Chapter 31: The Child with Endocrine Dysfunction

Cushings appearance & long term steroid use

- Excessive hair growth - Moon face, red cheeks - Weight gain- 2 months can gain 10-15lbs - Pendulous abdomen with red striae - Poor wound healing - Ecchymosis The longer on steroids the more of a chance to develop DM2

Hyperthyroidism & Graves Disease Signs & symptoms

- Goiter - Shaking/ tremors - Palpitation - Hypertension, Tachycardia - Psychosis, hallucinations

Daily preventive management Type 1 DM

- Insulin therapy - Glucose monitoring- Goal- 126 - Lab mgt of hemoglobin A1c - Urine testing Peds don't have sliding scale- have carb ratio & correction factor

Juvenile Hypothyroidism clinical manifestation & treatment

- Myxedematous skin Dry skin, Sparse hair, Periorbital edema - Decelerated growth - Constipation ** first sign - Sleepiness

Therapeutic management of Type 1

- Nutrition- Carb restriction Diet 200-350 depending on age - Exercise- exercise and insulin work the same way- reducing free circulating glucose & may require less insulin if complaining about lightheaded or just started a new sport have them check sugar before & after & have a snack before

DKA Signs & symptoms

- Polyuria - Polydipsia - Stomach ache - Lethargy - Tachycardia - Decreased LOC

Pituitary Hyperfunction: Acromegaly Treatment (3)

- Remove tumor if present - Irradiation & radioactive implants- if tumor - Hormone replacement therapy after surgery in some cases

Lymphocytic Thyroiditis

-Also known as Hashimoto disease or juvenile autoimmune thyroiditis -Most common cause of thyroid disease in children and adolescents -Accounts for largest percent of juvenile hypothyroidism -Occurs more frequently after age 6 years Therapeutic Management: -Goiter may be transient, asymptomatic -May resolve spontaneously within 1-2 years -Oral TH often decreases the goiter significantly -Surgery contraindicated for this disorder

Exophthalmos (protruding eyeballs) may occur in children with which condition? a. Hypothyroidism b. Hyperthyroidism c. Hypoparathyroidism d. Hyperparathyroidism

ANS: B Exophthalmos is associated with hyperthyroidism. Hypothyroidism, hypoparathyroidism, and hyperparathyroidism are not associated with exophthalmos.

1. Parents of a toddler with hypopituitarism ask the nurse, "What can we expect with this condition?" The nurse should respond with which statement? a. Growth is normal during the first 3 years of life. b. Weight is usually more retarded than height. c. Skeletal proportions are normal for age. d. Most of these children have subnormal intelligence.

ANS: C

19. Which is characteristic of the immune-mediated type 1 diabetes mellitus? a. Ketoacidosis is infrequent. b. Onset is gradual. c. Age at onset is usually younger than 20 years. d. Oral agents are often effective for treatment.

ANS: C

An adolescent diabetic is admitted to the emergency department for treatment of hyperglycemia and pneumonia. What are characteristics of diabetic hyperglycemia? a. Cold, clammy skin and lethargy b. Hunger and hypertension c. Thirst, being flushed, and fruity breath d. Disorientation and pallor

ANS: C The signs of hyperglycemia are thirst, being flushed, and fruity breath. The skin is not cold or clammy, and there is not hunger and hypertension. Disorientation and pallor are signs of hypoglycemia.

What statement is characteristic of type 1 diabetes mellitus? a. Onset is usually gradual. b. Ketoacidosis is infrequent. c. Peak age incidence is 10 to 15 years. d. Oral agents are available for treatment.

ANS: C Type 1 diabetes mellitus typically usually has its onset before the age of 20 years, with a peak incidence between ages 10 and 15 years. Type 1 has an abrupt onset, in contrast to type 2, which has a more gradual appearance. Ketoacidosis occurs when insulin is unavailable and the body uses sources other than glucose for cellular metabolism. Ketoacidosis is more common in type 1 diabetes than in type 2. At this time, oral agents are available only for type 2 diabetes.

5. The nurse is caring for a school-age child with hyperthyroidism (Graves disease). Which clinical manifestations should the nurse monitor that may indicate a thyroid storm? (Select all that apply.) a. Constipation b. Hypotension c. Hyperthermia d. Tachycardia e. Vomiting

ANS: C, D, E

29. The nurse is discussing with a child and family the various sites used for insulin injections. Which site usually has the fastest rate of absorption? a. Arm b. Leg c. Buttock d. Abdomen

ANS: D

5. A child will start treatment for precocious puberty. The nurse recognizes that this will involve the injection of which synthetic medication? a. Thyrotropin b. Gonadotropins c. Somatotropic hormone d. Luteinizing hormone-releasing hormone

ANS: D

7. The nurse is caring for a preschool child with suspected diabetes insipidus. Which clinical manifestation should the nurse expect to observe? a. Oliguria b. Glycosuria c. Nausea and vomiting d. Polyuria and polydipsia

ANS: D

What statement applies to the current focus of the dietary management of children with diabetes? a. Measurement of all servings of food is vital for control. b. Daily calculate specific amounts of carbohydrates, fats, and proteins. c. The number of calories for carbohydrates remains constant on a daily basis; protein and fat calories are liberal. d. The intake ensures day-to-day consistency in total calories, protein, carbohydrates, and moderate fat while allowing for a wide variety of foods.

ANS: D Essentially the nutritional needs of children with diabetes are no different from those of healthy children. Children with diabetes need no special foods or supplements. They need sufficient calories to balance daily expenditure for energy and to satisfy the requirement for growth and development.

What is a condition that can result if hypersecretion of growth hormone (GH) occurs after epiphyseal closure? a. Cretinism b. Dwarfism c. Gigantism d. Acromegaly

ANS: D Excess GH after closure of the epiphyseal plates results in acromegaly. Cretinism is associated with hypothyroidism. Dwarfism is the condition of being abnormally small. Gigantism occurs when there is hypersecretion of GH before the closure of the epiphyseal plates.

A child will start treatment for central precocious puberty. What synthetic hormone will be injected? a. Thyrotropin b. Gonadotropins c. Somatotropic hormone d. Luteinizing hormone-releasing hormone

ANS: D Precocious puberty of central origin is treated with monthly subcutaneous injections of luteinizing hormone-releasing hormone, which regulates pituitary secretions. Thyrotropin, gonadotropins, and somatotropic hormone are not the appropriate therapies for precocious puberty.

Disorders of the Pituitary Gland Anterior Vs. Posterior

Anterior: - Growth Hormone, - TSH - ACTH (adrenocorticotropic hormone) Posterior: - ADH (antidiuretic hormone) Anterior pituitary is the " master gland" & controlled by hypothalamus Pituitary gland also called: Hypophysis

Type 2 Diabetes Define, onset, increased risk, meds

Arises b/c of insulin resistance Onset: After 45 years old Increased Risk - Native americas, hispanic , & African american Affected people may or may not need insulin Metformin & insulin approved for peds

Juvenile Hypothryoidism

Congenital: -Congenital hypoplastic thyroid gland Acquired: -Partial or complete thyroidectomy for cancer or thyrotoxicosis -Following radiation for Hodgkin or other malignancy Rarely occurs from dietary insufficiency in United States Clinical Manifestations: -Decelerated growth -Myxedematous skin changes: +Dry skin +Sparse hair +Periorbital edema -Constipation -Sleepiness -Mental decline

Patho of DM & reason we can't cure

Deficiency of insulin- glucose unable to enter cell and remains in the blood = Hyperglycemia Glycouria= Glucose exceeds renal threshold and starts spilling into urine Glucogenesis= Cells break down protein for conversion to glucose by the liver You don't develop disease until 80% of pancreatic cells are ineffective

Type 1 Diabetes Define, onset, most cases& what kind of disease

Destruction of beta cells, leading to absolute insulin deficiency Onset: Childhood & adolescence but can occur at any age Most cases of DM of childhood are Type 1 Some type of autoimmune issue that stops the production of insulin

DKA Results from

EMERGENCY - Progressive deteroriantarion with dehydration - Electrolyte imbalance - Acidosis - Come, may cause death concern** cerebral edema- be careful when shifting fluids

Insulin Administration

FIG. 29-2 School-age children are able to administer their own insulin.

