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.. '"NTR 415 Exam 1 \ ) Q N \ ~ I \ o fSeptember 18, 2009Mllltiple choice questions are two points each, others as noted. Partial credit is given, so do yourbest Some questions have the notation CIRCLE ALL THAT APPLY. These may have morethan one correct response. Other multiple choice questions have only one correct response. Besure to answer each question completely.Case Study #1:The patient is a 63 yo male with a medical history notable for gastroesophageal reflux, a partialgastrectomy (partial removal of the stomach) 5 years ago, chronic alco b . J . l s . . ~ , and depression.He also has hypertension (high blood pressure). Medications include lasix (a 100 diuretic_cimetidine, Elavil, and Lisinopril. He is ~ ~ 2 " and weighs 201 ounds. He reports his weight hasbeen stable for the past 2-3 years. You conduct a 24-hour recall and find nothing out of theordinary, although he does have a limited intake of fruits and vegetables. He reports that he isnot taking any dietary supplements at this time. His laboratory results from a blood draw(including CBC) are as follows:

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Test Reference ranJ!e Subject valuesNa+ 135-145 mEq/L 140K+ 3.6-5 mEq/L 3.4 LCl 101-111 mEq/L 107HC03 21-3.1 mEq/L 29Glucose 70-110 mg/dl 101BUN 5-20 mg/dl 12Creatinine (Cr) 0.6-1.2 mg/dl 0.8Albumin 3.5-5 g/dl 3.7Calcium 8.5-10.5 mg/dl 9.1Total cholesterol >150 mg/dl 193ALT 4-36 U/L 187 H

,AST 0-35 U/L 203 H208-378 U/L 611 HTotal bilirubin 0.1-1 mg/dl 0.9RBC 4.3-5.9 x 100/mmJ 4.4Hgb 14-17 g/dl 15.1Hct 39-49% 43MCV 80-95 fL 99HMCH 27-31 pg 34HMCHC 32-36 g/dl 35WBC 5-10 X 10 j /mm j 8

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ted to determine his frame size, which one of the following methodes) would be(CIRCLE ALL THAT APPLY)

-;. Elbow breadthWrist circumferenceSchilling testd. 3-Methylhistidine excretion

lllch one of the following lab results tells you about the size of the red blood cells (RBCs)?a. WBC 'fb. RBC -c. Hgb() MCV

4. How would you classify his RBCs?a. Microcyticb. Normocytic/ . U / ' 1(,)BIt . u .....J j \o - t \.t:. ~ ' ( ' . . V I ( A v>\

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7. Cimetidine, an H2-receptor antagonist, reduces gastric acid production. Which nutrient or nutrients are most likely to have impaired absorption as a result of using this drug? (CIRCLEALL AT APPLY)

CalciumThiaminIron, : Vitamin B12Vitamin C

f. Vitamin Eg. Chromiumh. Vitamin D

8. Which of the following medications is the likely reason for the patient's hypokalemia (lowblood potassium)?

a. cimetidineb. Lisinopril

lasix - \ r D O \ ~ J \ " , \ ' ( . ~ ~ ~ - d. Elavil

9. The elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST) mostlikely indicate damage to which organ?

a. Kidneysb. Pancreas() Liverd. Heart

Case Study #2:An 43-year-old male ost-sur . .ellt,during routine nutrition screening is found to havethe following lab results. There i ~ h e i ~ t a . \ r a i l a b l e and his weight i s ~ _ . ---......}

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Test Reference ran/:e Subject valuesNa+ 135-145 mEq/L 141K+ 3.6-5 mEq/L 4.1Cl 101-111 mEq/L 103HC03 21-31 mEq/L 27Glucose 70-110 mg/dl 109BUN 5-20 mg/dl 13Creatinine (Cr) 0.6-1.2 mg/dl 1.0Albumin 3.5-5 g/dl 2.8LCalcium 8.5-10.5 mg/dl 7.9LTotal cholesterol >150 mg/dl 211Total bilirubin 0.1-1mg/dl 0.7RBC 4.3-5.9 x 10o/mm j 4.4Hgb 14-17 g/dl 16Hct 39-49% 45

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MCV 80-95 fL 91MCH 27-31 pg 29MCHC 32-36 g/dl 34WBC 5-10 x 10 j /mm j 8

10. You suspect his hypoalbuminemia is due to:a. Marasmusb. Kwashiorkor@ Acute phase responsed. None of the above

11. Albumin.-liays a role in maintaining colloid osmotic pressure. Given this role, in a personwith ' ~ h i o r k O n , how does hypoalbuminemia manifest itsel f clinically (what is the result)?

