MED SURG Ch 45 Obesity

Which statement best describes the etiology of obesity?

a. Obesity primarily results from a genetic predisposition.

b. Psychosocial factors can override the effects of genetics in the etiology of obesity.

c. Obesity is the result of complex interactions between genetic and environmental factors.

d. Genetic factors are more important than environmental factors in the etiology of obesity.

Correct answer: c Obesity is the result of complex interactions between genetic and environmental factors.

Rationale: The cause of obesity involves significant genetic and biologic susceptibility factors that are highly influenced by environmental and psychosocial factors.

Which statement by the nurse is most likely to help a 22-yr-old patient with extreme obesity in losing weight on a 1000-calorie diet?

a. "It will be necessary to change lifestyle habits permanently to maintain weight loss."

b. "You are likely to notice changes in how you feel after a few weeks of diet and exercise."

c. "You will decrease your risk for future health problems such as diabetes by losing weight now."

d. "Most of the weight that you lose during the first weeks of dieting is water weight rather than fat."

b. "You are likely to notice changes in how you feel after a few weeks of diet and exercise."

Motivation is a key factor in successful weight loss and a short-term outcome provides a higher motivation. Future health problems are unlikely to motivate a 22-yr-old patient. Telling a patient that the initial weight loss is water would be discouraging, although this may be correct. Changing lifestyle habits permanently is recommended, but this process occurs over time, and discussing this is not likely to motivate the patient.

After the nurse teaches about the recommended amounts of foods from animal and plant sources, which menu selections indicate that the patient understands the diet instructions?

a. 3 oz of lean beef, 2 oz of low-fat cheese, and a sliced tomato

b. 3 oz of roasted pork, a cup of broccoli, and a cup of carrot sticks

c. Cup of tossed salad and nonfat dressing topped with a chicken breast

d. Half cup of tuna mixed with nonfat mayonnaise and a half cup of celery

b. 3 oz of roasted pork, a cup of broccoli, and a cup of carrot sticks

This selection is most consistent with the recommendations to limit foods from animal sources and increase plant source foods. The other choices all have higher ratios of animal origin foods to plant source foods than would be recommended.

Which action would the nurse take when coaching adults who are obese in a behavior therapy program?

a. Having the adults write down the caloric intake of each meal

Which action would the nurse take when coaching adults who are obese in a behavior therapy program?

a. Having the adults write down the caloric intake of each meal

b. Asking the adults about situations that tend to increase appetite

c. Suggesting that the adults plan rewards such as sugarless candy for achieving their goals

d. Encouraging the adults to eat small amounts frequently rather than having scheduled meals

b. Asking the adults about situations that tend to increase appetite

Behavior therapy programs focus on how and when the person eats and de-emphasize aspects such as calorie counting. Nonfood rewards are recommended for achievement of weight-loss goals. Patients are often taught to restrict eating to designated meals when using behavior therapy.

The nurse is coaching a community group for persons who are overweight. Which participant behavior is an example of the best exercise plan for weight loss?

a. Walking for 40 minutes 6 or 7 days/week

b. Playing soccer for an hour on the weekend

c. Running for 10 to 15 minutes 3 times/week

d. Lifting weights for 2 hours with friends 1 time/week

a. Walking for 40 minutes 6 or 7 days/week

Exercise should be at least 150 minutes of moderate-intensity aerobic activity (i.e., brisk walking) every week. Muscle-strengthening activities on 2 or more days a week is recommended. Exercising in highly aerobic activities for short bursts or only once a week is not helpful and may be dangerous in an individual who has not been exercising. Running may be appropriate, but patients should start with an exercise that is less stressful and can be done for a longer period.

Four months after bariatric surgery, a patient tells the nurse, "My skin is hanging off me. I think I might want to surgery to remove the skinfolds." Which response would the nurse provide?

a. "The important thing now is that you are improving your health."

b. "The skinfolds show everyone how much weight you have lost."

c. "Perhaps you should talk to a counselor about your body image."

d. "Cosmetic surgery may be possible once your weight has stabilized."

d. "Cosmetic surgery may be possible once your weight has stabilized."

Reconstructive surgery may be used to eliminate excess skinfolds after at least a year has passed since the surgery. The responses, "The important thing is that your weight loss is improving your health," and "The skinfolds show everyone how much weight you have lost," ignore the patient's concerns about appearance and implies that the nurse knows what is important. It may be helpful for the patient to talk to a counselor; however, there is no indication given that the concern about skinfolds is dysfunctional.

After sleeve gastrectomy, a 42-yr-old male patient returns to the surgical nursing unit with a nasogastric tube to low, intermittent suction and a patient-controlled analgesia (PCA) machine for pain control. Which nursing action would be included in the postoperative plan of care?

a. Offer sips of fruit juices at frequent intervals.

b. Irrigate the nasogastric (NG) tube frequently.

c. Remind the patient that PCA use may slow the return of bowel function.

d. Support the surgical incision during patient coughing and turning in bed.

d. Support the surgical incision during patient coughing and turning in bed.

Protecting the incision from strain decreases the risk for wound dehiscence. The patient should be encouraged to use the PCA because pain control will improve the cough effort and patient mobility. NG irrigation may damage the suture line or overfill the stomach pouch.