Pancreatic Hormone Function

Function of islets of Langerhans: -Alpha cells produce glucagon -Beta cells produce insulin -Delta cells produce somatostatin (believed to regulate insulin and glucagon)

Hypopituitarism: Growth Hormone (GH) Deficiency

-Inhibits somatic growth -Primary site of dysfunction appears to be in the hypothalamus Diagnostic Evaluation: -Family history -Growth patterns and health history -Definitive diagnosis bases of radioimmunoassay of plasma GH levels -Hand x-rays to evaluate growth potential vs. ossification -Endocrine studies to detect deficiencies Therapeutic Management: -Biosynthetic growth hormone (injections) -Other hormone replacements as needed: +Thyroid extract +Cortisone +Testosterone or estrogens and progesterone Prognosis: -GH replacement successful in 80% of affected children -Response varies based on age, length of treatment, frequency of doses, dosage, weight, and GH receptor amount Nursing Considerations : -Principal consideration is identifying children with growth problems -Family support needs -Child's body image -Preparing child for daily injections -Treatment expensive

Patient Education: DM and Insulin Therapy

-Nature of the disease -Meal planning -Insulin therapy: types of insulin, duration, onset and peak action, mixing and administration of types of insulin, rotation of injection sites -Insulin pump therapy in some cases -Glucose monitoring -Recognition and treatment of hypoglycemia and hyperglycemia -Management of "minor" illnesses -Record keeping -Hygiene -Family support -Acute care

Diabetic Ketoacidosis (DKA)

-Pediatric emergency -Results from progressive deterioration with dehydration, electrolyte imbalance, acidosis, and coma; may cause death

Ketoacidosis

-When glucose is unavailable for cellular metabolism, the body breaks down alternate sources of energy -Ketones are released, and excess ketones are eliminated in urine (ketonuria) or by the lungs (acetone breath) -Ketones in the blood are strong acids that lower serum pH and produce ketoacidosis

The nurse is caring for an adolescent with anorexia nervosa. What pituitary dysfunction should the nurse assess for in the adolescent? a. Hypopituitarism b. Pituitary hyperfunction c. Hyperplasia of the pituitary cells d. Overproduction of the anterior pituitary hormones

ANS: A Anorexia nervosa can cause hypopituitarism. It does not cause the hyperfunction of the pituitary, hyperplasia of the pituitary cells, or overproduction of the anterior pituitary hormones.

The nurse is planning to admit an 8-year-old child with hypoparathyroidism. What clinical manifestations should the nurse expect to observe in this child? (Select all that apply.) a. Muscle cramps b. Positive Chvostek sign c. Emotional lability d. Laryngeal spasms e. Short attention span

ANS: A, B, D Clinical manifestations of hypoparathyroidism include muscle cramps, positive Chvostek sign, and laryngeal spasms. Emotional lability and short attention span are signs of Graves disease.

The nurse is preparing to admit a 7-year-old child with type 2 diabetes. What clinical features of type 2 diabetes should the nurse recognize? (Select all that apply.) a. Oral agents are effective. b. Insulin is usually needed. c. Ketoacidosis is infrequent. d. Diet only is often effective. e. Chronic complications frequently occur.

ANS: A, C, D The clinical features of type 2 diabetes include the following: oral agents are effective, ketoacidosis is infrequent, and diet only is often effective. Insulin is only needed in 20% to 30% of cases and chronic complications occur infrequently.

The nurse is planning to admit a 14-year-old adolescent with hyperparathyroidism. What clinical manifestations should the nurse expect to observe in this patient? (Select all that apply.) a. Polyuria b. Diarrhea c. Hypotension d. Vague bone pain e. Paresthesia in extremities

ANS: A, D, E Clinical manifestations of hyperparathyroidism include polyuria, vague bone pain, and paresthesia in the extremities. Constipation, not diarrhea, and hypertension, not hypotension, are manifestations of hyperparathyroidism.

1. Nursing care of a child diagnosed with a syndrome of inappropriate ADH should include which of the following? (Select all that apply.) a. Weigh daily b. Encourage fluids c. Turn frequently d. Maintain nothing by mouth (NPO) e. Restrict fluids

ANS: A, E

6. The nurse is conducting a staff in-service on childhood endocrine disorders. Diabetes insipidus is a disorder of: a. anterior pituitary. b. posterior pituitary. c. adrenal cortex. d. adrenal medulla.

ANS: B

Intranasal administration of desmopressin acetate (DDAVP) is used to treat which condition? a. Hypopituitarism b. Diabetes insipidus (DI) c. Syndrome of inappropriate antidiuretic hormone (SIADH) d. Acute adrenocortical insufficiency

ANS: B DDAVP is the treatment of choice for DI. It is administered intranasally through a flexible tube. The child's response pattern is variable, with effectiveness lasting from 6 to 24 hours

Kussmaul Respirations

Hyperventilation characteristic of metabolic acidosis, resulting from respiratory system's attempt to eliminate excess CO2 by increased depth and rate

Hypopituitarism: GH deficiency Define & site of dysfunction

Inhibits somatic growth in all cells of the body Primary site of dysfunction: Hypothalamus

Long term complications of diabetes Mico vs Macrovascular

Macrovascular complications: Nephropathy & Retinopathy Microvascular: Neuropathy - Develops after 25 years of disease - Problem in patients with type 2 DM

Hyperthyroidism & Graves Disease Most common cause, physically you'll see, peak, diagnosis based on

Most common cause of hyperthyroidism= Graves Disease Autoimmune response to TSH receptors Enlarged thyroid gland and exophthalmos- See thyroid enlarged until adolescences in infants thyroid not palpable Peak: 12-14 years old or present at birth Family association Increased level of T4 & T3 with suppressed TSH levels

What are the intermediate acting insulins?

NPH (Humulin N, Novolin N)

Diabetes Insipidus Define & results, causes

Principal disorder of the posterior pituitary gland Results from under secretion of antidiuretic hormone Uncontrolled diuresis Primary: Familial or idiopathic (45-50%) Secondary: Trauma, tumors, infection, aneurysm, granulomatous disease--> Hypernatremia & check sodium level before giving vasopressors

Syndrome of Innapropriate Antidiuretic hormone (SIADH) Define, s/s

Produced by hypersecretion of the posterior pituitaty (Increased ADH) S/s: Fluid retention & hypotonicity- & hyponatremia Symptoms disappear when ADH is decreased Kidneys are unable to secrete water Anorexia, N/V, irritability, and personality changes

Cushings: Treatment

Restrict Sodium observe for signs of infection

Precocious Puberty Ages, Most common & type & first sign

Sexual development before Boys: before 9 Years old Caucasian girls: before 7 years old African American: before 6 years old Occurs more frequently in girls Types: Central precocious puberty (80%) Have child do workup because its central- want to see if anything is triggering pituitary to start hormones earlier Males: Armpit hair and strong body odor

Precocious Puberty Assessment tool

Tanner Staging Measures physical development- done only if conceded These kids might have Brest buds development and may be more advanced- might struggle with body image issues at young age

Thyrotoxicosis Define, why it may occur & treatment

Thyroid storm May occur from sudden release of hormone unusual in children- but life threatening May be precipitated by infection, surgery, or discontinuing of antithyroid therapy Anytime these pts have infection T3 & 4 extremely increase & they have intensity of all symptoms Treatment: Antithyroid drugs or propranolol

Tx for CAH?

cortisone, psych support for child and family

*What is DKA?

emergency; from progressive deterioration with dehydration, electrolyte imbalance, acidosis, coma, death

*What are the priorities in DKA?

get IV access, fluid replacement, replace electrolytes, give insulin IV

What are the long acting insulins?

glargine (Lantus) detemir (Levemir)

The adrenal cortex secretes what?

glucocorticoids (cortisol, corticosterone), mineralocoricoids (aldosterone), sex steroids (androgens, estrogens, progestins)

*What is Type 2?

insulin resistance, after 45 yo,

S/S of hypoglycemia?

irritable, difficulty focusing, shaky, dizzy, diaphoresis, pallor

Notes to know about lupron depot?

it slows prepubertal growth to normal rates, it is d/c at the age at which normal pubertal changes would resume

*Clinical s/s of DM?

polyuria, polydipsia, polyphagia, weight loss, nocturia, personality changes, dry skin, poor wound healing

How is CAH diagnsoed?

presence of ambiguous genitalia, DNA testing to rule out other causes, and increased serum levels of cortisol precursor and potassium and decrease serum sodium and chloride

Timing for long acting insulins?

takes 6-14 hrs to start working, peak in 10-16 hrs, stays in blood 20-24 hrs

*What is DM?

total or partial deficiency of the hormone insulin; type 1 and type 2

parathyroid hormone Diagnosis & S/S

- Check albumin levels - ECG: Prolonged QT S/S: - Muscle cramps - Seizures - Laryngospasm - Bronchospasm

Hypopituitarism: GH deficiency: Diagnostic evaluation of GH deficiency

- Child, parental & family growth pattern - Definitive diagnosis: Based on the absence or subnormal reserves of pituitary GH > usually done with GH stimulation Give GH stimulation and then check 30, 60 & 90 mins after- if GH not increased- means we need to supplement them ** First thing that's done - Skeletal survey in children younger then 3 years old Xray of left hand - wrist to examine for centers of ossification (natural process of bone formation) & utilize that for assessment to compare where child should be at that age

Diabetes Insipidus Treatment

- Daily hormone replacement of vasopressin (DDAVP) - Unresponsiveness usually indicated nephrogentic DI

Pituitary Hyperfunction: Acromegaly Nursing care (4)

- Early identification of children - Early treatment for improved outcomes - Emotional support - Body image concerns

Cushings Diagnostics

- Excess cortisol level - X-ray to evaluate for osteoporosis and skull films to look for enlargement of the sella turcica Labs - Fasting blood glucose- can develop type 2 DM - Serum electrolytes - 24- hr urine- looking for glucose that spilled over into urine

