# FREE NSC Clinical Knowledge Questions and Answers

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#### What weight should an obese patient with chronic renal disease use when performing calculations?

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An essential component in the care of patients with chronic renal disease is anthropometric assessment. Weight is used as a basis for many computations, such as calorie and protein requirements, prescription drugs, and other therapies. It's crucial to record both your current weight and any previous weight fluctuations. Because the dry weight represents metabolically active lean body weight, it should be utilized for estimates for non-obese people. A patient's adjusted dry body weight has to be determined if they are overweight or obese. Using the adjusted dry body weight will help with fine-tuning energy and protein requirements based on the dry lean body mass to prevent overfeeding. The adjusted dry weight can be calculated using the following equation: adjusted dry weight = dry weight + [(standard body weight - dry weight) x 0.25], where the standard body weight can be obtained using data from NHANES II.

#### In the early postburn phase, what is a tolerable protein level for a patient with a 50% TBSA?

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Numerous formulas can be used to estimate how much protein burn patients will need. A significant burn will speed up the body's catabolic rate. Two to three quarters of the total calories, or roughly two to five grams per kilogram, are needed during the first post-burn injury phase. Extra protein may be needed as the burn heals, particularly in cases when the burn has a significant total surface area. High protein diets will help to achieve anabolism and start the healing process, but they won't stop catabolism. It is important to keep an eye on the patient's tolerance to an increased protein load, as well as their degree of wound healing and azotemia. The following formula can be used to calculate nitrogen balance: grams of nitrogen - grams of urine urea nitrogen + 4. Accurate records of intake and output as well as normal renal function are necessary. The target anabolic range for the acute recovery period is +5 to +10.

#### Which of the following instruments is most useful for evaluating a patient who has both ascites and chronic liver disease?

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It is challenging to estimate a patient's nutrition when they have ascites and advanced chronic liver disease since many of the standard parameters are unreliable. Measurements of triceps skinfold, BMI, and weight for height are examples of anthropometric metrics that are influenced by fluid state and do not precisely represent muscle mass or real weight. Because serum albumin and prealbumin are created by the liver and do not represent the protein status in liver disease, even in well-nourished patients, they are not good indicators of liver disease protein status. Studies on nitrogen balance may not be precise because of protein retention in the form of ammonias and the possibility of hepatorenal problems that impact nitrogen excretion. Subjective global assessment can be the most useful tool (SGA). This kind of instrument combines a physical and functional assessment. Evaluation criteria include past consumption, weight history, discernible muscle loss, and capacity to carry out everyday tasks. In addition to GI symptoms, other chronic diseases can also be assessed.

#### The LEAST reliable marker to utilize when determining malnutrition in a critically unwell patient would be

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The criteria used to diagnose malnutrition using ICD-10 codes are currently being revised. As a general rule, albumin and pre-albumin are not good indicators of protein status. This is because albumin and pre-albumin serve as inflammatory indicators during acute sickness. While there are detrimental effects of inflammation on nutritional status, these markers are not reliable indicators of visceral protein status. Weight, strength, and wound healing improvements are better measures of protein status. The amount of weight change over a specified length of time and the loss of muscle or subcutaneous fat are further indicators of overall nutritional condition. A better indicator would be reduced nutritional intake or modifications to physical abilities like hand grip strength.

#### In an ICU situation, which of the following anthropometric techniques is LEAST helpful for assessing nutrition?

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In an ICU context, the measurement of lean body mass by midarm muscle circumference (MAMC) and midarm circumference (MAC) is less useful than the measurement of subcutaneous fat by triceps skinfold (TSF). The patient's arm could not be easily accessible in an intensive care unit, which is one explanation for this. A secondary explanation is that healthy persons who were not admitted to the hospital were used to construct the TSF, MAC, and MAMC standards. Variations in the patient's state of hydration and in the methods used by different measurement personnel can occur. The body mass index, or BMI, is a helpful tool for determining a patient's nutritional health. BMI has other drawbacks as well, such as incorrectly labeling someone with significant muscle mass as obese. It's not too bad to compare a patient's present weight to their average weight, especially if you also consider the causes behind their weight loss. Comparing the patient to the general population can also be accomplished with the use of height and the Hamwi equation.

#### Which of the following drugs has the lowest potential to make you gain weight?

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It's crucial to find out what medications a patient may be taking for depression because the majority of antidepressants have the potential to cause weight gain. There could be more than one mechanism at work here. A metabolic impact, like a drop in metabolic rate, might occur. A drug may also cause an increase in appetite, which would raise calorie intake. It might also be the consequence of an all-around improvement in wellbeing brought on by a decline in depression and an increase in food consumption. The antidepressants Serzone, Effexor, and Wellbutrin are least likely to result in weight gain. Drugs such as selective serotonin reuptake inhibitors (SSRIs) increase the risk of weight gain. Paxil, Lexapro, Prozac, and Zoloft are a few of these. Tricyclics like Elavil and MAO inhibitors like Parnate and Nardil are also more likely to result in weight gain.