Sugar-free clear liquids are offered

Which assessment action would help the nurse determine if an obese patient has metabolic syndrome?

a. Take the patient's apical pulse.

b. Check the patient's blood pressure.

c. Ask the patient about dietary intake.

d. Dipstick the patient's urine for protein.

b. Check the patient's blood pressure.

Elevated blood pressure is one of the characteristics of metabolic syndrome. The other information will not assist with the diagnosis of metabolic syndrome

The obesity classification that is most often associated with cardiovascular health problems is

a. primary obesity.

b. secondary obesity.

c. gynoid fat distribution.

d. android fat distribution.

Correct answer: d android fat distribution.

Rationale: Individuals with fat located primarily in the abdominal area (i.e., whose body is apple-shaped) are at greater risk for obesity-related complications (e.g., heart disease) than are those whose fat is primarily located in the upper legs (i.e., whose body is pear-shaped). Individuals whose fat is distributed over the abdomen and upper body (i.e., neck, arms, and shoulders) are classified as having android obesity.

When teaching a patient about testing to diagnose metabolic syndrome, which topic would the nurse include?

a. Blood glucose test

b. Cardiac enzyme tests

c. Postural blood pressures

d. Resting electrocardiogram

a. Blood glucose test

A fasting blood glucose result greater than 100 mg/dL is one of the diagnostic criteria for metabolic syndrome. The other tests are not used to diagnose metabolic syndrome, but they may be used to check for cardiovascular complications of the disorder.

Which information will the nurse include in teaching for a 35-yr-old woman who is overweight and starting a weight-loss plan?

a. Weigh yourself at the same time every morning and evening.

b. Stick to a 600- to 800-calorie diet for the most rapid weight loss.

c. Low carbohydrate diets lead to rapid weight loss but are difficult to maintain.

d. Weighing all foods on a scale is necessary to choose appropriate portion sizes.

c. Low carbohydrate diets lead to rapid weight loss but are difficult to maintain.

The restrictive nature of fad diets makes the weight loss achieved by the patient more difficult to maintain. Portion size can be estimated in other ways besides weighing. Severely

calorie-restricted diets are not necessary for patients in the overweight category and need to be closely supervised. Patients should weigh weekly rather than daily.

Which adult would the nurse plan to teach about risks associated with obesity?

a. Man who has a BMI of 18 kg/m2

b. Man with a 42 inch waist and 44 inch hips

c. Woman who has a body mass index (BMI) of 24 kg/m2

d. Woman with a waist circumference of 34 inches (86 cm)

b. Man with a 42 inch waist and 44 inch hips

The waist-to-hip ratio for this patient with a 42 inch waist and 44 inch hips is 0.95, which exceeds the recommended level of less than 0.80. A patient with a BMI of 18 kg/m2 is considered underweight. A BMI of 24 kg/m2 is normal. Health risks associated with obesity increase in women with a waist circumference larger than 35 in (89 cm) and men with a waist circumference larger than 40 in (102 cm).

A patient is being admitted for bariatric surgery. Which nursing action can the nurse delegate to assistive personnel (AP)?

a. Demonstrate use of the incentive spirometer.

b. Plan methods for turning the patient after surgery.

c. Assist with IV insertion by holding adipose tissue out of the way.

d. Develop strategies to provide privacy and decrease embarrassment

c. Assist with IV insertion by holding adipose tissue out of the way.

AP can assist with IV placement by assisting with patient positioning or holding skinfolds aside. Planning for care and patient teaching require registered nurse (RN)-level education and scope of practice.

After successfully losing a pound per week for several months, a patient at the clinic has not lost any weight for the past month. Which action should the nurse take first?

a. Review the diet and exercise guidelines with the patient.

b. Instruct the patient to weigh and record weights weekly.

c. Ask the patient whether there have been any changes in exercise or diet patterns.

d. Discuss the possibility that the patient has reached a temporary weight loss plateau.

c. Ask the patient whether there have been any changes in exercise or diet patterns.

The initial nursing action should be assessment of reasons for weight stability. The other actions may be needed, but further assessment is required before any interventions are planned or implemented.

Which finding for a patient who has been taking orlistat (Xenical) is most important to report to the health care provider?

a. The patient has frequent liquid stools.

b. The patient is pale and has many bruises.

c. The patient feels very bloated after meals.

d. The patient is having a weight loss plateau.

b. The patient is pale and has many bruises

Because orlistat blocks the absorption of fat-soluble vitamins, the patient may not be receiving an adequate amount of vitamin K, resulting in a decrease in clotting factors. Abdominal bloating and liquid stools are common side effects of orlistat and indicate that the nurse should remind the patient that fat in the diet may increase these side effects. Weight loss plateaus are expected during weight reduction.

A 40-yr-old woman who is obese reports that she wants to lose weight. Which question would the nurse ask first?

a. "What factors led to your weight gain?"

b. "Which types of food do you like best?"

c. "How long have you been overweight?"

d. "What physical activities do you enjoy?"

a. "What factors led to your weight gain?"