Hypopituitarism: GH deficiency: Prognosis & based on what (5)

- GH replacement successful in 80% if caught early, usually at end of adolescent we stop treatment Response varies based on - Age - Length of treatment - Frequency of doses & dosage - Weight - GH receptor amount These kids should know they may never achieve their adult height

Ketoacidosis (DKA)

- Glucose unavailable for cellular metabolism - body breaks down alternitive sources of energy - Ketones are released and excess ketones are eliminated in the urine (ketonuria) or by the lungs ( acetone breath) - Ketones in the blood: strong acids that lower pH & produce ketoacidosis

Thyrotoxicosis Nursing considerations

- Identify child - Be alert of S&S - Child needs a quiet environment and rest period - Help family cope - Dietary requirements to meet the increased metabolic rate

Hypopituitarism: GH deficiency: Nursing considerations (5)

- Identifying child with growth problems - Family support needed - Childs body image - Preparing child for daily injections - Treatment is $$$

Precocious Puberty Treatment

- Treat cause if known - Psychological support for child & family - Central variety is treated with leuprolide (lupron, Depot) slows prepubertal growth to normal rate & treatment is discontinues at the age of normal puberty Lupton stem test - receive hormones to see how other hormones react to it

Cushing Syndrome

-A characteristic group of manifestations caused by excessive circulating free cortisol -May be caused by excessive or prolonged steroid therapy -Condition is reversible once steroids are discontinued -Abrupt withdrawal of steroids may precipitate acute adrenal insufficiency Etiology: -Pituitary: excess of adrenocorticotropic hormone (ACTH) -Adrenal: hypersecretion of glucocorticoids -Ectopic: extrapituitary neoplasm -Iatrogenic: administration of excessive steroids -Food dependent: inappropriate adrenal response to secretion of polypeptide Cushingoid Appearance: -Excessive hair growth -Moon face, red cheeks -Weight gain -Pendulous abdomen with red striae -Poor wound healing -Ecchymosis Diagnostic Evaluation: -Confirm excess cortisol levels -X-rays: evaluate for osteoporosis and take skull films to -look for enlargement of sella turcica -Laboratory tests: +Fasting blood glucose +Serum electrolytes +24-hour urine Therapeutic management: -Surgery -Replacement of GH, ADH, TH, gonadotropins, and steroids Nursing considerations

Diabetes Mellitus (DM)

-Characterized by a total or partial deficiency of the hormone insulin -The most common endocrine disorder of childhood -Peak incidence in early adolescence Three Major Groups of DM: -Type 1 -Type 2 -Maturity onset diabetes of the young (MODY) MODY: -Transmitted as autosomal dominant disorder with formation of structurally abnormal insulin with decreased biologic activity -Onset is generally before age 25 -Similar to type 2 DM -May be seen in obese teens -May be controlled with oral hypoglycemic agents and diet modifications -More benign disease, but increasing in frequency in pediatric population Type 1 Diabetes: -Characterized by destruction of beta cells, usually leading to absolute insulin deficiency -Typically, onset in childhood and adolescence, but can occur at any age -Most DM of childhood is type 1 Therapeutic Management of Type 1 DM: -Insulin therapy -Glucose monitoring: goal range 80-120 mg/dl -Laboratory measurement of hemoglobin A1c -Urine testing for ketones: +Not routinely used EXCEPT: ~Helpful to test q 3 hr during illness and whenever glucose is ≥240 mg/dl when illness not present -Nutrition -Exercise -Teach patient and family how to manage hypoglycemic episodes -Illness management -Management of DKA Type 2 Diabetes: -Arises because of insulin resistance -Onset usually after age 40 -Native American, Hispanic, and African-American children are at increased risk of type 2 DM -Affected persons may or may not require insulin injections Etiology of DM: -Type 1 DM believed to be autoimmune disease, arising when a person with a genetic predisposition is exposed to a precipitating event such as viral infection -Heredity is prominent factor in etiology Pathophysiology of DM: -With a deficiency of insulin, glucose is unable to enter the cell, and remains in blood, causing hyperglycemia -When serum glucose exceeds renal threshold, glucose spills into urine (glycosuria) -Cells break down protein for conversion to glucose by the liver (glucogenesis) Long-Term Complications of DM: -Microvascular complications, especially nephropathy and retinopathy -Macrovascular disease, neuropathy

Precocious Puberty

-Defined as sexual development before age 9 in boys or in Caucasian girls <7 years old; in African-American girls, <6 years old -Occurs more frequently in girls -3 types: +Central precocious puberty (CPP) +Peripheral precocious puberty (PPP) +Incomplete precocious puberty (IPP) Therapeutic Management: -Treatment of specific cause if known -Central variety treated with leuprolide (Lupron): +Slows prepubertal growth to normal rates +Treatment is discontinued at age for normal pubertal changes to resume -Psychologic support for child and family

Pituitary Hyperfunction: Acromegaly

-Excess GH after epiphyseal closure is called acromegaly -Typical facial features: +Overgrowth of head, lips, nose, tongue, jaw, paranasal and mastoid sinuses +Separation and malocclusion of the teeth +Disproportion of face to cerebral division of skull +Increased facial hair +Thickened, deeply creased skin Diagnostic Evaluations: -Radiologic studies -Endocrine studies Therapeutic Management: -Surgical treatment to remove tumor -Radiation and radioactive implants -Hormone replacement therapy after surgery in some cases Nursing Care Management: -Early identification of children with excessive growth rates -Early treatment for improved outcomes -Emotional support -Body image concerns

Pituitary Hyperfunction

-Excess GH before closure of epiphyseal shafts results in overgrowth of long bones -Reach heights of 8 feet or more -Vertical growth + increased muscle -Weight generally in proportion to height

Goiter

-Hypertrophy of the thyroid gland -Congenital: +Usually results from maternal ingestion of antithyroid drugs during pregnancy -Acquired: +Result of neoplasm, inflammatory disease, dietary deficiency (but rarely in children), or increased secretion of pituitary TSH Nursing Care Management: -Thyroid enlargement at birth may compromise newborn's airway -Large goiters may be obvious; smaller nodules evident only on palpation -Thyroid hormone (TH) replacement necessary for treatment of hypothyroidism

Disorders of Pituitary Function

-Pituitary gland is also called hypophysis -Pituitary gland is the "master gland" -Responsible for regulating other glands -Two portions, each with unique functions: +Anterior +Posterior

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

-Produced by hypersecretion of the posterior pituitary (increased ADH) -Signs and symptoms: fluid retention, hypotonicity -Kidneys unable to reabsorb water -Anorexia, nausea and vomiting, irritability, personality changes -Symptoms disappear when ADH is decreased

Possible Nursing Diagnoses for Child with DM

-Risk for Injury related to insulin deficiency -Risk for Injury related to hypoglycemia -Knowledge Deficit (Diabetes Management) related to care of child with newly diagnosed diabetes mellitus

Diabetes Insipidus (DI)

-The principal disorder of the posterior pituitary -Results from hyposecretion of antidiuretic hormone (ADH) -Produces uncontrolled diuresis -Primary causes: familial or idiopathic -Secondary causes: trauma, tumors, granulomatous disease, aneurysm Clinical Manifestations: -Cardinal signs: polyuria and polydipsia -First sign is often enuresis accompanied by insatiable thirst -Infants: +Irritability relieved with feedings of water but not milk +Dehydration often occurs Therapeutic Management: -Instruct parents on difference between DI and diabetes mellitus (DM) -Daily hormone replacement of vasopressin -Unresponsiveness usually indicates nephrogenic DI Nursing Management: -Accurate I&O -Observe for signs of fluid overload -Seizure precautions -Administer ADH-antagonizing medicines

Management of Graves Disease

-Therapy is controversial -Goal of therapy: to retard rate of hormone secretion -Treatments: +Antithyroid drugs (propylthiouracil [PTU] and methimazole) +Subtotal thyroidectomy +Ablation with radioiodine

Thyrotoxicosis

-Thyroid "crisis" or "storm" -May occur from sudden release of hormone -Unusual in children, but can be life threatening -May be precipitated by infection, surgery, or discontinuation of antithyroid therapy -Treatment of thyroid storm: +Antithyroid drugs +Propranolol Nursing Care Management: -Identify children with hypothyroidism -Be alert for signs and symptoms -Child needs quiet environment, rest periods -Help family cope with emotional lability associated with disorder -Dietary requirements to meet child's increased metabolic rate -Medications: side effects

Disorders of Thyroid Function

-Thyroid hormone regulates basal metabolic rate (BMR) -Thyroid secretes two types of hormones: +Thyroid hormone, which is made up of: ~Thyroxine (T4) ~Triiodothyronine (T3) +Thyrocalcitonin -May have hypothyroidism or hyperthyroidism -May have disturbance in secretion of thyroid-stimulating hormone (TSH)

*What is type 1?

destruction of beta cells > absolute insulin deficiency; in childhood, autoimmune disease,

*Diagnostic goals for Type 1 DM?

glucose at 80-120 mg/dL, A1C at 6.5-8%, ketones tested Q3h during an illness and whenever the glucose is 240 mg/dL or more

What is Congenital Adrenal Hyperplasia (CAH)?

group of disorders caused by decreased cortisol production in the adrenal cortex, in both sexes,

10. A goiter is an enlargement or hypertrophy of which gland? a. Thyroid b. Adrenal c. Anterior pituitary d. Posterior pituitary

ANS: A

3. A child with growth hormone (GH) deficiency is receiving GH therapy. When is the best time for the GH to be administered? a. At bedtime b. After meals c. Before meals d. On arising in the morning

ANS: A

31. The nurse is implementing care for a school-age child admitted to the pediatric intensive care in diabetic ketoacidosis (DKA). Which prescribed intervention should the nurse implement first? a. Begin 0.9% saline solution intravenously as prescribed. b. Administer regular insulin intravenously as prescribed. c. Place child on a cardiac monitor. d. Place child on a pulse oximetry monitor.

