Dunphy Endocrine and Metabolic Problems

Mary, age 72, has been taking insulin for several years. She just called you because she realized that yesterday she put her short-acting insulin in the long-acting insulin box and vice versa. She just took 22 units of regular insulin when she was supposed to take only 5 units. She says that she tried to do a fingerstick to test her glucose level but was unable to obtain any blood. She states that she feels fine. What do you tell her to do first? 1. "Keep trying to get a fingerstick and call me back with the results." 2. "Call 911 before you collapse." 3. "Drive immediately to the emergency room." 4. "Drink four ounces of fruit juice."

"Drink four ounces of fruit juice." Rationales Option 1: Mary should eventually be able to get a fingerstick but does not need to call if it is okay. Option 2: Drinking 4 oz of fruit juice will probably correct the problem, so she may not need to call 911. Option 3: If her blood sugar is low, Mary should certainly not drive herself to the emergency room. Option 4: Treatment of hypoglycemia is 15 g of carbohydrates and can be achieved by drinking 8 oz of milk or 4 oz of orange juice. The milk option is preferred to decrease the elevation in blood sugar that occurs with orange juice. The patient should wait for 15 minutes to see if the symptoms subside and repeat the treatment again if needed. All patients on insulin should be prescribed a glucagon pen, and family or friends should be instructed on its use. [Page reference: 937]

Tamika, who has diabetes, states that she heard fiber is especially good to include in her diet. How do you respond? 1. "Fiber is important in all diets." 2. "Too much fiber interferes with insulin, so include only a moderate amount in your diet." 3. "Fiber, especially soluble fiber, helps improve carbohydrate metabolism, so it is more important in the diet of persons with diabetes." 4. "You get just the amount of fiber you need with a normal diet."

"Fiber, especially soluble fiber, helps improve carbohydrate metabolism, so it is more important in the diet of persons with diabetes." Rationales Option 1: While fiber is important in all diets, this answer does not address why fiber is especially good to include in the diet of a patient with diabetes. Option 2: A diet high in fiber, especially soluble fiber, helps improve carbohydrate metabolism. Option 3: Fiber is important in the dietary management of diabetes. A diet high in fiber, especially soluble fiber, helps improve carbohydrate metabolism and lowers both total cholesterol and low-density lipoprotein cholesterol. Soluble fiber is found in dried beans, oats, and barley as well as some vegetables and fruits (peas, corn, zucchini, cauliflower, broccoli, prunes, pears, apples, bananas, and oranges). Option 4: It should not be assumed that individuals get enough fiber in their diet because most dietary habits are not perfect. An intake of 20 to 30 g of fiber per day is recommended.

Jeremiah, age 72, has gout and is obese. When teaching him about diet, which of the following do you tell him? 1. "Beer and wine are okay because they have no effect on uric acid." 2. "Keeping your weight stable, even if you are a little overweight, is better than fluctuating." 3. "You must go on a restricted, very low calorie diet to effect immediate change." 4. "Fluid intake should exceed three thousand milliliters daily to prevent formation of uric acid kidney stones."

"Fluid intake should exceed three thousand milliliters daily to prevent formation of uric acid kidney stones."\ Rationales Option 1: Because both wine and beer in excessive amounts impair the ability of the kidneys to excrete uric acid, they should be used in moderation. Clients must be aware that binge drinking may provoke an acute attack. Option 2: If the client is obese, weight loss should be encouraged because loss of excess body fat may normalize serum uric acid without pharmacological intervention. Weight loss will also decrease stress on weight-bearing joints. Option 3: Caution regarding severe, rapid weight loss should be given because secondary hyperuricemia may result. A restricted, very low calorie diet may precipitate an acute attack. Option 4: Fluid intake should exceed 3000 mL daily to prevent formation of uric acid kidney stones. Clients should avoid dehydration because it may precipitate an acute attack.

Dan, age 45, is obese and has type 2 diabetes. He has been having trouble getting his glycohemoglobin under control. He has heard that exenatide (Byetta) causes weight loss and wants to try it. What do you tell him? 1. "Let's adjust your oral antidiabetic agents instead." 2. "That's a myth. People usually change their eating habits when taking this, and that's what causes the weight loss." 3. "With type 2 diabetes, you never want to be on injectable insulin." 4. "Let's try it. Your glycohemoglobin will be lowered and you may lose weight."

"Let's try it. Your glycohemoglobin will be lowered and you may lose weight." Rationales Option 1: Adjusting the client's oral antidiabetic agents may not be as effective, but these drugs are less expensive. Option 2: Exenatide (Byetta) can cause weight loss in some individuals. Option 3: Glucagon-like peptide-1 (GLP-1) injectables like exenatide are not injectable insulins. Option 4: Unlike many oral antidiabetic agents, injectable exenatide (Byetta) can cause weight loss in some individuals. The active ingredient is a protein that encourages digestion and the production of insulin. Glucagon-like peptide-1 (GLP-1) injectables like exenatide and liraglutide (Victoza) may be used as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

What is the primary pathological irregularity associated with diabetes mellitus type 1? 1. Nonfunctioning beta cells. 2. Insulin resistance. 3. Overproducing beta cells. 4. Elevated free fatty acids in the plasma.