#### Which of the following best sums up when an enteral feeding regimen should be started for a patient who has had a traumatic brain injury?

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For patients who are really sick, enteral feeding is always the best option. Feeding intolerance and gastrointestinal reflux are common after a traumatic brain injury (TBI). Although nasogastric tubes are usually easy to insert, early feeding is not advised with them because of the possibility of aspiration pneumonia and feeding intolerance. The insertion of a nasoenteric tube into the duodenum or jejunum can be tolerated by certain patients. It is best to start enteral feeding during the first 24 hours after a traumatic brain injury (TBI) as it has been demonstrated to be advantageous. It is recommended to supply a minimum of half of the patient's calorie and protein needs. Enteral feedings are started early because, according to theory, this helps to lessen the patient's inflammatory reaction, which usually peaks during the second week. It has also been demonstrated that early feeding lowers mortality. Early feeding increases blood flow to the gut and decreases bacterial translocation.

#### The patient is taking Zerit, an anti-HIV medication. This medication could lead to

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The anti-HIV medication Zerit (stavudine) may result in lipodystrophy. Lipodystrophy has also been linked to protease inhibitor use. A shift in the body's production, storing, and utilization of fat is known as lipodystrophy. In both men and women, lipodystrophy can result in fat buildup in certain body parts such the breasts, the belly, and the back of the neck. This is determined by measuring the skin folds and other impacted areas in addition to the waist-to-hip ratio. Additionally, lipodystrophy can result in fat loss in the buttocks and extremities, as well as in the face, where it can create sunken cheeks and temporal wasting. Other metabolic disorders like hyperlipidemia, hyperglycemia, and lactic acidosis can also be brought on by lipodystrophy. It is more common for older Caucasian men to develop lipodystrophy. This disorder is also more likely to occur in obese people and those who have had HIV for a longer duration.

#### Which of the following clinical factors in an acute care hospital is LEAST likely to be a sign of a patient who is nutritionally at risk?

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Nutrition screening must be finished within 24 hours of admission, according to a Joint Commission requirement (previously known as the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO). To ascertain each patient's level of nutritional risk, risk variables are identified. It is common to utilize weight as a risk factor. Particularly if the patient was adhering to a diet that was appropriate in terms of nutrients, an unanticipated weight change of more than 10% over a 6-month period or a 5% unplanned change over a 1-month period would be deemed a nutritional concern. A duration of malnutrition exceeding seven days; alterations in gastrointestinal function, such as nausea, vomiting, or constipation; or a history of major gastrointestinal surgery are additional risk factors. Nutritional status would also be impacted by numerous chronic illnesses. Social variables, alterations in chewing or swallowing abilities, and the usage of specific drugs can all have an impact on nutritional status.

#### With the intention of weaning in the next days, a COPD patient who is experiencing respiratory failure is presently receiving mechanical ventilation. At 95% of his typical body weight, he is 85% of his optimum weight. Which weight would be most appropriate to use when figuring out how much energy is needed?

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The most accurate method for estimating a patient's energy needs who has COPD and respiratory failure is indirect calorimetry. This is frequently not an option, thus the qualified dietitian must determine the expected energy needs. Giving too many calories might lead to overfeeding, which makes the process of weaning off the ventilator more challenging. Carbon dioxide output may rise in cases of overfeeding. Additionally, underfeeding is not ideal since it deconditions a patient who is already compromised and promotes catabolism. Actual body weight should be utilized to determine energy demands for underweight patients, particularly during the weaning phase. When making estimates for patients who are at or up to 24 percent over their ideal body weight, ideal body weight should be utilized. An adjusted body weight should be utilized for patients who exceed their optimal body weight by at least 25%. (Actual Body Weight - Ideal Body Weight) x 0.25 + Ideal Body Weight is the formula for determining modified Ideal Body Weight.

#### Scaly, dry skin may be an indicator of malnutrition when conducting a physical examination that focuses on nutrition.

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The patient's skin can provide valuable insight into their general nutritional state during a physical examination that focuses on nutrition. Dermatitis or dry, scaly skin could be signs of an essential fatty acid shortage. Protein, zinc, or vitamin C deficiencies may be the cause of poor wound healing. One useful measure of skin moisture is the skin's turgor, or its capacity to revert to its natural shape. A low level of iron, vitamin B, or folate may be indicated by pale skin. Occasionally, people with elevated cholesterol levels may develop little nodules on their elbows or eyelids. Lack of vitamins C or K may be the cause of excessive bruising that is accompanied by petechiae or ecchymosis.