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1 A 4-year-old presents with a 2-day history of fever, conjunctivitis, hacking cough, and
congestion. According to the mother, there is no “bark” and there is no “whoop” with his
cough. Examination of his mouth is notable for pinpoint white dots on a red base. The
patient moved 3 years ago from Australia at 1 year of age. His parents have refused
Which vitamin supplement would you include in your treatment plan?
a. Vitamin D
b. Vitamin A
c. Vitamin E
d. Vitamin B12
e. Vitamin K
3-2. A 17-year-old girl presents after being recently diagnosed a week ago with anorexia
nervosa. The diagnosis was based on a >30-kg weight loss over the last 8 months. She had
been restricting herself to less than 1000 kcal/day. Although hospitalization was
recommended last week, the family refused inpatient treatment. She now presents with a
recent onset of confusion, ataxia, and nystagmus for 2 days. On further questioning, she
admits to a recent eating binge 3 days ago to avoid hospitalization. She consumed foods
high in carbohydrates. On examination, she has a BMI of 15.9. Eye examination reveals both
vertical and horizontal nystagmus. Mini-mental state examination reveals a score of 21 out
of 30. She has gait ataxia. Urine toxicology screen is negative. CT scan shows diffuse cortical
atrophy consistent with restrictive dietary intake.
Which vitamin deficiency is suspected in this patient?
a. Thiamin (B1)
b. Riboflavin (B2)
c. Niacin (B3)
d. Vitamin A
e. Vitamin E
3-3. While working at an underserved health clinic in Southeastern Asia, an 11-month-old
baby boy presents with shortness of breath. The parents note that he also has a hoarse,
weak cry with poor feeding. One month prior to presentation, the child was treated for a
viral gastroenteritis and diarrhea. During the visit 1 month ago, the mother was advised to
stop feeding infant formula temporarily and give rice water. The diarrhea was quickly
controlled; however, during your diet history, you learn that the mother never restarted
infant formula and has instead continued with rice water for the last month. On
examination, the infant has a heart rate of 152 beats/min. There is an S3 gallop. Liver is
noted 3 cm below the left costal margin. There is sacral and pedal edema.
Given the dietary history and examination findings, which vitamin deficiency is suspected in
this patient?
a. Vitamin A
b. Thiamin (B1)
c. Niacin (B3)
d. Vitamin D
e. Vitamin E
3-4. You are asked for an inpatient consult on a 16-year- old girl who has just been admitted
with a diagnosis of anorexia nervosa. She was admitted with a 40% weight loss over the past
6 months. During that time she had placed herself on a calorie-restricted diet (about 400
kcal/day). One month prior to admission, she had become irritable and had a depressed
mood. Over the past week she has also developed diarrhea (not related to laxative abuse)
and an erythematous rash that is exacerbated by sunlight exposure. Over the past week, the
skin in the erythematous area has become rough, cracked, and thick. In addition, the
diarrhea has also persisted along with continued irritability and confusion. Given the dietary
history and examination findings, which vitamin deficiency is suspected in this patient?
a. Vitamin A
b. Thiamin (B1)
c. Niacin (B3)
d. Vitamin D
e. Vitamin E
3-5. You are asked to interpret dietary reference ranges for a vitamin provided by the
National Academy of Science and the Food and Nutrition Board. The data available include
the intake that would be associated with a tolerable upper limit (UL) for a vitamin, the
estimated average requirement (EAR) for a vitamin, and the recommended dietary
allowance (RDA) for a vitamin. You need to provide a range that not only could ensure that
deficiency will not occur but would also avoid vitamin toxicity. What would you
a. Select an intake level above the EAR, but below the RDA.
b. Select an intake level above the EAR, but below the UL.
c. Select an intake level above the RDA, but below the UL.
d. Select an intake level above the RDA, but below the EAR.
e. None of the above.
3-6. Total body water composition changes with age. Which statement accurately describes
the changes in total body water composition of children?
a. Water accounts for almost all 85% to 90% of body weight for infants and decreases over
time (to 60%) in adolescents and young adults.
b. Water accounts for 70% to 75% of body weight for infants and decreases over time (to
50%-60%) in adolescents and young adults.
c. Water accounts for less than half (40%-50%) of body weight for infants and decreases
over time (to 35%) in adolescents and young adults.
d. Water accounts for 40% to 50% of body weight for infants and increases over time (to
50%-60%) in adolescents and young adults.
e. Water accounts for 60% of body weight for infants and increases over time (to 85%) in
adolescents and young adults.
3-7. Which of following statements is correct regarding protein intake for children?
a. Compared with carbohydrates and fats, children can derive more kilocalories (kcal) per
gram from protein.
b. Unlike carbohydrates, both fat and protein are sufficient dietary sources of nitrogen.
c. Dietary protein requirements beyond infancy are easily obtained in the typical Western
d. Protein needs are approximately 2.0 g/kg/day in infancy and linearly increase over time
until they triple by late adolescence.
e. Kwashiorkor refers to excessive intake of dietary protein, which is endemic in
subpopulations in the United States.