The nurse should obtain information about the patient's perceptions of the reasons for the obesity to develop a plan individualized to the patient. The other information also will be obtained from the patient, but the patient is more likely to make changes when the patient's beliefs are considered in planning.

The nurse is caring for a patient on the first postoperative day after a Roux-en-Y gastric bypass procedure. Which assessment finding should be reported immediately to the provider?

a. Bilateral crackles audible at both lung bases

b. Redness, irritation, and skin breakdown in skinfolds

c. Emesis of bile-colored fluid past the nasogastric (NG) tube

d. Use of patient-controlled analgesia (PCA) several times an hour for pain

c. Emesis of bile-colored fluid past the nasogastric (NG) tube

Vomiting with an NG tube in place indicates that the NG tube needs to be repositioned by the provider to avoid putting stress on the gastric sutures. The nurse should implement actions to decrease skin irritation and have the patient cough and deep breathe, but these do not indicate a need for rapid notification of the provider. Frequent PCA use after bariatric surgery is expected.

Which information will the nurse prioritize in planning preoperative education for a patient undergoing a Roux-en-Y gastric bypass?

a. Explaining the nasogastric (NG) tube to the patient

b. Teaching the patient coughing and breathing techniques

c. Discussing necessary postoperative modifications in lifestyle

d. Demonstrating passive range-of-motion exercises for the legs

b. Teaching the patient coughing and breathing techniques

Coughing and deep breathing can prevent major postoperative complications such as carbon monoxide retention and hypoxemia. Information about passive range of motion, the NG tube, and postoperative modifications in lifestyle will also be discussed, but avoidance of respiratory complications is the priority goal after surgery.

After bariatric surgery, a patient who is being discharged tells the nurse, "I prefer to be independent. I am not interested in any support groups." Which initial response would the nurse provide?

a. "I hope you change your mind so that I can suggest a group for you."

b. "Tell me what types of resources you think you might use after this surgery."

c. "Support groups have been found to lead to more successful weight loss after surgery."

d. "Because there are many lifestyle changes after surgery, we recommend support groups."

b. "Tell me what types of resources you think you might use after this surgery."

This statement allows the nurse to assess the individual patient's potential needs and preferences. The other statements offer the patient more information about the benefits of support groups but do not acknowledge the patient's preferences.

To evaluate an obese patient for adverse effects of Plenity, which action will the nurse take?

a. Measure the apical pulse.

b. Check sclera for jaundice.

c. Ask about bowel movements.

d. Assess for agitation or restlessness.

c. Ask about bowel movements.

Constipation is a common side effect of Plenity, a gel substance taken to increase the volume of stomach and small intestine contents and induce satiety. The other assessments would be appropriate for other weight-loss medications

This bariatric surgical procedure involves creating a stoma and gastric pouch that is reversible, and no malabsorption occurs. What surgical procedure is this?

a. Vertical gastric banding

b. Biliopancreatic diversion

c. Roux-en-Y gastric bypass

d. Adjustable gastric banding

Correct answer: d Adjustable gastric banding

Rationale: With adjustable gastric banding (AGB), the stomach size is limited by an inflatable band placed around the fundus of the stomach. The band is connected to a subcutaneous port and can be inflated or deflated to change the stoma size to meet the patient's needs as weight is lost. The procedure is performed laparoscopically and, if necessary, can be modified or reversed after the initial procedure.

Which information in this male patient's EHR will the nurse use to confirm that the patient has metabolic syndrome?

a. Weight 200lb (961kg)

b. Waist size 41 inches

c. Fasting Blood glucose 124 mg/dL

d. Blood pressure 126/82

e. Triglyceride level 130 mg/dL

f. Total cholesterol level 234 mg/dL

b. Waist size 41 inches

c. Fasting Blood glucose 124 mg/dL

The patient's waist circumference, high-density lipoprotein level, and fasting blood glucose level indicate that he has metabolic syndrome. The other data are not used in making a metabolic syndrome diagnosis or do not meet the criteria for this diagnosis

Which information would the nurse teach patients about self-management after gastric bypass surgery?

a. Drink fluids between meals but not with meals.

b. Choose high-fat foods for at least 30% of intake.

c. Developing flabby skin can be prevented by exercise.

d. Choose foods high in fiber to promote bowel function.

a. Drink fluids between meals but not with meals.

Intake of fluids with meals tends to cause dumping syndrome and diarrhea. Food choices should be low in fat and fiber. Exercise does not prevent the development of flabby skin.

Health risks associated with obesity include (select all that apply)

a. colorectal cancer.

b. rheumatoid arthritis.

c. polycystic ovary syndrome.

d. nonalcoholic steatohepatitis.

e. systemic lupus erythematosus.

Correct answers: a, c, d

Rationale: Health risks associated with obesity include cardiovascular disease (related to increased low-density lipoprotein levels, increased triglyceride levels, and decreased high-density lipoprotein levels), hypertension, sleep apnea, obesity hypoventilation syndrome, reduced chest wall compliance, increased work of breathing, decreased total lung capacity and functional residual capacity, type 2 diabetes mellitus (i.e., hyperinsulinemia and insulin resistance), osteoarthritis, hyperuricemia, gout, gastroesophageal reflux disease, gallstones, nonalcoholic steatohepatitis, fatty liver and cirrhosis, cancer (mainly breast, endometrial, kidney, colorectal, pancreas, esophagus, and gallbladder), psychosocial problems (employment, education, and health care), low self-esteem, withdrawal from social interactions, and major depression.