ANS: A

A goiter is an enlargement or hypertrophy of which gland? a. Thyroid b. Adrenal c. Anterior pituitary d. Posterior pituitary

ANS: A A goiter is an enlargement or hypertrophy of the thyroid gland. Goiter is not associated with the adrenal, anterior pituitary, or posterior pituitary secretory organs.

The thyroid-stimulating hormone (TSH) increases secretion in response to which hormone? a. Low levels of circulating thyroid hormone b. High levels of circulating thyroid hormone c. Low levels of circulating adrenocorticotropic hormone d. High levels of circulating adrenocorticotropic hormone

ANS: A As blood concentrations of the target hormones reach normal levels, a negative message is sent to the anterior pituitary to inhibit release of the tropic hormone. For example, TSH responds to low levels of circulating TH. As blood levels of TH reach normal concentrations, a negative feedback message is sent to the anterior pituitary, resulting in diminished release of TSH. Adrenocorticotropic stimulates the adrenals to secrete glucocorticoids

The nurse is planning care for a child recently diagnosed with diabetes insipidus (DI). What intervention should be included? a. Encourage the child to wear medical identification. b. Discuss with the child and family ways to limit fluid intake. c. Teach the child and family how to do required urine testing. d. Reassure the child and family that this is usually not a chronic or life-threatening illness.

ANS: A DI is a potentially life-threatening disorder if the voluntary demand for fluid is suppressed or the child does not have access to fluids. Medical alert identification should be worn. Fluid intake is not restricted in children with DI. The child is unable to concentrate urine and can rapidly become dehydrated. Fluid intake may be limited during diagnosis, when the lack of intake will result in decreased urinary output and dehydration. Urine testing is not required in DI. Changes in body weight provide information about approximate fluid balance. This is a lifelong disorder that requires supplemental vasopressin throughout life

What nursing care should be included for a child diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)? a. Maintain the child NPO (nothing by mouth). b. Turn the child frequently. c. Restrict fluids. d. Encourage fluids.

ANS: C Increased secretion of ADH causes the kidney to reabsorb water, which increases fluid volume and decreases serum osmolarity with a progressive reduction in sodium concentration. The immediate management of the child is to restrict fluids but not food. Frequently turning the child is not necessary unless the child is unresponsive. Encouraging fluids will worsen the child's condition.

A 12-year-old girl is newly diagnosed with diabetes when she develops ketoacidosis. How should the nurse structure a successful education program? a. Essential information is presented initially. b. Teaching should take place in the child's semiprivate room. c. Education is focused toward the parents because the child is too young. d. All information needed for self-management of diabetes is taught at once.

ANS: A Diagnosis of type 1 diabetes can be traumatic for the child and family. Most families are not psychologically ready for the complex teaching that is needed for self-management. Most structured diabetes education programs begin with essential or survival information followed by the complex background material when the family is better able to learn. Teaching can take place either as an outpatient or as an inpatient. The actual teaching area should be free from distractions that would interfere with learning. A semiprivate room would have many individuals entering and leaving the room, causing distraction. A 12-year-old child who is cognitively age appropriate needs to be included in the educational process. Most children older than the age of 8 years can be involved in blood glucose monitoring and insulin administration. Teaching all information needed for self-management of diabetes at once would be too overwhelming for a family in crisis.

During the summer many children are more physically active. What changes in the management of the child with diabetes should be expected as a result of more exercise? a. increase food intake b. decrease food intake c. increase risk of hyperglycemia d. decrease risk of insulin reaction

ANS: A Exercise is encouraged and never restricted unless indicated by other health conditions. Exercise lowers blood glucose levels, depending on the intensity and duration of the activity. Consequently, exercise should be included as part of diabetes management, and the type and amount of exercise should be planned around the child's interests and capabilities. However, in most instances, children's activities are unplanned, and the resulting decrease in blood glucose can be compensated for by providing extra snacks before (and, if the exercise is prolonged, during) the activity. In addition to a feeling of well-being, regular exercise aids in utilization of food and often results in a reduction of insulin requirements.

A child with growth hormone (GH) deficiency is receiving GH therapy. When is the best time for the GH to be administered? a. At bedtime b. After meals c. Before meals d. After arising in morning

ANS: A Injections are best given at bedtime to more closely approximate the physiologic release of GH. After meals, before meals, and after arising in the morning do not parallel the physiologic release of the hormone.

A school-age child with diabetes gets 30 units of NPH insulin at 0800. According to when this insulin peaks, the child should be at greatest risk for a hypoglycemic episode between when? a. Lunch and dinner b. Breakfast and lunch c. 0830 to his midmorning snack d. Bedtime and breakfast the next morning

ANS: A Intermediate-acting (NPH and Lente) insulins reach the blood 2 to 6 hours after injection. The insulins peak 4 to 14 hours later and stay in the blood for about 14 to 20 hours

The nurse is assisting with a growth hormone stimulation test for a child with short stature. What should the nurse monitor closely on this child during the test? a. Hypotension b. Tachycardia c. Hypoglycemia d. Nausea and vomiting

ANS: A Patients receiving clonidine (Catapres) for a growth hormone stimulation test require close blood pressure monitoring for hypotension. Tachycardia, hypoglycemia, and nausea and vomiting do not occur with Catapres administered for a growth hormone stimulation test.

What form of diabetes is characterized by destruction of pancreatic beta cells, resulting in insulin deficiency? a. Type 1 diabetes b. Type 2 diabetes c. Gestational diabetes d. Maturity-onset diabetes of the young (MODY)

ANS: A Type 1 diabetes is characterized by the destruction of the pancreatic beta cells, which leads to absolute insulin deficiency. Type 2 diabetes results usually from insulin resistance. The pancreatic beta cells are not destroyed in gestational diabetes. MODY is an autosomal dominant monogenetic defect in beta cell function that is characterized by impaired insulin secretion with minimum or no defects in insulin action.

The nurse is preparing to assist with a growth hormone provocative test for a child with short stature. The nurse recognizes that which pharmacologics should be used to provoke the release of growth hormone (GH)? (Select all that apply.) a. Larodopa (levodopa) b. Clonidine (Catapres) c. Propranolol (Inderal) d. Cortisone (hydrocortisone) e. Biosynthetic growth hormone

ANS: A, B, C GH stimulation, or provocative testing, involves the use of pharmacologics to provoke the release of GH either directly or indirectly. Provocative testing involves the use of neuromodulators such as levodopa or agents such as clonidine, arginine, insulin, propranolol, or glucagon followed by the measurement GH blood levels. Cortisone is given to replace hormone deficiencies that can occur with GH deficiency. Biosynthetic GH is used to treat GH deficiency.

The clinic nurse is assessing a child with central precocious puberty. What conditions can cause central precocious puberty? (Select all that apply.) a. Trauma b. Neoplasms c. Radiotherapy d. Exogenous sex hormones e. Primary hypothyroidism

ANS: A, B, C Trauma, neoplasms, and radiotherapy can be the cause of central precocious puberty. Exogenous sex hormones and primary hypothyroidism can cause peripheral precocious puberty.

The nurse is planning to admit a 12-year-old with Graves disease (GD). What clinical manifestations should the nurse expect to observe in this child? (Select all that apply.) a. Insomnia b. Irritability c. Tonic rigidity d. Hyperactivity e. Muscle cramps

ANS: A, B, D Signs and symptoms of hyperthyroidism develop gradually, with an interval between onset and diagnosis of approximately 6 to 12 months. Clinical features include irritability, hyperactivity, short attention span, tremors, insomnia, and emotional lability. Tonic rigidity and muscle cramps are signs of hypoparathyroidism.

The nurse is planning to admit a 14-year-old adolescent with Cushing syndrome. What clinical manifestations should the nurse expect to observe in this child? (Select all that apply.) a. Truncal obesity b. Decreased pubic hair c. Petechial hemorrhage d. Hyperpigmentation of elbows e. Facial plethora f. Headache and weakness

ANS: A, C, E Clinical manifestations of Cushing syndrome include truncal obesity, petechial hemorrhage, and facial plethora. Decreased pubic and axillary hair; hyperpigmentation of elbows, knees, and wrists; and headache and weakness are clinical manifestations of adrenocortical insufficiency.

