# A nurse is caring for a 79-year-old client admitted from a long-term care facility with weight loss of 9 kg over 4 months, BMI 18.1, MNA-SF score of 6 (high risk for malnutrition), serum albumin 2.4 g/dL, and a stage 2 pressure injury on the sacrum. The client has been NPO for 3 days due to a recent procedure. Which actions support comprehensive nutritional management? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=368305&lang=en  
> language: en  
> subject: Nutrition and Oral Hydration  
> category: BCC

## Question

A nurse is caring for a 79-year-old client admitted from a long-term care facility with weight loss of 9 kg over 4 months, BMI 18.1, MNA-SF score of 6 (high risk for malnutrition), serum albumin 2.4 g/dL, and a stage 2 pressure injury on the sacrum. The client has been NPO for 3 days due to a recent procedure. Which actions support comprehensive nutritional management? Select all that apply.

1

Initiate gradual oral or enteral refeeding starting at 25 to 50 percent of calculated needs to prevent refeeding syndrome

2

Begin TPN immediately at full goal calories on Day 1 to rapidly correct the calorie deficit

3

Monitor serum phosphorus, magnesium, and potassium daily during the first week and replace as needed

4

Replace thiamine 100 mg before or with the first carbohydrate dose to prevent Wernicke encephalopathy

5

Discontinue all dietary supplements including oral nutritional supplements until weight stabilizes

6

Wait until the pressure injury is healed before introducing high-protein nutrition

## Explanation

Severe malnutrition (BMI under 18.5, MNA-SF 0 to 7, low albumin, prolonged NPO) plus pressure injury and weight loss require careful nutritional rehabilitation that prevents refeeding syndrome. Required actions: (1) gradual refeeding at 25 to 50 percent of goal in the first 24 to 48 hours, advance over 3 to 7 days based on tolerance — direct refeeding syndrome prevention; (2) thiamine 100 mg before or with the first carbohydrate load — prevents Wernicke encephalopathy in alcoholics and prolonged starvation; (3) daily monitoring of phosphorus, magnesium, and potassium during the first week with replacement — captures intracellular shifts before arrhythmia or respiratory failure. Full TPN at goal on day 1 (option 2) is the textbook trigger for refeeding syndrome — life-threatening. Stopping oral supplements until weight stabilizes (option 5) worsens malnutrition; supplements should continue with monitoring. Waiting for pressure injury healing before high-protein nutrition (option 6) is backwards — protein deficit IS what impairs healing; aggressive protein (1.2 to 1.5 g/kg/day) supports wound healing while monitoring electrolytes.

## In-depth explanation

Severe Malnutrition + Refeeding Risk
This client meets multiple criteria: BMI 18.1, MNA-SF 6, albumin 2.4, weight loss 9 kg over 4 months, NPO 3 days, pressure injury.

MNA-SF Risk Tiers
- 12 to 14: normal
- 8 to 11: at risk
- 0 to 7: high risk

Refeeding Prevention Bundle
1. Start at 25 to 50 percent goal calories
2. Thiamine 100 mg before first carb
3. Daily phos and Mg and K first week, replace
4. Cardiac monitor for severe malnutrition
5. Advance over 3 to 7 days as tolerated

Pressure Injury + Nutrition
- Protein 1.2 to 1.5 g/kg/day (wound healing)
- Vitamin C 500 mg, zinc 25 mg supplementation
- Adequate hydration
- Do NOT delay nutrition for healing — opposite is true

Wrong Answers
4: Full TPN on day 1 equals textbook refeeding trigger.
5: Stopping ONS worsens deficit.
6: Protein restriction worsens wound healing.

NCSBN Theme
BCC — Nutrition and chronic disease.

## Clinical scenario

Scenario
79-year-old, LTC admit, severe malnutrition.

Profile
- Weight loss 9 kg over 4 months
- BMI 18.1
- MNA-SF 6 (high risk)
- Albumin 2.4 g/dL
- Sacral pressure injury stage 2
- NPO 3 days post-procedure

Risk
Refeeding syndrome high risk. Gradual restart plus thiamine plus electrolyte monitoring required.

Approach
Slow refeed plus thiamine plus daily lytes plus protein for wound healing.

## Key concepts

- **MNA-SF (Mini Nutritional Assessment Short Form)** — Validated nutrition screening tool for adults 65 and older: 6 items (food intake, weight loss, mobility, psychological stress or acute disease, neuropsychological problems, BMI). Total score 0 to 14: 12 to 14 normal, 8 to 11 at risk, 0 to 7 high risk for malnutrition. Triggers comprehensive assessment and intervention. Used in hospital, LTC, and community.
- **Thiamine in refeeding** — Vitamin B1 cofactor for carbohydrate metabolism. Thiamine stores deplete in 2 to 3 weeks of starvation. Refeeding with carbohydrate without thiamine repletion precipitates Wernicke encephalopathy (confusion, ataxia, ophthalmoplegia) and Korsakoff (memory). Standard: 100 mg IV, IM, or PO before or with first carbohydrate load, repeat daily for 3 to 5 days in high-risk clients.
- **Pressure injury nutrition** — Higher protein (1.2 to 1.5 g/kg/day for stage 2 to 4 PI), adequate calories (30 to 35 kcal/kg/day), vitamin C 500 mg/day, and zinc 15 to 25 mg/day support wound healing. Hydration 30 mL/kg/day. Restricting nutrition until healing is contraindicated — protein deficit IS the underlying impediment. Refer to dietitian for an individualized plan, especially if there is comorbid CKD or DM.

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