The best nutritional therapy plan for a person who is obese is

a. the Zone diet.

b. the Atkins diet.

c. Sugar Busters.

d. foods from the basic food groups.

Correct answer: d foods from the basic food groups.

Rationale: Restricted food intake is a cornerstone for any weight loss or maintenance program. A good weight loss plan should include foods from the basic food groups.

A severely obese patient has undergone Roux-en-Y gastric bypass surgery. In planning postoperative care, the nurse anticipates that the patient

a. may have severe diarrhea early in the postoperative period.

b. will not be allowed to ambulate for 1 to 2 days postoperatively.

c. will require nasogastric suction until the incision heals.

d. may have only liquids orally, and in very limited amounts, during the postoperative period.

Correct answer: d may have only liquids orally, and in very limited amounts, during the postoperative period.

Rationale: During the immediate postoperative period, water and sugar-free clear liquids are given (30 mL every 2 hours while the patient is awake).

Which statement about obesity is explained by genetics?

a. Older obese patients have exacerbated changes of aging.

b. Android body shape and weight gain are influenced by genetics.

c. White Americans have a higher incidence of obesity than African Americans.

d. Men have a harder time losing weight, as they have more muscle mass than women.

Correct answer: b Android body shape and weight gain are influenced by genetics.

Rationale: Twin studies and studies with adopted children have shown that body shape and weight gain are influenced by genetics but more research is needed. Older obese people do have exacerbated aging problems related to declines in physical function. African Americans and Hispanics have a higher incidence of obesity than whites. Women have a higher incidence of obesity and more difficulty losing weight than men because women have a higher percentage of metabolically less-active fat.

A woman is 5 ft, 6 in (166 cm) tall and weighs 200 lb (90.9 kg) with a waist-to-hip ratio of 0.7. The nurse counsels the patient with the knowledge that the patient is at greatest risk for

a. heart disease.

b. osteoporosis.

c. diabetes mellitus.

d. endometrial cancer.

Correct answer: b osteoporosis.

Rationale: A patient who is obese (BMI of 32.2) but has a waist-to-hip ratio of less than 0.8, indicating gynoid obesity, has an increased risk for osteoporosis. The other conditions are risks associated with android obesity.

Priority Decision: Before selecting a weight reduction plan with an obese patient, what is most important for the nurse to first assess?

a. The patient's motivation to lose weight

b. The length of time that the patient has been obese

c. Whether financial considerations will affect the patient's choices

d. The patient's anthropometric measures of height, weight, BMI, waist-to-hip ratio, and skinfold thickness

Correct answer: a The patient's motivation to lose weight

Rationale: Motivation is essential. Focus on the reasons for wanting to lose weight. The rest of the options will asset in planning the weight loss if the patient is motivated.

Priority Decision: The nurse is teaching a moderately obese woman interventions for the management of obesity. Initially, which strategies will support restricting dietary intake to below energy requirements (select all that apply)?

a. Limit alcohol

b. Rest when fatigued

c. Determine portion sizes

d. 1800- to 2200-calorie diet

e. Attend Overeaters Anonymous

Correct answers: a, c

Rationale: To restrict dietary intake so that it is below energy requirements, the moderately obese woman should limit or avoid alcohol intake because it increases caloric intake and has low nutritional value. Portion sizes have increased over the years and are larger than they should be. Teach the patient to determine portion sizes by weight or learn equivalencies such as that a serving of fruit is the size of a baseball. A progressive exercise program will increase energy requirements and a diet with an initial 800- to 1200-calorie limit would decrease calorie intake. Overeaters Anonymous would not restrict dietary intake below energy requirements, although it may offer support for the patient.

Which explanation about weight reduction should be included when teaching the obese patient and her obese husband?

a. Weight gain is caused by psychologic factors.

b. Daily weighing is recommended to monitor weight loss.

c. Fat is not burned until the glycogen-water pool is depleted.

d. Men lose weight less quickly than women because they have a higher percentage of metabolically less-active fat.

Correct answer: c Fat is not burned until the glycogen-water pool is depleted.

Rationale: With reducing diets that severely restrict carbohydrates, the body's glycogen stores become depleted within a few days. The glycogen normally binds to water in fat cells and it is this water loss that causes weight loss in the first few days. Fat is not burned until the glycogen-water pool is depleted. Although psychosocial components (i.e., using food for comfort or reward and inability to buy high-nutritional quality food) may have an influence on weight gain, these factors along with lack of physical exercise, underestimation of portion size, and genetics contribute to weight gain. Weekly weighing is recommended as a more reliable indicator of weight loss because daily weighing shows frequent fluctuation from retained water (including urine) and elimination of feces. Men are able to lose weight more quickly than women because women have a higher percentage of metabolically less-active fat.