The nurse is preparing a community outreach program for adolescents about the characteristic differences between type 1 and type 2 diabetes mellitus (DM). What concepts should the nurse include? (Select all that apply.) a. Type 1 DM has an abrupt onset. b. Type 1 DM is often controlled with oral glucose agents. c. Type 1 DM occurs primarily in whites. d. Type 2 DM always requires insulin therapy. e. Type 2 DM frequently has a familial history. f. Type 2 DM occurs in people who are overweight.

ANS: A, C, E, F Characteristics of type 1 DM include having an abrupt onset, primarily occurring in whites, and not being controlled with oral glucose agents (insulin is required for therapy). Type 2 DM frequently has a familial history, occurs in people who are overweight, and does not always require insulin therapy (it is used in 20% to 30% of patients).

4. A nurse is planning interventions for a toddler with juvenile hypothyroidism. Which interventions should the nurse plan to implement for this child? (Select all that apply.) a. Moisturizer for dry skin b. Antidiarrheal medications c. Medications to help with insomnia d. Implementation of thyroxine therapy

ANS: A, D

2. The nurse should expect to assess which clinical manifestations in an adolescent with Cushing syndrome? (Select all that apply.) a. Hyperglycemia b. Hyperkalemia c. Hypotension d. Cushingoid features e. Susceptibility to infections

ANS: A, D, E

11. Exophthalmos (protruding eyeballs) may occur in children with: a. hypothyroidism. b. hyperthyroidism. c. hypoparathyroidism. d. hyperparathyroidism.

ANS: B

16. Chronic adrenocortical insufficiency is also referred to as: a. Graves disease. b. Addison disease. c. Cushing syndrome. d. Hashimoto disease.

ANS: B

17. A neonate born with ambiguous genitalia is diagnosed with congenital adrenogenital hyperplasia. Therapeutic management includes administration of: a. vitamin D. b. cortisone. c. stool softeners. d. calcium carbonate.

ANS: B

18. The parents of a neonate with adrenogenital hyperplasia tell the nurse that they are afraid to have any more children. The nurse should explain which statement about adrenogenital hyperplasia? a. It is not hereditary. b. Genetic counseling is indicated. c. It can be prevented during pregnancy. d. All future children will have the disorder.

ANS: B

28. The nurse is caring for an 11-year-old boy who has recently been diagnosed with diabetes. Which should be included in the teaching plan for daily injections? a. The parents do not need to learn the procedure. b. He is old enough to give most of his own injections. c. Self-injections will be possible when he is closer to adolescence. d. He can learn about self-injections when he is able to reach all injection sites.

ANS: B

32. The nurse should teach parents of a preschool child with type 1 diabetes that which can raise the blood glucose level? a. Exercise b. Steroids c. Decreased food intake d. Lantus insulin

ANS: B

33. A nurse is reviewing the laboratory results on a school-age child with hypoparathyroidism. Which results are consistent with this condition? a. Decreased serum phosphorus b. Decreased serum calcium c. Increased serum glucose d. Decreased serum cortisol level

ANS: B

4. An adolescent is being seen in the clinic for evaluation of acromegaly. The nurse understands that which occurs with acromegaly? a. There is a lack of growth hormone (GH) being produced. b. There is excess growth hormone (GH) after closure of the epiphyseal plates. c. There is an excess of growth hormone (GH) before the closure of the epiphyseal plates. d. There is a lack of thyroid hormone being produced.

ANS: B

8. A nasal spray of desmopressin acetate (DDAVP) is used to treat which disorder? a. Hypopituitarism b. Diabetes insipidus c. Acute adrenocortical insufficiency d. Syndrome of inappropriate antidiuretic hormone

ANS: B

A child with hypopituitarism is being started on growth hormone (GH) therapy. Nursing considerations should be based on which knowledge? a. Therapy is most successful if it is started during adolescence. b. Replacement therapy requires daily subcutaneous injections. c. Hormonal supplementation will be required throughout child's lifetime. d. Treatment is considered successful if children attain full stature by adolescence.

ANS: B Additional support is required for children who require hormone replacement therapy, such as preparation for daily subcutaneous injections and education for self-management during the school-age years. Young children, obese children, and those who are severely GH deficient have the best response to therapy. Replacement therapy is not needed after attaining final height. The children are no longer GH deficient. When therapy is successful, children can attain their actual or near-final adult height at a slower rate than their peers.

The nurse is caring for a child after a parathyroidectomy. What medication should the nurse have available if hypocalcemia occurs? a. Insulin b. Calcium gluconate c. Propylthiouracil (PTU) d. Cortisone (hydrocortisone)

ANS: B Because hypocalcemia is a potential complication after a parathyroidectomy, observing for signs of tetany, instituting seizure precautions, and having calcium gluconate available for emergency use are part of the nursing care

Congenital adrenal hyperplasia (CAH) is suspected in a newborn because of ambiguous genitalia. The parents are appropriately upset and concerned about their child's gender. In teaching the parents about CAH, what should the nurse explain? a. Reconstructive surgery as a female is preferred. b. Sexual assignment should wait until genetic sex is determined. c. Prenatal masculinization will strongly influence the child's development. d. The child should be raised as a boy because of the presence of a penis and scrotum.

ANS: B It is preferable to raise the child according to genetic sex. With hormone replacement and surgical intervention if needed, genetically female children achieve satisfactory results in reversing virilism and achieving normal puberty and ability to conceive. Reconstructive surgery as a female is only preferred for infants who are genetically female. Infants who are genetically male should be given hormonal supplementation. Sex assignment and rearing depend on psychosocial influences, not on genetic sex hormone influences during fetal life. It is not advised to raise the child as a boy because of the presence of a penis and scrotum unless the child is genetically male. If a genetic female, the child will be sterile and may never be able to function satisfactorily in a heterosexual relationship.

A preadolescent has maintained good glycemic control of his type 1 diabetes through the school year. During summer vacation, he has had repeated episodes of hypoglycemia. What additional teaching is needed? a. Carbohydrates in the diet need to be replaced with protein. b. Additional snacks are needed to compensate for increased activity. c. The child needs to decrease his activity level to minimize episodes of hypoglycemia. d. Insulin dosage should be increased to compensate for a change in activity level.

ANS: B Most children have a different schedule during summer vacation. The increased activity and exercise reduce insulin resistance and increase glucose utilization. Additional snacks should be eaten before physical activity to increase carbohydrates and protein and compensate for increased activity. Physical activity should always be encouraged if the child is capable. The benefits include improved glucose utilization and decreased insulin requirements. In consultation with the practitioner, insulin dosage may need to be decreased because of improved glucose utilization.

Glucocorticoids, mineralocorticoids, and sex steroids are secreted by which gland? a. Thyroid gland b. Adrenal cortex c. Anterior pituitary d. Parathyroid glands

ANS: B The glucocorticoids, mineralocorticoids, and sex steroids are secreted by the adrenal cortex. The thyroid gland produces thyroid hormone and thyrocalcitonin. The anterior pituitary produces hormones such as growth hormone, thyroid-stimulating hormone, adrenocorticotropic hormone, gonadotropin, prolactin, and melanocyte-stimulating hormone. The parathyroid glands produce parathyroid hormone.

A child is having tests done to determine parathyroid function. The clinic nurse knows that the parathyroid hormone (PTH) regulates the homeostasis of what in the serum? a. Sodium b. Calcium c. Potassium d. Magnesium

ANS: B The parathyroid glands secrete PTH. Along with vitamin D and calcitonin, PTH regulates the homeostasis of serum calcium concentrations

The nurse is teaching the parent of a preschool child how to administer the child's insulin injection. The child will be receiving 2 units of regular insulin and 12 units of NPH insulin every morning. What should the parent be taught? a. Draw the insulin in separate syringes. b. Draw the regular insulin first and then the NPH into the same syringe. c. Draw the NPH insulin first and then the regular into the same syringe. d. Check blood sugar first, and if below 120, hold the regular insulin and give the NPH.

ANS: B To obtain maximum benefit from mixing insulins, the recommended practice is to (1) inject the measured amount of air (equivalent to the dosage) into the long-acting insulin; (2) inject the measured amount of air into the rapid-acting (clear) insulin and, without removing the needle; (3) withdraw the clear insulin; and (4) insert the needle (already containing the clear insulin) into the long-acting (cloudy) insulin and then withdraw the desired amount. The blood sugar may be checked before giving the insulin, but the prescribed dose should not be withheld if the blood sugar is 120.

