Chapter 29 — Exercises

Three tiers. 🔄 retrieval; 🪞 reflection. ⚠️ Closes Part V.**

Tier 1 — Recall and Comprehension

R1. ⚠️ Reconstruct Ivor's nine days. How many were nil by mouth, and why was each reasonable?

R2. Give the reported prevalence range of malnutrition on hospital admission and six associated outcomes.

R3. ⚠️ What are the GLIM criteria's two categories? Give three examples of each.

R4. Name four screening tools. ⚠️ Give §29.2's four reasons screening fails, and say which is the commonest.

R5. ⚠️ List §29.3's mechanisms of the nil-by-mouth cascade. What is the single highest-yield fix?

R6. ⚠️ What are the modern preoperative fasting rules?

R7. ⚠️ How fast does bed rest cause muscle loss, and what four factors compound it? Why are nutrition and mobilization described as the same intervention?

R8. Give the four routes in order. ⚠️ State the governing principle.

R9. ⚠️ How should oral nutritional supplements be taken, and what is the standard failure mode?

R10. ⚠️ What is the NG tube never event, and how is position confirmed? Which two checks were abandoned?

R11. ⚠️ What does PEG feeding in advanced dementia NOT achieve? What is recommended instead, and why does aspiration continue?

R12. Give the indications for parenteral nutrition and four complications.

R13. ⚠️ Explain the refeeding syndrome mechanism in five steps. What is the hallmark electrolyte abnormality?

R14. ⚠️ Give the high-risk criteria for refeeding syndrome, both the single-criterion and two-criterion lists.

R15. ⚠️ State the four management principles for someone at refeeding risk. What comes before feeding?

R16. ⚠️ Summarize what EPaNIC, EDEN, TARGET and EFFORT Protein found. What is the current consensus?

R17. ⚠️ Give three proposed explanations for why early full feeding doesn't help in critical illness.

R18. ⚠️ What is the correct warfarin advice, and what is the common error?

R19. ⚠️ State §29.13's distinction about eating and dying.

R20. ⚠️ Give §29.11's inversion table. What is described as the most dangerous sentence in the book?

Tier 2 — Application

A1. 🔄 Audit the admission. For each of Ivor's nine days, state what could have been done differently and what it would have cost.

⚠️ Then: how many of your fixes require money?

A2. ⚠️ The refeeding screen. For each, assess risk and state your first three actions:

a) A 62-year-old with alcohol use disorder, admitted after five days of not eating b) A 19-year-old with anorexia nervosa, BMI 14, admitted for medical stabilization c) An 80-year-old post-stroke, nil by mouth for six days pending swallow assessment d) A 45-year-old three months after bariatric surgery with persistent vomiting e) A well-nourished 30-year-old who fasted for 36 hours before an endoscopy

A3. The critical care predictions. ⚠️ Compare your Learning Check-In answers with §29.8.

a) Which did you get wrong? b) ⚠️ What was your reasoning, and where exactly did it fail? c) Does the autophagy explanation persuade you? ⚠️ Compare its evidential status here with Chapter 21 §21.6.

A4. ⚠️ The diet order. An 84-year-old with type 2 diabetes is admitted with pneumonia, eating about a third of meals, and is on a "diabetic diet."

a) ⚠️ What is the trade being made? b) What would you do instead? c) ⚠️ Use Chapter 26's tiers to justify your answer.

A5. The family conversation. A relative asks why their dying mother isn't being given a feeding tube.

a) ⚠️ Write what you would say. Under 150 words. b) ⚠️ What must you address besides the clinical facts? c) What would you offer them to do?

A6. ⚠️ Design the system fix. §29.12b says nobody owns the total.

a) Who should? b) ⚠️ Design the trigger — what happens automatically when intake falls below a threshold? c) What would it cost, and what would resist it?

Tier 3 — Analysis and Synthesis

S1. ⚠️ Nine reasonable decisions. §29's hook argues no individual decision was wrong.

a) ⚠️ Is that true? Test it — find the one you'd most defend as an error. b) What kind of failure is this? Name the category. c) ⚠️ Find two other examples in this book with the same structure. (Chapter 16's biotin case is one.)

S2. When mechanism loses to trial. §29.8's critical care findings.

a) ⚠️ List every case in this book where a clean mechanism produced a confident recommendation that trials overturned. b) Is there a common feature? c) ⚠️ Does this argue for less confidence in mechanism generally, or for something more specific?

S3. ⚠️ The restriction pattern, five instances. §29.12 states the general rule.

a) List all five with what was restricted and by whom. b) ⚠️ The general rule says the question is "are they getting enough, and of what?" — is that always right? Find a genuine counter-example. c) ⚠️ Design the single question a clinician should ask before issuing any dietary restriction.

S4. The re-audit, examined. §29.16 argues the rise from 15.4% to 42% is honest.

a) ⚠️ Steelman the objection that the standard loosened. b) The chapter's counter is that the 🟡 count also grew. ⚠️ Is that a good argument? What else would you want to see? c) ⚠️ Design the audit you'd run to check for standard drift properly.

S5. ⚠️ End of life. §29.13.

a) Why is "they stopped eating because they are dying" so hard to accept? b) ⚠️ Is there a circumstance where artificial nutrition at end of life IS appropriate? Describe it. c) ⚠️ "Food is love." How should that be handled — as a barrier to overcome, or as information?

S6. 🔄 ⚠️ Part V, in one page. Chapters 23–29 covered sport, weight, lifespan, chronic disease, the microbiome, allergy, and clinical nutrition.

a) ⚠️ What is the single idea that connects them? b) Which chapter's material is most likely to be wrong in twenty years? ⚠️ Justify. c) ⚠️ Write the 150-word summary of Part V you'd give someone who won't read it.

🪞 Reflection

M1. ⚠️ Have you, or someone you love, been in hospital? Do you know what they ate? Did anyone ask?

M2. ⚠️ §29.8's trials contradicted a strong intuition. How did it feel to be wrong about something that seemed obvious? Where else might that be true for you?

M3. ⚠️ §29.13 asks a question most people avoid. Do you know what someone you love would want if they could no longer eat? Have you asked?

M4. Ivor said "Nobody was unkind. Not one person." ⚠️ What does it mean for a system to harm someone without anyone behaving badly? Where else does that happen?

M5. 🔄 ⚠️ Part V's register was "the arguing is over." Did you find it more or less useful than Part IV? What does your answer tell you about what you want from a book like this?