A patient has been on a 1000-calorie diet with a daily exercise routine. In 2 months, the patient has lost 20 lb (9kg) toward a goal of 50 lb (23 kg) but is now discouraged that no weight has been lost in the last 2 weeks. What should the nurse tell the patient about this?

a. Plateaus where no weight is lost normally occur during a weight-loss program.

b. A weight considered by the body to most efficient for functioning has been reached.

c. A return to former eating habits is the most common cause of not continuing to lose weight.

d. A steady weight may be due to water gain from eating foods high in sodium.

Correct answer: a Plateaus where no weight is lost normally occur during a weight-loss program.

Rationale: Plateau periods during which no weight is lost are normal occurrences during weight reduction and may last for several days to several weeks but weight loss will resume if the prescribed weight reduction plan is continued. Weight loss may stop if former eating habits are resumed but this not the most common cause of plateaus.

When teaching a patient about weight reduction diets, the nurse teaches the patient that an appropriate single serving of a food is

a. a 6-inch bagel.

b. 1 cup of chopped vegetables.

c. a piece of cheese the size of three dice.

d. a chicken breast the size of a deck of cards.

Correct answer: d a chicken breast the size of a deck of cards.

Rationale: A chicken breast the size of a deck of cards is about 3 oz, a recommended portion size of meat. Other normal portions include a 3-inch bagel, 1/2 cup of chopped vegetables, and a piece of cheese the size of six dice.

Priority Decision: When medications are used in the treatment of obesity, what is most important for the nurse to teach the patient?

a. Over-the-counter (OTC) diet aids are safer than other agents and con be useful in controlling appetite.

b. Drugs should be used only as adjuncts to a diet and exercise program as treatment for a chronic condition.

c. All drugs used for weight control are capable of altering central nervous system (CNS) function and should be used with caution.

d. The primary effect of the medications is psychologic, controlling the urge to eat in response to stress or feelings of rejection.

Correct answer: b Drugs should be used only as adjuncts to a diet and exercise program as treatment for a chronic condition.

Rationale: Medications are used only as adjuncts to diet and exercise programs in the treatment of obesity. Drugs do not cure obesity; without changes in food intake and physical activity, weight gain will occur when the medications are discontinued. The medications used work in a variety of ways to control appetite but over-the-counter drugs are probably the least effective and most abused of these drugs.

A patient asks the nurse about taking phentermine and topiramate (Qsymia) for weight loss. To avoid side effects, it is important for the nurse to determine whether the patient has a history of

a. glaucoma.

b. hypertension.

c. valvular heart disease.

d. irritable bowel disease.

Correct answer: a glaucoma.

Rationale: Qsymia is a combination of phentermine and topiramate. It must not be used in patients with glaucoma or hyperthyroidism.

The nurse has completed initial instruction with a patient regarding a weight-loss program. Which patient comment indicates to the nurse that the teaching has been effective?

a. "I will keep a diary of daily weight to illustrate my weight loss."

b. "I plan to lose 4 lb a week until I have lost the 60 lb I want to lose."

c. "I should not exercise more than what is required so I don't increase my appetite."

d. "I plan to join a behavior modification group to help establish long-term behavior changes."

Correct answer: d "I plan to join a behavior modification group to help establish long-term behavior changes."

Rationale: People who have undergone behavior therapy are more successful in maintaining weight losses over time because most programs deemphasize the diet, focus on how and when the person eats and education, and provide support from others. Weighing daily is not recommended and plateaus may not allow for consistent weight loss. A goal for weight loss must be set and 1 to 2 pounds a week is realistic. A more rapid loss often causes skin and underlying tissue to lose elasticity and become flabby folds of tissue. Exercising more often depresses appetite and exercise need not be limited.

A 40-year-old severely obese female patient with type 2 diabetes wants to lose weight. After learning about the surgical procedures, she thinks a combination of restrictive and malabsorptive surgery would be best. Which procedure should the nurse teach her about?

a. Lipectomy

b. Roux-en-Y gastric bypass

c. Adjustable gastric banding

d. Vertical sleeve gastrectomy

Correct answer: b Roux-en-Y gastric bypass

Rationale: The Roux-en-Y gastric bypass is a common combination of restrictive (limiting the size of the stomach) and malabsorptive (less food is absorbed) surgery. Lipectomy is used to remove unsightly flabby folds of adipose tissue. Adjustable gastric banding is the most common restrictive procedure. Vertical sleeve gastrectomy is a restrictive procedure that preserves stomach function.

Priority Decision: During care of the severely obese patient, what is most important for the nurse to do?

a. Avoid reference to the patient's weight to avoid embarrassing the patient.

b. Emphasize to the patient how important it is to lose weight to maintain health.

c. Plan for necessary modifications in equipment and nursing techniques before initiating care.

d. Recognize that a full assessment of each body system might not be possible because of numerous layers of skinfolds.

Correct answer: c . Plan for necessary modifications in equipment and nursing techniques before initiating care.

Rationale: Special considerations are needed for the care of the severely obese patient because most hospital units are not prepared with beds, chairs, BP cuffs, and other equipment that will need to be used with the very obese patient. Consideration of all aspects of care should be made before implementing care for the patient, including extra time and perhaps assistance for positioning, physical assessment, and transferring the patient.