The school nurse practitioner is consulted by a fifth-grade teacher about a student who has become increasingly inattentive and hyperactive in the classroom. The nurse notes that the child's weight has changed from the 50th percentile to the 30th percentile. The nurse is concerned about possible hyperthyroidism. What additional sign or symptom should the nurse anticipate? a. Skin that is cool and dry b. Blurred vision and loss of acuity c. Running and being active during recess d. Decreased appetite and food intake

ANS: B Visual disturbances such as loss of visual acuity and blurred vision are associated with hyperthyroidism. They may occur before the actual onset of other symptoms. The child's skin is usually warm, flushed, and moist. Although the signs of hyperthyroidism include excessive motion, irritability, hyperactivity, short attention span, and emotional lability, these children are easily fatigued and require frequent rest periods. Children with hyperthyroidism have increased food intake. Even with voracious appetites, weight loss occurs

A child with hypoparathyroidism is receiving vitamin D therapy. The parents should be advised to watch for which signs or symptoms of vitamin D toxicity? a. Headache and seizures b. Weakness and lassitude c. Anorexia and insomnia d. Physical restlessness, voracious appetite without weight gain

ANS: B Vitamin D toxicity can be a serious consequence of therapy. Parents are advised to watch for weakness, fatigue, lassitude, headache, nausea, vomiting, and diarrhea. Renal impairment is manifested through polyuria, polydipsia, and nocturia. Headaches may be a sign of vitamin D toxicity, but seizures are not. Anorexia and insomnia are not characteristic of vitamin D toxicity. Physical restlessness and a voracious appetite with weight loss are manifestations of hyperthyroidism.

The nurse is preparing to admit a 9-year-old child with syndrome of inappropriate antidiuretic hormone (SIADH). What interventions should the nurse include in the child's care plan? (Select all that apply.) a. Provide a low-sodium, low-fat diet. b. Initiate seizure precautions. c. Weigh daily at the same time each day. d. Encourage intake of 1 l of fluid per day. e. Measure intake and output hourly.

ANS: B, C, E Nursing care of the child with SIADH includes placing the child on seizure precautions, obtaining a daily weight at the same time each day, and accurately measuring the child's intake and output. The nurse does not need to provide a low-sodium, low-fat diet because there are no diet restrictions. The child would be on fluid precautions to avoid fluid overload, so 1 l of fluid would not be encouraged.

What are characteristics of diabetic ketoacidosis? (Select all that apply.) a. Pallor b. Acidosis c. Bradypnea d. Dehydration e. Electrolyte imbalance

ANS: B, D, E Characteristics of diabetic ketoacidosis include acidosis, dehydration, and electrolyte imbalance. Respirations are rapid (Kussmaul respirations), not slow, and flushing, not pallor, would occur.

The nurse is planning to admit a 10-year-old child with syndrome of inappropriate antidiuretic hormone (SIADH). What clinical manifestations should the nurse expect to observe in this child? (Select all that apply.) a. Polyuria b. Anorexia c. Polydipsia d. Irritability e. Stomach cramps

ANS: B, D, E Clinical signs of SIADH are directly related to fluid retention and hyponatremia. When cells in the brain are exposed to too much water as opposed to sodium, swelling occurs. When serum sodium levels are diminished to 120mEq/l, affected children may display anorexia, nausea, vomiting, stomach cramps, irritability, and personality changes. Polyuria and polydipsia are manifestations of diabetes insipidus

What clinical manifestation occurs with hypoglycemia? a. Lethargy b. Confusion c. Nausea and vomiting d. Weakness and dizziness

ANS: D Some of the clinical manifestations of hypoglycemia include weakness; dizziness; difficulty concentrating, speaking, focusing, and coordinating; sweating; and pallor. Lethargy, confusion, and nausea and vomiting are manifestations of hyperglycemia

The nurse is teaching the family of a child with type 1 diabetes about insulin. What should the nurse include in the teaching session? (Select all that apply.) a. Unopened vials are good for 60 days. b. Diabetic supplies should not be left in a hot environment. c. Insulin can be placed in the freezer if not used every day. d. After it has been opened, insulin is good for up to 28 to 30 days. e. Insulin bottles that have been opened should be stored at room temperature or refrigerated.

ANS: B, D, E Insulin bottles that have been "opened" (i.e., the stopper has been punctured) should be stored at room temperature or refrigerated for up to 28 to 30 days. After 1 month, these vials should be discarded. Unopened vials should be refrigerated and are good until the expiration date on the label. Diabetic supplies should not be left in a hot environment. Insulin need not be refrigerated but should be maintained at a temperature between 15° and 29.5° C (59° and 85° F). Freezing renders insulin inactive.

The nurse is caring for a child with an anterior pituitary tumor. What hormones are secreted by the anterior pituitary? (Select all that apply.) a. Oxytocin b. Luteinizing hormone c. Antidiuretic hormone d. Thyroid-stimulating hormone e. Adrenocorticotrophic hormone

ANS: B, D, E The anterior pituitary is responsible for secreting the following hormones: growth hormone, thyroid-stimulating hormone, adrenocorticotrophic hormone, follicle-stimulating hormone, luteinizing hormone, and prolactin. The posterior pituitary secretes antidiuretic hormone and oxytocin.

12. The nurse is teaching the parents of a child who is receiving methimazole (Tapazole) for the treatment of hyperthyroidism (Graves disease). Which statement made by the parent indicates a correct understanding of the teaching? a. "I would expect my child to gain weight while taking this medication." b. "I would expect my child to experience episodes of ear pain while taking this medication." c. "If my child develops a sore throat and fever, I should contact the physician immediately." d. "If my child develops the stomach flu, my child will need to be hospitalized."

ANS: C

14. A child with hypoparathyroidism is receiving vitamin D therapy. The parents should be advised to watch for which sign of vitamin D toxicity? a. Headache and seizures b. Physical restlessness and voracious appetite without weight gain c. Weakness and lassitude d. Anorexia and insomnia

ANS: C

15. Glucocorticoids, mineralocorticoids, and sex steroids are secreted by the: a. thyroid gland. b. parathyroid glands. c. adrenal cortex. d. anterior pituitary.

ANS: C

2. A child with hypopituitarism is being started on growth hormone (GH) therapy. Nursing considerations should be based on which knowledge? a. Treatment is most successful if it is started during adolescence. b. Treatment is considered successful if children attain full stature by adulthood. c. Replacement therapy requires daily subcutaneous injections. d. Replacement therapy will be required throughout the child's lifetime.

ANS: C

23. A parent asks the nurse why self-monitoring of blood glucose is being recommended for her child with diabetes. The nurse should base the explanation on which knowledge? a. It is a less expensive method of testing. b. It is not as accurate as laboratory testing. c. Children are better able to manage the diabetes. d. Parents are better able to manage the disease.

ANS: C

25. The parents of a child who has just been diagnosed with type 1 diabetes ask about exercise. Which should the nurse explain about exercise in type 1 diabetes? a. Exercise will increase blood glucose. b. Exercise should be restricted. c. Extra snacks are needed before exercise. d. Extra insulin is required during exercise.

ANS: C

30. To help the adolescent deal with diabetes, the nurse must consider which characteristic of adolescence? a. Desire to be unique b. Preoccupation with the future c. Need to be perfect and similar to peers d. Need to make peers aware of the seriousness of hypoglycemic reactions

ANS: C

9. The nurse is admitting a toddler with the diagnosis of juvenile hypothyroidism. Which is a common clinical manifestation of this disorder? a. Insomnia b. Diarrhea c. Dry skin d. Accelerated growth

ANS: C

To help an adolescent deal with diabetes, the nurse needs to consider which characteristic of adolescence? a. Desire to be unique b. Preoccupation with the future c. Need to be perfect and similar to peers d. Awareness of peers that diabetes is a severe disease

ANS: C Adolescence is a time when the individual has a need to be perfect and similar to peers. Having diabetes makes adolescents different from their peers. Adolescents do not wish to be unique; they desire to fit in with the peer group. An adolescent is usually not future oriented. Awareness of peers that diabetes is a severe disease would further alienate the adolescent with diabetes. The peer group would focus on the differences

A child is receiving propylthiouracil for the treatment of hyperthyroidism (Graves disease). The parents and child should be taught to recognize and report which sign or symptom immediately? a. Fatigue b. Weight loss c. Fever, sore throat d. Upper respiratory tract infection

ANS: C Children being treated with propylthiouracil must be carefully monitored for the side effects of the drug. Parents must be alerted that sore throat and fever accompany the grave complication of leukopenia. These symptoms should be immediately reported. Fatigue and weight loss are manifestations of hyperthyroidism. Their presence may indicate that the drug is not effective but does not require immediate evaluation. Upper respiratory tract infections are most likely viral in origin and not a sign of leukopenia.

What is a common clinical manifestation of juvenile hypothyroidism? a. Insomnia b. Diarrhea c. Dry skin d. Rapid growth

ANS: C Dry skin, mental decline, and myxedematous skin changes are associated with juvenile hypothyroidism. Children with hypothyroidism often have sleepiness, constipation, and decelerated growth.

The parents of a child who has just been diagnosed with type 1 diabetes ask about exercise. What effect does exercise have on a type 1 diabetic? a. Exercise increases blood glucose. b. Extra insulin is required during exercise. c. Additional snacks are needed before exercise. d. Excessive physical activity should be restricted.

ANS: C Exercise lowers blood glucose levels, decreasing the need for insulin. Extra snacks are provided to maintain the blood glucose levels. Exercise is encouraged and not restricted unless indicated by other health conditions.