1. Nonfunctioning beta cells. Rationales Option 1: Beta cells in the pancreas secrete insulin. When they don't work, your body can't lower its blood sugar; this is the pathophysiology of diabetes mellitus type 1. Option 2: This is most commonly associated with diabetes mellitus type 2. Option 3: This is a beta cell reaction associated with hyperglycemia. Option 4: This is a product of hyperglycemia, not the cause of diabetes mellitus type 1.

Martin, age 62, has acute nontransient abdominal pain that grows steadily worse in the epigastric area and radiates straight through to the back. The pain has lasted for days. He is also complaining of nausea, vomiting, sweating, weakness, and pallor. Physical examination reveals abdominal tenderness and distention and a low-grade fever. What do you suspect? 1. Cholecystitis. 2. Acute pancreatitis. 3. Cirrhosis. 4. Cushing syndrome.

2. Acute pancreatitis. Rationales Option 1: The pain with cholecystitis is in the upper right quadrant and is intermittent, usually after a fatty meal. Option 2: Acute pancreatitis is an inflammation of the pancreas caused by the release of activated pancreatic enzymes into the surrounding parenchyma, with subsequent destruction of tissue, blood vessels, and supporting structures. Although pancreatitis may be acute or chronic, acute symptoms include continuous abdominal pain of several days' duration that increases in the epigastric area and radiates to the back, nausea, vomiting, sweating, weakness, pallor, abdominal tenderness, distention, and low-grade fever. Pancreatitis occurs primarily in middle-aged adults and slightly more often in women than in men. Option 3: The gastrointestinal (GI) manifestations of cirrhosis include parotid enlargement, esophageal or rectal varices, peptic ulcers, and gastritis. Option 4: The clinical manifestation of Cushing syndrome related to the gastrointestinal (GI) system is a peptic ulcer, which would result in intermittent pain related to meals.

Which of the following statements about metformin is untrue? 1. Metformin works by decreasing hepatic glucose production and increasing peripheral cell sensitivity to insulin. 2. Metformin can cause lactic acidosis. 3. Metformin is typically used in conjunction with other diabetes medications. 4. Metformin cannot be used in patients with significant renal impairment.

3. Metformin is typically used in conjunction with other diabetes medications. Rationales Option 1: This is metformin's mechanism of action. Option 2: Metformin has a black box warning due to this side effect associated with its use. Option 3: Metformin is first-line treatment for diabetes type 2 and can be used as monotherapy. Option 4: The glomerular filtration rate must be greater than 45 in order to use metformin.

Which of the following body mass index (BMI) values defines class 1 obesity? 1. 30. 2. 25. 3. 40. 4. 35.

30. Rationales Option 1: Class 1 obesity is defined as a BMI of 30 to less than 35. Option 2: Overweight is defined as a BMI of 25 to less than 30. Option 3: Class 3 obesity is defined as a BMI of 40 or higher. Option 4: Class 2 obesity is defined as a BMI of 35 to less than 40.

Which of the following statements about diabetes mellitus is untrue? 1. Diabetes mellitus is the most common etiology of renal failure in the United States. 2. Diabetes mellitus is the most common endocrine disorder in the United States. 3. Diabetes mellitus is characterized by impaired insulin secretion and insulin action. 4. Diabetes mellitus is curable.

4. Diabetes mellitus is curable. Rationales Option 1: This is true; it is also the most common etiology of acquired blindness. Option 2: This is true; it affects over 30 million people. Option 3: These are the 2 characterizations that apply to diabetes mellitus. Option 4: Diabetes mellitus is manageable with lifestyle modifications and medications but is not curable.

The process of aging results in: 1. An increase in liver weight and mass. 2. A decreased absorption of fat-soluble vitamins. 3. An increase in enzyme activity. 4. Constricted pancreatic ducts.

A decreased absorption of fat-soluble vitamins. Rationales Option 1: There is a decrease in the number and size of hepatic cells, leading to a decrease in liver weight and mass. Option 2: The process of aging results in a decreased absorption of fat-soluble vitamins. Option 3: There is a decrease in enzyme activity, which diminishes the liver's ability to detoxify drugs. This increases the risk of toxic levels of many medications in older adults. Option 4: There is calcification of the pancreatic vessels, and the ducts distend and dilate. These changes lead to a decrease in the production of lipase.

What is the medication of choice for an initial acute attack of gout? 1. A nonsteroidal anti-inflammatory drug (NSAID). 2. Colchicine. 3. A corticosteroid. 4. Allopurinol (Zyloprim).