In preparing to care for the obese patient with cancer, what physiologic problems is this patient at a greater risk for having (select all that apply)?

a. Tinnitus

b. Fractures

c. Sleep apnea

d. Trousseau's sign

e. Type 2 diabetes mellitus

f. Gastroesophageal reflux disease (GERD)

Correct answers: c, e, f Sleep apnea, Type 2 diabetes mellitus, Gastroesophageal reflux disease (GERD)

Rationale: Obese patients are at a higher risk for cancer, sleep apnea and sleep deprivation, type 2 diabetes mellitus, gastroesophageal reflux disease (GERD), nonalcoholic steatohepatits, osteoarthritis, and cardiovascular problems. The other options are not related to obesity.

Priority Decision: The nurse admitting a patient for bariatric surgery obtains the following information from the patient. Which finding should be brought to the surgeon's attention before proceeding with further patient preparation?

a. History of hypertension

b. History of untreated depression

c. History of multiple attempts at weight loss

d. History of sleep apnea treated with continuous positive airway pressure (CPAP)

Correct answer: b History of untreated depression

Rationale: Patients with histories of untreated depression or psychosis are not good candidates for surgery. All other historical information includes medical complications of severe obesity that would help to qualify the patient for the surgery.

What is a postoperative nursing intervention for the obese patient who has undergone bariatric surgery?

a. Irrigating and repositioning the nasogastric (NG) tube as needed

b. Delaying ambulation until the patient has enough strength to support self

c. Keeping the patient positioned on the side to facilitate respiratory function

d. Providing adequate support to the incision during coughing, deep breathing, and turning

Correct answer: d Providing adequate support to the incision during coughing, deep breathing, and turning

Rationale: Turning, coughing, and deep breathing are essential to prevent postoperative complications. Protecting the incision from strain is important since wound dehiscence is a problem for obese patients. If a nasogastric (NG) tube that is present following gastric surgery for severe obesity becomes blocked or needs repositioning, the health care provider should be notified. Ambulation is usually started on the evening of surgery and addition help will be needed to support the patient. Respiratory function is promoted by keeping the head of the bed elevated at an angle of 35 to 40 degrees.

What information should be included in the dietary teaching for the patient following a Roux-en-Y gastric bypass?

a. Avoid sugary foods and limit fluids to prevent dumping syndrome.

b. Gradually increase the amount of food ingested to preoperative levels.

c. Maintain a long-term liquid diet to prevent damage to the surgical site.

d. Consume foods high in complex carbohydrates, protein, and fiber to add bulk to contents.

Correct answer: a Avoid sugary foods and limit fluids to prevent dumping syndrome.

Rationale: Fluids and foods high in carbohydrates tend to promote diarrhea and symptoms of dumping syndrome in patients with gastric bypass surgery. The diet generally should be high in protein and low in carbohydrates, fat, and roughage and consists of six small feedings a day because of the small stomach size. Liquid diets are likely to be used longer for the patient with a gastroplasty.

Which female patient is most likely to have metabolic syndrome?

a. BP 128/78 mm Hg, triglycerides 160 mg/dL, fasting blood glucose 102 mg/dL

b. BP 142/90 mm Hg, high-density lipoproteins 45 mg/dL, fasting blood glucose 130 mg/dL

c. Waist circumference 36 in, triglycerides 162 mg/dL, high-density lipoproteins 55 mg/dL

d. Waist circumference 32 in, high-density lipoproteins 38 mg/dL, fasting blood glucose 122 mg/dL

Correct answer: b BP 142/90 mm Hg, high-density lipoproteins 45 mg/dL, fasting blood glucose 130 mg/dL

Rationale: Three of the following five measures are needed for a woman to be diagnosed with metabolic syndrome: waist circumference >35 in, triglycerides >150 mg/dL, high-density lipoproteins <50 mg/dL, BP >130 mm Hg systolic or >85 mm Hg diastolic, fasting blood glucose >110 mg/dL. Although the other options have some abnormal measures, none has all three measures in the diagnostic ranges. The criteria for metabolic syndrome for both women and men are listed in Table 41-10.

Which teaching points are important when providing information to a patient with metabolic syndrome (select all that apply)?

a. Stop smoking.

b. Monitor weight daily.

c. Increase level of activity.

d. Decrease saturated fat intake.

e. Reduce weight and maintain lower weight.

f. Check blood glucose each morning prior to eating.

Correct answers: a, c, d, e Stop smoking, Monitor weight daily.

Increase level of activity, Decrease saturated fat intake, Check blood glucose each morning prior to eating.

Rationale: Patients with metabolic syndrome need to lower their risk factors by reducing and maintaining weight, increasing physical activity, establishing healthy diet habits, and smoking cessation. Some patients with metabolic syndrome are diabetic and would need to monitor glucose levels frequently. When monitoring weight reduction, it is recommended to check weight weekly, not daily.

What is the main underlying risk factor for metabolic syndrome?

a. Age

b. Heart disease

c. Insulin resistance

d. High cholesterol levels

Correct answer: c Insulin resistance

Rationale: Insulin resistance is the main underlying risk factor for metabolic syndrome. Aging is associated with metabolic syndrome. High cholesterol, hypertension, and increased clotting risk are characteristics of metabolic syndrome.