Peripheral precocious puberty (PPP) differs from central precocious puberty (CPP) in which manner? a. PPP results from a central nervous system (CNS) insult. b. PPP occurs more frequently in girls. c. PPP may be viewed as a variation in sexual development. d. PPP results from hormonal stimulation of the hypothalamic gonadotropin-releasing hormone (Gn-RH).

ANS: C PPP may be viewed as a variation in sexual development. PPP results from hormone stimulation other than the hypothalamic Gn-RH. Isolated manifestations of secondary sexual development occur. PPP can be missed if these changes are viewed as variations in pubertal onset. CPP results from CNS insult, occurs more frequently in girls, and results from hormonal stimulation of the hypothalamic Gn-RH

A 20-kg (44-lb) child in ketoacidosis is admitted to the pediatric intensive care unit. What order should the nurse not implement until clarified with the physician? a. Weigh on admission and daily. b. Replace fluid volume deficit over 48 hours. c. Begin intravenous line with D5 0.45% normal saline with 20 mEq of potassium chloride. d. Give intravenous regular insulin 2 units/kg/hr after initial rehydration bolus.

ANS: C The initial hydrating solution is 0.9% normal saline. Potassium is not given until the child is voiding 25 ml/hr, demonstrating adequate renal function. After initial rehydration and insulin administration, then potassium is given. Dextrose is not given until blood glucose levels are between 250 and 300 mg/dl. An accurate, current weight is essential for determination of the amount of fluid loss and as a basis for medication dosage. Replacing fluid volume deficit over 48 hours is the current recommendation in diabetic ketoacidosis in children. Cerebral edema is a risk of more rapid administration. Intravenous regular insulin 2 units/kg/hr after initial rehydration bolus is the recommended insulin administration for a child of this weight. Only regular insulin can be given intravenously, and it is given after initial fluid volume expansion

3. A nurse is planning care for a school-age child with type 1 diabetes. Which insulin preparations are rapid and short acting? (Select all that apply.) a. Novolin N b. Lantus c. NovoLog d. Novolin R

ANS: C, D

13. Which clinical manifestation may occur in the child who is receiving too much methimazole (Tapazole) for the treatment of hyperthyroidism (Graves disease)? a. Seizures b. Enlargement of all lymph glands c. Pancreatitis or cholecystitis d. Lethargy and somnolence

ANS: D

20. Which is considered a cardinal sign of diabetes mellitus? a. Nausea b. Seizures c. Impaired vision d. Frequent urination

ANS: D

21. Hyperglycemia associated with diabetic ketoacidosis is defined as a blood glucose measurement equal to or greater than _____ mg/dl. a. 100 b. 120 c. 180 d. 200

ANS: D

22. Type 1 diabetes mellitus is suspected in an adolescent. Which clinical manifestation may be present? a. Moist skin b. Weight gain c. Fluid overload d. Poor wound healing

ANS: D

24. The parent of a child with diabetes mellitus asks the nurse when urine testing will be necessary. The nurse should explain that urine testing is necessary for which? a. Glucose is needed before administration of insulin. b. Glucose is needed four times a day. c. Glycosylated hemoglobin is required. d. Ketonuria is suspected.

ANS: D

26. A child eats some sugar cubes after experiencing symptoms of hypoglycemia. This rapid-releasing sugar should be followed by: a. fat. b. fruit juice. c. several glasses of water. d. complex carbohydrate and protein.

ANS: D

27. The nurse is caring for an 8-year-old child with type 1 diabetes. The nurse should teach the child to monitor for which manifestation of hypoglycemia? a. Lethargy b. Thirst c. Nausea and vomiting d. Shaky feeling and dizziness

ANS: D

The nurse is taking care of a child who had a thyroidectomy. The nurse recognizes what as a positive Chvostek sign? a. Paresthesia occurring in feet and toes b. Frequent sharp flexion of wrist and ankle joints c. Carpal spasm elicited by pressure applied to the nerves of the upper arm d. Facial muscle spasm elicited by tapping the facial nerve in the region of the parotid gland

ANS: D A positive Chvostek sign is a facial muscle spasm that is elicited by tapping the facial nerve in the region of the parotid gland. Paresthesia occurring in the feet and toes and frequent sharp flexion of the wrist and ankle joints can be signs of hypoparathyroidism but are not part of a positive Chvostek sign. Carpal spasm elicited by pressure applied to nerves of the upper arm is called a positive Trousseau sign.

The nurse is teaching an adolescent about giving insulin injections. The adolescent asks if the disposable needles and syringes can be used more than once. The nurse's response should be based on which knowledge? a. It is unsafe. b. It is acceptable for up to 24 hours. c. It is acceptable for families with very limited resources. d. It is suitable for up to 3 days if stored in the refrigerator.

ANS: D Bacterial counts are unaffected if insulin syringes are handled in an aseptic manner and stored in the refrigerator between use. The syringes can be used up to 3 days and result in a considerable cost savings. Bacterial counts remain low for up to 72 hours with proper technique. The family's resources are not an issue; if a practice is unsafe, the family should not be encouraged to endanger the child by reusing equipment.

What blood glucose measurement is most likely associated with diabetic ketoacidosis? a. 185 mg/dl b. 220 mg/dl c. 280 mg/dl d. 330 mg/dl

ANS: D Diabetic ketoacidosis is a state of relative insulin insufficiency and may include the presence of hyperglycemia, a blood glucose level greater than or equal to 330 mg/dl; 185, 220, and 280 mg/dl are values that are too low for the definition of ketoacidosis.

What clinical manifestation is considered a cardinal sign of diabetes mellitus? a. Nausea b. Seizures c. Impaired vision d. Frequent urination

ANS: D Hallmarks of diabetes mellitus are glycosuria, polyuria, and polydipsia. Nausea and seizures are not clinical manifestations of diabetes mellitus. Impaired vision is a long-term complication of the disease.

The clinic nurse is assessing a child with hypopituitarism. Hypopituitarism can lead to which disorder? a. Gigantism b. Hyperthyroidism c. Cushing syndrome d. Growth hormone deficiency

ANS: D Hypopituitarism can lead to a growth hormone deficiency. An overproduction of the anterior pituitary hormones can result in gigantism (caused by excess growth hormone production during childhood), hyperthyroidism, or hypercortisolism (Cushing syndrome).

A child eats some sugar cubes after experiencing symptoms of hypoglycemia. This rapid-releasing sugar should be followed by which dietary intervention? a. Sports drink and fruit b. Glucose tabs and protein c. Glass of water and crackers d. Milk and peanut butter on bread

ANS: D Symptoms of hypoglycemia are treated with a rapid-releasing sugar source followed by a complex carbohydrate and protein. Milk supplies lactose and a more prolonged action from the protein. The bread is a complex carbohydrate, which with the peanut butter provides a sustained action. The sports drink contains primarily simple carbohydrates. The fruit contains additional carbohydrates. A protein source is needed for sustained action. The glucose tabs are simple carbohydrates. Complex carbohydrates are needed with the protein. Crackers are a complex carbohydrate, but protein is needed to stabilize the blood sugar.

The nurse is discussing with a child and family the various sites used for insulin injections. What site usually has the fastest rate of absorption? a. Arm b. Leg c. Buttock d. Abdomen

ANS: D The abdomen has the fastest rate of absorption but the shortest duration. The arm has a fast rate of absorption but a short duration. The leg has a slow rate of absorption but a long duration. The buttock has the slowest rate of absorption and the longest duration

Homeostasis in the body is maintained by what is collectively known as the neuroendocrine system. What is the name of the nervous system that is involved? a. Central b. Skeletal c. Peripheral d. Autonomic

ANS: D The autonomic nervous system (composed of the sympathetic and parasympathetic systems) controls involuntary functions. In combination with the endocrine system, it maintains homeostasis. The central, skeletal, and peripheral subdivisions of the nervous system are not part of the neuroendocrine system.

The nurse is preparing to administer a prescribed dose of desmopressin acetate (DDAVP) intramuscularly (IM) to a child with diabetes insipidus. What action should the nurse take before drawing the medication into a syringe? a. Mix the medication with sterile water. b. Mix the medication with sterile normal saline. c. Have another nurse double-check the medication dose. d. Hold the medication under warm water for 10 to 15 minutes and then shake vigorously.

ANS: D To be effective, vasopressin must be thoroughly mixed in the oil by being held under warm running water for 10 to 15 minutes and shaken vigorously before being drawn into the syringe. If this is not done, the oil may be injected minus the antidiuretic hormone. Small brown particles, which indicate drug dispersion, must be seen in the suspension

Prolonged steroid therapy has caused a child to have Cushing syndrome. To lessen the cushingoid effects, the steroid should be administered at which time? a. In the PM b. After lunch c. QD in the AM d. QOD in the AM

ANS: D When cushingoid features are caused by steroid therapy, the effects may be lessened with administration of the drug early in the morning and on an alternate-day basis. Giving the drug early in the day maintains the normal diurnal pattern of cortisol secretion. If given during the evening, it is more likely to produce symptoms because endogenous cortisol levels are normally low and the additional supply exerts more pronounced effects. An alternate-day schedule allows the anterior pituitary an opportunity to maintain more normal hypothalamic-pituitary-adrenal control mechanisms.