3-8. Which of following statements is incorrect regarding carbohydrate intake for children?
a. Dietary carbohydrate provides between 35% and 60% of the average American diet.
b. Fruits and vegetables contain simple sugars, such as glucose, fructose, and sucrose.
c. Soda, sweets, and candy contain simple sugars such as fructose.
d. Intake of complex carbohydrates should be encouraged and simple sugars such as glucose
and fructose should be eliminated.
e. Glucose is the preferred energy substrate for the brain.
3-9. A 1-year-old girl is noted to have failure to thrive and persistent diarrhea with foul-
smelling stool for several months. The mother describes the stool as “greasy.”
On examination, you note that the child has a scaly, diffuse dermatitis and hair loss. As you
prepare to work up the underlying condition, you are also concerned about the possibility of
a nutritional deficiency. Which of the following is the most likely nutritional deficiency
present in this child?
a. Linoleic acid deficiency
b. Vitamin C deficiency
c. Vitamin B12 deficiency
d. Protein deficiency (kwashiorkor)
e. Protein and caloric deficiency (marasmus)
3-10. Which of following statements is incorrect regarding fat intake for children?
a. Essential fatty acids include linoleic acid and linolenic acid.
b. Hair loss, diarrhea, and poor wound healing are all symptoms of essential fatty acid
c. Prematurity and fat malabsorption are risk factors for essential fatty acid deficiency.
d. Linoleic acids comprise a smaller percentage of total calories in human milk compared
with typical commercial infant formulas.
e. Linoleic deficiency can be diagnosed by low plasma linoleic acid levels, as well as a high
buildup of serum levels of arachidonic acid.
3-11. Which of the following nutritional factors is least helpful in preventing later bone loss?
a. A high peak bone density in the third decade of life b. High green vegetable intake
c. High cow’s milk intake
d. High intake of phosphates (eg, cola drinks)
e. High levels of human milk intake during infancy
3-12. Which of the following situations is not a
contraindication for breast-feeding?
a. A 22-year-old mother with human immunodeficiency virus infection in the United States
b. A 32-year-old mother with active tuberculosis who has been treated for 1 week
c. A 21-year-old mother with a history of cocaine use with a positive urine screen for
cocaine and marijuana
d. A 29-year-old mother currently on therapeutic doses of chemotherapy
e. A 19-year-old mother with hepatitis B infection
3-13. Which of the following has the lowest potential renal solute load (PRSL)?
a. Skim milk
b. Whole milk
c. Raw cow whole milk
d. Soy-based infant formula
e. Cow’s milk–based infant formula
3-14. According to the World Health Organization, which of the following hospital-based
nursery interventions is associated with increased newborn breast-feeding rates?
a. Initiation of breast-feeding for all babies within the first hour after birth
b. Separation of babies and mothers from other siblings
c. Screening for galactosemia in the newborn period
d. A strict breast-feeding schedule of feeding every 3 hours
e. All of the above
3-15. You are counseling the mother of a newborn about breast-feeding. Which
recommendations will help increase prolactin and breast milk production?
a. Establishment of a breast-feeding routine
b. The touch, sight, or smell of an infant
c. Emptying the breast of milk with each feed
d. Infant sucking of the breast
e. All of the above
3-16. A 10-day-old former 3.02-kg full-term infant presents for a routine follow-up visit. The
infant is breast- feeding. He was discharged at 2 days of age from the nursery. His discharge
weight was 2.85 kg. At 4 days of age, his weight reached a nadir of 2.79 kg. Parents report
that stools transitioned from meconium to yellow/mustard-colored by 3 days of age. He is
now 3.03 kg today at his 10-day-old visit. He has several wet diapers per day. All of the
following are signs of the adequacy of breast-feeding except:
a. Regaining birth weight by 10 days of age
b. Loss of less than 10% of birth weight
c. Transition to mustard-colored stools by 5 days of age
d. Presence of several wet diapers per day
e. None of the above
3-17. A 3-day-old infant presents after discharge from the nursery for routine follow-up. The
mother has been breast-feeding, but complains of breast tenderness. Since discharge, the
infant has been slowly establishing a routine of feeding every 3 hours. Both breasts are
warm and throbbing. She denies fever, chills, or aches. There is no specific area of
tenderness. The areola and nipple appear normal with no shiny or flaky skin. What do you
recommend to the mother?
a. Miconazole or nystatin cream applied to the mother’s nipples
b. A 10- to 14-day course of antibiotics to cover Staphylococcus aureus for a mastitis
c. Warm compresses to treat a plugged duct
d. Increase feedings to 10 to 12 times per day; hand expression and application of cold
compresses for engorgement
e. Discontinuation of breast-feeding
3-18. A breast-feeding mother complains of breast pain. The following factors are associated
with candidal infection of the nipple of a breast-feeding mother except:
a. Recent antibiotic use by the mother.
b. History of diabetes.
c. Maternal fever.
d. Mother is sleeping with milk-soaked breast pads.
e. History of maternal vaginal candidiasis.