The nurse instructs an obese 22-year-old man with a sedentary job about the health benefits of an exercise program. The nurse evaluates that teaching is effective when the patient makes which statement?

a. "The goal is to walk at least 10,000 steps every day of the week."

b. "Weekend aerobics for 2 hours is better than exercising every day."

c. "Aerobic exercise will increase my appetite and result in weight gain."

d. "Exercise causes weight loss by decreasing my resting metabolic rate."

Correct answer: a "The goal is to walk at least 10,000 steps every day of the week."

Rationale: A realistic activity goal is to walk 10,000 steps a day. Increased activity does not promote an increase in appetite or lead to weight gain. Exercise should be done daily, preferably 30 minutes to an hour a day. Exercise increases metabolic rate.

The nurse teaches a 50-year-old woman who has a body mass index (BMI) of 39 kg/m2 about weight loss. Which dietary change would be appropriate for the nurse to recommend to this patient?

a. Decrease fat intake and control portion size

b. Increase vegetables and decrease fluid intake

c. Increase protein intake and avoid carbohydrates

d. Decrease complex carbohydrates and limit fiber

Correct answer: a Decrease fat intake and control portion size

Rationale: The safest dietary guideline for weight loss is to decrease caloric intake by maintaining a balance of nutrients and adequate hydration while controlling portion size and decreasing fat intake.

In the immediate postoperative period a nurse cares for a severely obese 72-year-old man who had surgery for repair of a lower leg fracture. Which assessment would be most important for the nurse to make?

a. Cardiac rhythm

b. Surgical dressing

c. Postoperative pain

d. Oxygen saturation

Correct answer: d Oxygen saturation

Rationale: After surgery an older and/or severely obese patient should be closely monitored for oxygen desaturation. The body stores anesthetics in adipose tissue, placing patients with excess adipose tissue (e.g., obesity, older) at risk for resedation. As adipose cells release anesthetic back into the bloodstream, the patient may become sedated after surgery. This may depress the respiratory rate and result in a drop in oxygen saturation.

The nurse cares for a 34-year-old woman after bariatric surgery. The nurse determines that discharge teaching related to diet is successful if the patient makes which statement?

a. "A high protein diet that is low in carbohydrates and fat will prevent diarrhea."

b. "Food should be high in fiber to prevent constipation from the pain medication."

c. "Three meals a day with no snacks between meals will provide optimal nutrition."

d. "Fluid intake should be at least 2000 mL per day with meals to avoid dehydration."

Correct answer: a "A high protein diet that is low in carbohydrates and fat will prevent diarrhea."

Rationale: The diet generally prescribed is high in protein and low in carbohydrates, fat, and roughage and consists of six small feedings daily. Fluids should not be ingested with the meal, and in some cases, fluids should be restricted to less than 1000 mL per day. Fluids and foods high in carbohydrate tend to promote diarrhea and symptoms of the dumping syndrome. Generally, calorically dense foods (foods high in fat) should be avoided to permit more nutritionally sound food to be consumed.

Which patient is at highest risk for developing metabolic syndrome?

a. A 62-year-old white man who has coronary artery disease with chronic stable angina

b. A 54-year-old Hispanic woman who is sedentary and has nephrogenic diabetes insipidus

c. A 27-year-old Asian American woman who has preeclampsia and gestational diabetes mellitus

d. A 38-year-old Native American man who has diabetes mellitus and elevated hemoglobin A1C

Correct answer: d A 38-year-old Native American man who has diabetes mellitus and elevated hemoglobin A1C

Rationale: African Americans, Hispanics, Native Americans, and Asians are at an increased risk for development of metabolic syndrome. Other risk factors include individuals who have diabetes that cannot maintain a normal glucose level, have hypertension, and secrete a large amount of insulin, or who have survived a heart attack and have hyperinsulinemia.

During the initial postoperative period following bariatric surgery, the nurse recognizes the importance of monitoring obese patients for respiratory insufficiency based on what knowledge?

a. The body stores anesthetics in adipose tissue.

b. Postoperative pain may cause a decreased respiratory rate.

c. Intubation may be difficult because of extra chin skinfolds.

d. The patient's head must remain flat for a minimum of 2 hours postprocedure.

Correct answer: a The body stores anesthetics in adipose tissue.

Rationale: The body stores anesthetics in adipose tissue, placing patients with excess adipose tissue at risk for re-sedation. As adipose cells release anesthetics back into the bloodstream, the patient may become sedated after surgery, increasing the risk of hypoventilation and resultant respiratory insufficiency. Difficult intubation does not cause respiratory insufficiency. Pain usually increases respiratory rate. The patient's head should be elevated after bariatric surgery to decrease abdominal pressure and facilitate respirations.