. 4hydra t ion L ~ C L ~ ~ b ~ - , \e.- ,,1... ~ ' 4 $ . { t l J .cc,"(Edema

c. Hypertension (high blood pressure)d. No effect

12. Suppose you decide to measure urinary creatinine as a somatic indicator of protein-energymalnutrition. Which of the following is/are TRUE of creatinine (CIRCLE ALL THATAPPLY).@ Its urinary excretion is affected by meat consumption

b. It is a posttranslationally-modified amino acidc. It is a good indicator of visceral protein status@ It is a byproduct of creatine metabolism

13. Which of the following are typical criteria used as part of nutrition screening (CIRCLE ALLTHA PPLY)?Laboratory data/values

Height and weight, . DiagnosisMedications

14. Nutrition screening, as in this patient, is the entry point to the Nutrition Care Process (NCP).What is the first step in the NCP?

a. Nutrition Diagnosis Nutrition Assessmentc. Nutrition Monitoring and Evaluationd. Nutrition Intervention

15. When the Nutrition Care Process is applied in practice, the overall care and service providedis known as:

a. Applied Medical Nutritionb. Medical Nutrition Treatment

Medical Nutrition TherapyCi> Applied Medical Dietetics

(j)

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16. The classes ofNutrition Intervention include (CIRCLE ALL THAT APPLY):a. Nutrition screening l ) H$I,oi I4.+d lOI(" N . \ A . H ' ~ < - . e , \ t ~ t " ~ , . d . 't.') t - J ~ \ . - ... c..>-V'\. ~ k - o . 1NutntlOn e ucatlOn ~ }, L . t , _... I,.t, , . " ) , , ~ w . ~ , .. \ \-- .....'" '" '\/1I\.-'fV.c,." l ~ .c. Chmcal - ~ ' \ . V 2 " " y . . ; < : l ' ~ J " " ' ..' "" '-\ e . . . t > / , . ) \ ~ t>-A e : ; ~ ~ t : ' . . . , . . ~ @) Food and/or nutrient delivery

Case Study #3:An 89 yo female is admitted to the hospital with progressively w o r s e n i n g _ ~ o n f u s i o n , l ~ t h a r g y , and ~ y p o t e n s i o n low bloosLllressure). There is no height available and the patient is unable tostand in her current state. Her skin is dr wib 12 or turgor and she has had ;:ry l o uri!1e out J:l1over the past 24 hours. She has had !ype-2 diabetes for many years and it is fairly wellcontrolled. Her admission weight i ~ o u n d s . Usual weight reported by her daughter is 132pounds. Her laboratory results (including patiial data from CBC and urinalysis) are as follows:Test Reference range SubJect valuesNa+ 135-145 mEq/L 152 HK+ 3.6-5 mEq/L . 3.8CI 101-111 mEq/L 111HC03 21-31 mEq/L 29Glucose 70-110 mg/dl 175 HBUN 5-20 mg/dl 27 HCreatinine (Cr) 0.6-1.2 mg/dl 0.8Albumin 3.5-5 g/dl 4.3Osmolality 280-320 mOsm/kg 327 HTotal cholesterol >150 mg/dl 193Total bilirubin 0.1-1 mg/dl 0,6RBC 3,5-5,9 x lOo/mmJ 5.6Hgb 12-15 g/dl 16Hct 33-43% 42MCV 80-95 fL 81MCH 27-31 pg 28MCHC 32-36 g/dl 33WBC 5-10 x 10J /mmJ 9Urine specific gravity 1.010-1.025 mg/ml 1.039 HUrine nitrite Negative PositiveUrine leukocyte esterase Negative Positive17. What do you suspect is happening with this patient and which factors are clues in thediagnosis? (4 points) ~ . 1 " " , ~ , " U 4 ,'':,.. cl6JW,-/' ~ , , ( , " \ ~ . t , " - ' J ~ kk ( ',,,..-(., s;\U.'f\ IJ-n' ' U ' I ~ r ~ , ' ~ c " " It)w \"VI\"'",, ",, \ \.... A, . ~