3-19. You are asked by a parent about infant nutrition for her 3-month-old child. The
mother plans to stop breast- feeding over the next week. She notes that infants can be fed a
cow’s milk–based infant formula; however, unmodified whole cow’s milk is not
recommended for infants less than 1 year of age. She asks why infants can’t be fed the same
whole cow’s milk that she feeds to her 19-month-old child. Which of the following reasons
supports the recommendation not to feed infants (less than 1 year of age) unmodified cow’s
a. Unmodified cow’s milk has unacceptable low protein content.
b. Unmodified cow’s milk has a high renal solute load that is not appropriate for infants.
c. Unmodified cow’s milk has excessive iron content that increases the risk for constipation.
d. Unmodified cow’s milk increases the risk of development of allergic disease.
e. Unmodified cow’s milk has an increased whey protein to casein protein ratio, compared
with human milk.
3-20. Place the following steps in the introduction of complementary foods in appropriate
order by age:
Age Complementary Food Introduced
4-6 months
6-8 months
8-10 months
10-12 months
12-24 mon
a. Mashed table food, plain yogurt, cooked scrambled eggs
b. Iron-fortified infant cereal
c. Wheat cereal, strained chicken, mashed cooked
d. Mixed table food (avoiding grapes, nuts, hot dogs, raisins, peanut butter)
e. Strained fruited and vegetables
3-21. You are seeing a 4-week-old infant for the first time. She is the product of a 33-week
gestation. The infant currently weighs 2.84 kg. She was recently discharged from the nursery
on 22 kcal/oz preterm discharge formula. The parents ask you when she can transition to a
routine newborn formula. What are the general recommendations for when to transition a
former premature infant to a routine newborn formula?
a. When the infant is greater than 3 kg
b. When the infant is 6 months of age
c. When the infant has achieved catch-up growth to the 10th percentile for adjusted age
d. A and B
e. A and C
3-22. During a well-child visit for an 18-month-old, you learn that your patient consumes
over 32 oz of whole milk per day. Which of the following recommendations would you
include in your counseling?
a. Immediately eliminate all whole milk intake. b. Encourage increased intake of red meat,
decreased intake of fish and poultry.
c. Encourage consumption of foods high in vitamin C.
d. Suggest replacement of whole cow’s milk with soy milk.
e. No recommendations are necessary.
3-23. You are caring for an exclusively breastfed 2-month- old infant. The mother is a strict
vegetarian or vegan and does not eat any animal products. What specific dietary
supplementation would you recommend for the mother?
a. Vitamin D.
b. Vitamin A.
c. Vitamin B12.
d. Vitamin E.
e. No supplementation is necessary.
3-24. You are a consultant on a medical relief mission and are asked to help manage a child
with a severely malnourished 7-year-old boy. All of the following recommendations would
be appropriate except:
a. Check baseline potassium, phosphorus, calcium, and magnesium. If baseline levels are
low, correct and continue supplementation.
b. Administer thiamin before refeeding.
c. Monitor for signs of cardiac and respiratory distress.
d. Start aggressive caloric replacement and gradually taper to full routine feeds when at 10%
of ideal body weight.
e. Do not exceed maintenance fluid needs.
3.26. Match the symptom or sign with the condition associated with obesity:
1. Polyuria and polydipsia
2. Cranial nerve VI palsy
3. Knee pain
4. Oligomenorrhea or amenorrhea
5. Undescended testicle
6. Red hair
a. Pseudotumor cerebri
b. Slipped capital femoral epiphyses
c. Prader-Willi syndrome
d. Type 2 diabetes mellitus
e. Proopiomelanocortin (POMC) deficiency syndromes
f. Polycystic ovary disease
3.27 You are asked to consult on for the care of a patient who is unable to be fed enterally
and requires long- term nutritional support. A hematocrit suggests iron-deficiency anemia,
and iron replacement is needed. What is the most appropriate method of iron replacement?
a. Intravenous bolus infusion
b. Prolonged intravenous iron administration
c. Addition of iron to routine prolonged parenteral nutrition
d. Subcutaneous iron administration
e. Intramuscular iron administration
3-28. Match the vitamin deficiency with the clinical syndrome:
Clinical Syndrome
1. Vitamin A a. Megaloblastic anemia
2. Vitamin D b. Rickets
3. Vitamin K c. Night blindness, poor growth, photophobia
4. Folate d. Scurvy
5. Vitamin B12 e. Dermatitis, dementia, diarrhea
6. Niacin f. Pernicious anemia
7. Vitamin C g. Hemorrhagic disease during the newborn period
3-29. Match the trace element deficiency with the clinical syndrome:
Trace Element Deficiency
Clinical Syndrome
1. Zinc a. Glucose intolerance
2. Fluoride b. Growth failure
3. Chromium c. Cardiomyopathy
4. Selenium d. Dental caries
Answer key
1. B
2. A
3. B
4. C
5. C
6. B
7. C
8. D
9. A
10. E
11. D
12. E
13. E
14. A
15. E
16. E
17. D
18. C
19. B
20. b, e, c, a, d
21. e
22. c
23. c
24. d
25. d
26. 1—d, 2—a, 3—b, 4—f, 5—c, 6—e
27. a
28. 1—c, 2—b, 3—g, 4—a, 5—f, 6—e, 7—d
29. 1—b, 2—d, 3—a, 4—c