Hypopituitarism: GH deficiency: what will you see & what age group

Acquired Might see growth curve start to level out or drop Normally not seen until preschool( 3 - 4 years old) " my child isn't keeping up with peers"

Disorders of adrenal function Whats secreted

Adrenal cortex secretes 3 types of steroids: -Glucocorticoids ( cortisol, corticosterone) - Mineralcorticoids (aldosterone) - Sex steroids (androgens, estrogen, progestins)

Disorders of adrenal function Adrenal medulla

Adrenal medulla secretes: Catecholamines, epi and nor epic Primary cause of adrenal hyper function: Catecholamine- secreting tumor

Pituitary Hyperfunction: Acromegaly Facial features & what kind of disease & concern

Autoimmune Disease - Overgrowth of head, lips, nose, tongue, jaw, paranasal & mastoid sinuses - Separation of the teeth - Disproportion of the face to cerebral division of the skull - Increased facial hair - Thickened, deeply creased skin Might have benign tumor on thyroid gland- MRI

Causes of Type 1 Diabetes

Autoimmune Disease A person with genetic predisposition is exposed to viral infection

Hypopituitarism: GH deficiency: Treatment

Biosynthetic growth hormone- SQ injections- given every evening (5pm-bedtime) other hormone replacements as needed: - Thyroid extract - Cortisone - Testosterone or estrogen and progesterone

Hypopituitarism: GH deficiency: Synthetic GH: Taking & side effects

Biosynthetic growth hormone- SQ injections- given every evening (5pm-bedtime) Has to do with Basel rate & absorption Can cause: Vagus muscle pain & tenderness Some of this can be alleviated by giving at night

What do DI & SIADH have in common

Both have excessive thirst DI is being treated with meds so should resolve But SIADH pts do to great length for water

Juvenile Hypothyroidism Define, reasons for developling

Deficiency of thyroid hormone secretion Congenital: - Congenital hypoplastic thyroid gland - Newborn screening Acquired: - Partial or complete thyroidectomy from cancer or thyrotoxicosis - Following radiation for Hodgkin or other malignant disease Rarely occurs from iodine insufficiency

Addison's disease Diagnosis, Treatment

Diagnosis - Low cortisol level - Plasma ACTH levels high when stimulated Treatment - Replacement with glucocorticoids Have cortisol at home and take regularly but also have an emergency dose (solo cortex) * Anytime sick give 2 1/2 or 3 times the normal dose & come to ER immediately- Why? b/c stress on body in any form- cortisol not able to produce = Shock

Thyroid storm

EMERGENCY! High mortality rate - Hospitalization (PICU) - Hemostatic support fluid, glucose, O2, fever, CV - May need to be intubated - Monitor & correct electrolytes - Monitor & treat cardiac arrhythmia - Treat hyperthermia- Give antipyretics Tachycardia & hypertension--> closer to shock will become hypotensive

Adrenal Crisis Management

EMERGENCY! - ABC - Draw blood: electrolytes,CBC, blood gas, creatinine, calcium, accucheck - ECG - Fluids: aggressive fluid replacement (D5NS) - Glucose & Glucocorticoids: Dextrose ( treat hypoglycemia ) & hydrocortisone Hospitalize: ICU

Pituitary Hyperfunction: Acromegaly Define & results in

Excess GH after epiphyseal closure Overgrowth of long bones Can reach 8 ft or more Delay in fontanel closure due to enlargement of head circumference Vertical growth with rapid & increased muscle development Weight in proportion with height

Cushing Syndrome Caused by

Excessive circulating free cortisol - Young children = could be adrenal tumor - Excessive or prolonged steroid therapy (reversible when steroids stopped)

Glucose Monitoring

FIG. 29-4 Child using blood glucose monitor and reagent strips to test blood for glucose.

Adrenal Crisis Factors & Diagnosis

Factors: - Hemorrhage into the gland from trauma - Fulminating infection (abrupt or sever onset) - Abrupt withdrawal from cortisone - Failure to increase cortisone at time of stress Diagnosis based on symptoms

Diabetes Insipidus Clinincal manifestations

First sign- Enuresis (bedwetting) accompanied by insatiable thirst (impossible to satisfy) ***Cardiac Signs- Polyuria (excessive urination) & Polydipsia (excessive thirst) Infants: Irritability relieved with feeding of water but not milk Dehydration often occurs

Syndrome of Innapropriate Antidiuretic hormone (SIADH) Treatment & Nursing management

Fluid restriction * Pts go to great lengths to get water - I&O - Observe for signs of fluid overload - Seizure precaution (b/c hyponatremia) - Administer ADH- antagonizing med

Diabetes Insipidus what will you see if ___ given

Give synthetic antidiuretic hormone Fluid restrict & follow their electrolytes Fluid restrict & they come dehydrated=DI Fluid restrict & correct issue = SIADH

Hyperthyroidism & Graves Disease Goal & treatment

Goal: Decrease the rate of hormone secretion - Antithyroid drugs Methimazole + Beta blocker (Propranolol) Want to use BB & once HR & BP controlled then methimazole only - Subtotal thyroidectomy - Ablation with radio iodine

Kussmaul Respirations

Hyperventilation characteristic of metabolic acidosis, resulting from the respiratory system's attempt to eliminate excess CO2 by increased depth and rate won't be tachpneac but long &slow breaths- trying to compensate

Addisons Disease (insufficiency) Define, cause, & when do symptoms appear

Hypo producers of cortisol Rare in children if occurs= Neoplasm or lesion of the adrenal glands, or idiopathic cause Symptoms appear gradually after 90% of adrenal tissue is nonfunction

DKA Management & treatment

Insulin dependency is the problem- Give insulin but don't bolus start a continue insulin delivery b/c if we shift fluid too fast we can cause cerebral edema Insulin Delivery is the solution ! Treatment: - Fluid bolus w 0.9 NS- dehydration in DKA give slow bolus & run over hour - Insulin drip - hourly accuckeck & electrolyte levels - 24 hours - Hospital admission & NPO until out of DKA

What are the rapid acting insulins?

Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra)

Parathyroid Functions: Feedback & your patients __Low

Negative feedback Parathyroid takes calcium from bones Serum levels drop get to point where bones don't have any more left = More deficiencies & bones themselves will have functionalists & growth issue If pts calcium low before thinking about parathyroid we should asses albumin B/c calcium bind to albumin- if both low - use formulate correct

Cushings syndrome

Pituitary cause - Excess of adrenocorticotropic hormone (ACTH) Adrenal Cause - Hyper-secretion of glucocorticoids Ectopic Cause Extrapituitary neoplasm Iatrogenic cause - Administration of excessive steroids Food- dependent cause - Inappropriate adrenal response to the secretion of polypeptide

What are the short acting insulins?

Regular (Humulin R, Novolin R)

Thyroid functions Define, Hormones secreted, may have

Regulate basal metabolic rate (BMR) Calcitonin Thyroxine (T4). Triiodithyronine (T3) - If newborn screen comes back += recheck asap if not treated= Intellectual disabilities quickly if + again = Hypothroidism =High TSH -Hypothroidism - Hyperthryoidism - May have disturbance in the secretion of thyroid stimulating hormone (TSH)

Diabetes mellitus dependency & Peak

Total or partial dependency of insulin Most common endocrine disorder in childhood Peak: Early adolescence (10-15 years)

s/s of hyperglycemia?

lethargic, confusion, n/v, fruity breath, 3 p's

Tx for Precocious Puberty?

lupron depot, psych support,

*What do you need to educate pts about diabetes?

meal planning, Insulin therapy: Types of insulin; duration, onset, and peak action of various types; mixing and administration of various types; rotation of injection sites, insulin pump therapy, glucose monitoring, recognizing and treating hypo/hyperglycemia, managing minor illnesses, record keeping, hygiene, family support, acute care

*What are some long-term complications of DM?

nephropathy, retinopathy, neuropathy, macrovascular disease, altered thyroid funciton, limited joint ROM

*Tx for type 1 DM?

no concentrated sweets, eat more fiber, do regular exercise, hypoglycemic management, illness management, management of diabetic ketoacidosis

Timing for intermediate acting insulins?

reach blood in 2-6 hrs, peak in 4-14 hrs, and last for 14-20 hrs

Timing for rapid acting insulin?

reaches blood in 15 min, peaks in 30-90 min later and lasts for 5 hrs

Timing for short acting insulins?

reaches blood in 30 min, peaks 2-4 hrs later, lasts for 4-8 hrs

What does the endocrine system do?

regulates metabolic processes

*What are the nursing diagnoses for a child with DM?

risk for injury related to insulin deficiency, risk for injury related to hypoglycemia, knowledge deficit related to the care of a child with newly diagnosed DM

What is precocious puberty?

sexual development before age 9 years in boys; before age 7 years in Caucasian girls; or before 6 years in African-American girls; 3 types: Central, Peripheral, and Incomplete Precocious puberty