by a physician must be provided to the school. This request must identify the conditions that require the special diet, what foods need to be omitted, and what foods should be substituted.

7. Which developmental disorder is associated with Pierre Robin sequence? a. Spina bifida b. Cleft palate c. Rett syndrome

d. Prader-Willi syndrome ANS: B

Pierre Robin sequence is a birth condition that involves the development of either a smaller-sized lower jaw or an upper jaw that is set back. As a result, the tongue tends to be displaced toward the back of the throat, where it can obstruct the airway. This occurs in infants with cleft palate. Spina bifida results in spinal lesions that affect many systems of the body but has no effect in regard to the development of the mouth. Rett syndrome is a neurologic disorder that involves a loss of motor skills and is characterized by a decrease in head growth between 5 to 48 months postpartum. Individuals with Pierre Robin syndrome present with short stature, small hands and feet, and obesity.

8. What is the role of the RDN in complementary and integrative therapies? a. Supervise use of therapies. b. Discuss potential harm of using therapies. c. Ensure evidence-based research involving the therapies. d. All the above.

ANS: D

The RDN should be cognizant of complementary and integrative therapies of interest to his/her clients. The RDN should investigate therapies for any evidence-based research demonstrating benefit or harm of the therapy. The potential harm and benefit of the therapy should be discussed with the client so that a decision to use or not to use a therapy is based on reliable data. If the client decides to pursue the therapy, the RDN should supervise the use of the therapy to minimize risk and optimize benefit.

9. To make standard 20-calorie/oz formula, how much powdered formula needs to be mixed

with every 2 oz of water? a. 1 tsp b. 1 Tbsp c. 1 scoop d. 2 scoops ANS: C

Standard formula that provides 20 calories/oz is the equivalent of breastmilk. All powdered infant formulas come with a scoop provided in the can. The proper mixing ratio for standard formula is 1 scoop for every 2 oz of water. Of course, the water should be purified to prevent the development of infant infection or diarrhea.

10. Which of the following dietary interventions should be used in treating children with

attention-deficit hyperactivity disorder? a. Eliminate table and added sugars from the child’s diet. b. Serve meals at regular eating times and provide small servings. c. Prevent the child from consuming foods with caffeine. d. Provide large doses of vitamin supplements to the child.

ANS: B

Children with attention-deficit hyperactivity disorder (ADHD) have no nutrient needs or exclusions additional to those of otherwise healthy children. These children do run the risk of not getting enough to eat because of behaviors associated with the disorder. To promote adequate intake, parents should establish regular meal times and provide initial small portions in a distraction-free environment. Children with ADHD may eat a little and then walk away from the table, expecting to graze later. Some recommend removing the food and returning it only once after explaining to the child what behaviors are desired in relation to eating. Various dietary manipulations in the past have attempted to treat children with ADHD by eliminating sugars, eliminating artificial food colors, eliminating caffeine, and using megavitamin therapy. Research has not substantiated the effectiveness of any of these.

11. Which class of feeding problems is associated with head control and trunk stability? a. Behavioral feeding problems b. Oral motor feeding problems c. Positioning feeding problems d. Self-feeding problems ANS: C

Positioning of children for feeding is related to the child’s motor development, head control, trunk stability, and the ability to have the hips and legs at a right angle. The infant or child has to be in a proper position to allow for feeding. Otherwise, correction of oral motor problems may not be possible. Children with spina bifida, Down syndrome, and cerebral palsy are likely to have positioning problems.

12. Children with which developmental disorder are most likely to experience oral motor

problems? a. Prader-Willi syndrome b. Spina bifida c. Autism d. Cerebral palsy ANS: D

Because of the lack of coordination of muscle control, children with cerebral palsy are likely to experience oral motor problems in regard to feeding. Other children with developmental disabilities who experience oral motor feeding problems are those with Down syndrome and those with cleft palate. Infants with Prader-Willi syndrome may have weak sucking ability. Infants with spina bifida may have swallowing difficulties. In

children with autism, feeding difficulties center around limited food selection and strong food dislikes.

13. Children with

may be affected by Arnold Chiari malformation of the brain.

a. autism b. spina bifida c. Down syndrome d. Prader-Willi syndrome ANS: B

Arnold Chiari malformation of the brain is a structural disorder affecting the brainstem that can affect swallowing. This occurs in many children with spina bifida. Children with autism have problems with eating behaviors as opposed to difficulties with swallowing.

During infancy, children with Down syndrome have difficulty coordinating sucking, swallowing, and breathing. Infants with Prader-Willi syndrome also experience weak sucking ability.

14. Which of the following developmental disorders results from a chromosomal aberration? a. Attention-deficit hyperactivity disorder b. Cerebral palsy c. Autism d. Prader-Willi syndrome ANS: D

Prader-Willi syndrome is a genetic disorder in which the child either inherits chromosome 15 from the father with a deletion in the q arm region of the chromosome or receives both chromosome 15s from the mother. ADHD is known as a neurobehavioral disorder that does not have a genetic influence. Cerebral palsy and autism result from neurologic defects.

15. A casein-free and gluten-free diet has been used in individuals with a. Prader-Willi syndrome. b. cerebral palsy. c. autism. d. fetal alcohol syndrome.

ANS: C

A casein-free and gluten-free diet has been used in some children with autism spectrum disorder. There are anecdotal reports of success with exclusion diets.

16. People with Down syndrome have a total of

chromosomes.

a. 21 b. 23 c. 46 d. 47 ANS: D

Down syndrome is also known as trisomy 21 because the child inherits an extra chromosome 21 from each parent. Children usually inherit 23 chromosomes for a total of

46. Because children with Down syndrome inherit the extra chromosome 21, they have a total of 47 chromosomes.

17. Children with which of the following disorders are least likely to have short stature? a. Down syndrome b. Cerebral palsy c. Autism d. Prader-Willi syndrome ANS: C

The height of children affected with autism spectrum disorders is comparable to that of children without developmental disorders. Down syndrome, Prader-Willi syndrome, spina bifida, and cerebral palsy all present with short stature in children.

18. What disorder is associated with these three specific facial features: a smooth philtrum,

small palpebral fissures, and a thin upper lip? a. Fetal alcohol syndrome b. Cerebral palsy c. Spina bifida d. Prader-Willi syndrome ANS: A

The diagnosis of fetal alcohol syndrome requires the presence of the three identifiable facial features: a smooth philtrum, a thin upper lip, and small palpebral fissures.

19. Which developmental disorder is characterized by the child having an insatiable appetite? a. Attention-deficit hyperactivity disorder b. Spina bifida c. Down syndrome d. Prader-Willi syndrome ANS: D

One of the greatest nutritional risks in children with Prader-Willi syndrome (PWS) has to do with the child’s appetite control. Children with PWS begin to gain excessive weight between the ages of 1 and 4 years because of an uncontrollable appetite. This, along with a low basal metabolic rate and decreased activity, makes the child with PWS susceptible to obesity. Children with ADHD treated with medications have to be monitored for potential anorexia. Children with spina bifida and Down syndrome also are susceptible to excessive weight gain because of lowered basal metabolism and limited activity.

20. By current methods, which developmental disorder is preventable? a. Down syndrome b. Spina bifida c. Autism d. Prader-Willi syndrome ANS: B

Down syndrome and Prader-Willi syndrome are both genetic disorders and the cause of autism has yet to be identified, but the neural tube defect associated with spina bifida can

be prevented by adequate maternal intake of folic acid.