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31. Read the following diagnostic statements and circle all that are appropriately formattednutrition diagnoses for this patient. On those selected (1-3), label correctly the threecomponents of a nutrition diagnosis (do NOT just use the letters - use the whole tenns) (5 pts):

Hypertension (high blood pressure) related to obesity as evidenced by BMf. X---. ,~ i : , ~ ~ , . . ~ ~ i L i C \ ~ , t J ~ " '. ....- ~ = - ~ - './ ( , E ) f f e . . . . . : ! ! : . ~ . ! . . g y intake elated tofJrequen!fast fogd dining as evidenced byr:..aloric intake j \\ 15% ~ . b o v e esti"!ated !..equirements..) - - )

...., _ ' " : : : > \ ~ ! I ' " [ ~ ' Y,J"'I"r1'" t (.,t'l'A J ).. ... '" .

Cardiovascular disease related to frequent fast food dining as evidenced by high Xcholesterol and a prescription for cholesterol-lowering medication.

32. Her physician has prescribed Lipitor, a statin drug, for Ellen. Which ONE food should Ellennot consume while taking this statin drug due to risk of drug toxicity (2 points)?

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Case Study #5:Teenie is a 78-year-old woman with hypertension higt.l:?I.Q.Qd.me!l.te) for which she is takingspironolactone, a potassium-sparing diuretic. She also takes Nardil a monoamine oxidaseinhibitor ?rall fo er de ression and ~ a . r t m I l . She i 5' 1,; a ~ weighsC 50 ~ p ~ n d s . Due to herhypertensIOn, she recently began purchaSIng some reduce sodIUm foods contaInIng KCI(potassium chloride) as a salt substitute. Her lab data are as follows:Test Reference ranf(e Teenie's valuesNa+ 135-145 mEq/L 136K+ 3.6-5 mEq/t 5.3 HCI . .101-111 mEq/L 111HC03 21-31 mEq/L 29Glucose 70-110 mg/dl 125HBUN 5-20 mg/dl 15Creatinine (Cr) 0.6-1.2 mg/dl 0.8Albumin 3.5-5 g/dl 2.8LTotal cholesterol - >150 mg/dl 173Total bilirubin 0.1-1 mg/dl 0.6RBC 3.5-5.9 x 10o/mm J 5.6Hgb 12-15 g/dl 13Hct 33-43% 37WBC 5-10 x 10J /mm J 9INR 0.85-1.00 (ratio) 1.5 H34. Why does she need to limit pressor amines, such as tyramine, in her diet (what would be theeffect and why?) and what are two examples of foods sl}e shou.ld avoid? (4 points), .

i ~ ' ( ~ ~ \-;." (? . \ F< ;C . 'C

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37. Teenie's albumin is 2.8 gldl. Hypoalbuminemia can have what effect on drug metabolism?Increased pharmacodynamic effect leading to potential drug toxicityb. Increased rate ofbiotransfOlmation leading to low levels of the drug and lack of effect ofthe drugc. Increased absorption of the drugd. No effect

38. The warfarin interferes with the nom1al actions of which vitamin?a. Vitamin Db. Folatec. Vitamin CVitamin Ke. None of the above

39. What is the appropriate dietary management for a patient taking warfarin? What is the effectif they consume too much or too little of the specific nutrient involved? (4 points)- . . . , 1 J . 1 L' r ,'" ..,- ....\,. ... ~ " ' , I " Y P. Qf ~