In developing an effective weight reduction plan for an overweight patient who states a willingness to try to lose weight, it is most important for the nurse to first assess which factor?

a. The length of time the patient has been obese

b. The patient's current level of physical activity

c. The patient's social, emotional, and behavioral influences on obesity

d. Anthropometric measurements, such as body mass index and skinfold thickness

Correct answer: c The patient's social, emotional, and behavioral influences on obesity

Rationale: Eating patterns are established early in life, and eating has many meanings for people. To establish a weight reduction plan that will be successful for the patient, the nurse should first explore the social, emotional, and behavioral influences on the patient's eating patterns. The duration of obesity, current physical activity level, and current anthropometric measurements are not as important for the weight reduction plan.

In developing a weight reduction program with a 45-year-old female patient who weighs 197 lb, the nurse encourages the patient to set a weight loss goal of how many pounds in 4 weeks?

a. 1-2

b. 3-5

c. 4-8

d. 5-10

Correct answer: c 4-8

Rationale: A realistic weight loss goal for patients is 1 to 2 lb/wk, which prevents the patient from becoming frustrated at not meeting weight loss goals.

The nurse has completed initial instruction with a patient regarding a weight loss program. The nurse determines that the teaching has been effective when the patient makes which statement?

a. "I plan to lose 4 lb a week until I have lost the 60-pound goal."

b. "I will keep a diary of weekly weights to illustrate my weight loss."

c. "I will restrict my carbohydrate intake to less than 30 g/day to maximize weight loss."

d."I should not exercise more than my program requires since increased activity increases the appetite."

Correct answer: b "I will keep a diary of weekly weights to illustrate my weight loss."

Rationale: The patient should monitor and record weight once per week. This prevents frustration at the normal variations in daily weights and may help the patient to maintain motivation to stay on the prescribed diet. Weight loss should occur at a rate of 1 to 2 lb/week. The diet should be well balanced rather than lacking in specific components that may cause an initial weight loss but is not usually sustainable. Exercise is a necessary component of any successful weight loss program.

A community health nurse is conducting an initial assessment of a new patient. Which assessments should the nurse include when screening the patient for metabolic syndrome (select all that apply)?

a. Blood pressure

b. Resting heart rate

c. Physical endurance

d. Waist circumference

e. Fasting blood glucose

Correct answers: a, d, e Blood pressure, Waist circumference, Fasting blood glucose

Rationale: The diagnostic criteria for metabolic syndrome include elevated blood pressure, fasting blood glucose, waist circumference, triglycerides, and HDL cholesterol. Resting heart rate and physical endurance are not part of the diagnostic criteria.

The severely obese patient has elected to have the Roux-en-Y gastric bypass (RYGB) procedure. The nurse will know the patient understands the preoperative teaching when the patient makes which statement?

a. "This surgery will preserve the function of my stomach."

b. "This surgery will remove the fat cells from my abdomen."

c. "This surgery can be modified whenever I need it to be changed."

d. "This surgery decreases how much I can eat and how many calories I can absorb."

Correct answer: d "This surgery decreases how much I can eat and how many calories I can absorb."

Rationale: The RYGB decreases the size of the stomach to a gastric pouch and attaches it directly to the small intestine so food bypasses 90% of the stomach, the duodenum, and a small segment of the jejunum. The vertical sleeve gastrectomy removes 85% of the stomach, but preserves the function of the stomach. Lipectomy and liposuction remove fat tissue from the abdomen or other areas. Adjustable gastric banding can be modified or reversed at a later date.

When developing a weight reduction plan for an obese patient who wants to lose weight, which question should the nurse ask first?

a. "Which food types do you like best?"

b. "How long have you been overweight?"

c. "What kind of physical activities do you enjoy?"

d. "What factors do you think led to your obesity?"

d. "What factors do you think led to your obesity?"

The nurse should obtain information about the patient's perceptions of the reasons for the obesity to develop a plan individualized to the patient. The other information also will be obtained from the patient, but the patient is more likely to make changes when the patient's beliefs are considered in planning.

On the first postoperative day the nurse is caring for a patient who has had a RouxenY gastric bypass procedure. Which assessment finding should be reported immediately to the surgeon?

a. Use of patientcontrolled analgesia (PCA) several times an hour for pain

b. Irritation and skin breakdown in skinfolds

c. Bilateral crackles audible at both lung bases

d. Emesis of bilecolored fluid past the nasogastric (NG) tube

d. Emesis of bilecolored fluid past the nasogastric (NG) tube

ANS: D

Vomiting with an NG tube in place indicates that the NG tube needs to be repositioned by the surgeon to avoid putting stress on the gastric sutures. The nurse should implement actions to decrease skin irritation and have the patient cough and deep breathe, but these do not indicate a need for rapid notification of the surgeon. Frequent

In planning preoperative teaching for a patient undergoing a RouxenY gastric bypass as treatment for morbid obesity, the nurse places the highest priority on

a. demonstrating passive rangeofmotion exercises to the legs.

b. discussing the necessary postoperative modifications in lifestyle.

c. teaching the patient proper coughing and deep breathing techniques.

d. educating the patient about the postoperative presence of a nasogastric (NG) tube.

c. teaching the patient proper coughing and deep breathing techniques.

Coughing and deep breathing can prevent major postoperative complications such as carbon monoxide retention and hypoxemia. Information about passive range of motion, the NG tube, and postoperative modifications in lifestyle also will be discussed, but avoidance of respiratory complications is the priority goal after surgery.