A nonsteroidal anti-inflammatory drug (NSAID). Rationales Option 1: The medication of choice for an initial acute attack of gout is an NSAID. Indomethacin (Indocin) is the most commonly prescribed NSAID for this use. An initial dose of 50 to 75 mg is given, followed by 25 to 50 mg every 8 hours for 5 to 10 days. An alternative to indomethacin is naproxen (Naprosyn). The first dose of naproxen is 750 mg, followed by 250 mg every 8 hours for 5 to 10 days. Option 2: Colchicine is an effective medication to terminate an acute attack only if administered within 48 hours of the initial onset of symptoms. Unfortunately, the attack is usually not diagnosed within this time frame. Option 3: Corticosteroids can provide dramatic systematic relief but are contraindicated in septic conditions; therefore, they should not be administered before analysis of the synovial aspirate. Option 4: Allopurinol (Zyloprim) is used to decrease uric acid production. Although it is effective, it may take weeks to decrease the uric acid level and therefore is not the initial choice in an acute attack.

Martin, age 62, has acute nontransient abdominal pain that grows steadily worse in the epigastric area and radiates straight through to the back. The pain has lasted for days. He is also complaining of nausea, vomiting, sweating, weakness, and pallor. Physical examination reveals abdominal tenderness and distention and a low-grade fever. What do you suspect? 1. Cholecystitis. 2. Acute pancreatitis. 3. Cirrhosis. 4. Cushing syndrome.

Acute pancreatitis. Rationales Option 1: The pain with cholecystitis is in the upper right quadrant and is intermittent, usually after a fatty meal. Option 2: Acute pancreatitis is an inflammation of the pancreas caused by the release of activated pancreatic enzymes into the surrounding parenchyma, with subsequent destruction of tissue, blood vessels, and supporting structures. Although pancreatitis may be acute or chronic, acute symptoms include continuous abdominal pain of several days' duration that increases in the epigastric area and radiates to the back, nausea, vomiting, sweating, weakness, pallor, abdominal tenderness, distention, and low-grade fever. Pancreatitis occurs primarily in middle-aged adults and slightly more often in women than in men. Option 3: The gastrointestinal (GI) manifestations of cirrhosis include parotid enlargement, esophageal or rectal varices, peptic ulcers, and gastritis. Option 4: The clinical manifestation of Cushing syndrome related to the gastrointestinal (GI) system is a peptic ulcer, which would result in intermittent pain related to meals.

Morton has type 2 diabetes. His treatment, which includes diet, exercise, and 3 oral antidiabetic agents at maximum dose, is insufficient to achieve acceptable glycemic control. Your next course of action is to: 1. Give the patient a sliding scale with mealtime coverage with regular insulin. 2. Add a dosage of long-acting insulin at bedtime to the regimen. 3. Discontinue the oral antidiabetic agents and start insulin therapy with N and R. 4. Suggest treatment using an insulin pump.

Add a dosage of long-acting insulin at bedtime to the regimen. Rationales Option 1: As a first step, the addition of a bedtime injection of long-acting insulin such as insulin glargine (Lantus) or insulin detemir (Levemir) is recommended. Option 2: If treatment with diet, exercise, and oral antidiabetic agents is insufficient to achieve acceptable glycemic control in clients with type 2 diabetes, adding a dosage of insulin at bedtime to the regimen may be necessary. As a first step, the addition of a bedtime injection of long-acting insulin such as insulin glargine (Lantus) or insulin detemir (Levemir) is recommended. Intermediate-acting insulin such as neutral protamine Hagedorn (NPH) is no longer recommended because of the peaks in drug levels that can cause hypoglycemia. Initially, the dosage is 10 units at bedtime; then the dose is adjusted to reduce overnight hepatic glucose production and achieve a normal or near-normal fasting blood glucose concentration. If this regimen does not achieve the desired effect, the oral antidiabetic agents should be discontinued, and mealtime analogue rapid-acting insulin can be added to the largest meal. Most clients will eventually require 4 injections with the basal-bolus regimen. Option 3: As a first step, the addition of a bedtime injection of long-acting insulin such as insulin glargine (Lantus) or insulin detemir (Levemir) is recommended. Option 4: Insulin pumps are sometimes ordered for type 1 diabetes.

Joan has severe asthma and has been on high doses of oral corticosteroids for 2 years. She has been reading some home remedy books and stops all of her medications. What condition may she develop? 1. Myxedema crisis. 2. Diabetes insipidus. 3. Hypoparathyroidism. 4. Addisonian crisis.

Addisonian crisis. Rationales Option 1: With a myxedema crisis, there is the possibility of secondary hypothyroidism and associated hypopituitarism, so hydrocortisone should be administered until adrenal insufficiency has been ruled out. Option 2: Diabetes insipidus should not be affected by Joan's stopping her corticosteroid medication. Option 3: Hypoparathyroidism should not be affected by Joan's stopping her corticosteroid medication. Option 4: Addisonian crisis is a serious, life-threatening response to acute adrenal insufficiency and may be precipitated by abruptly stopping glucocorticoid medications. Other causes include major stressors, especially if the person has poorly controlled Addison disease, and hemorrhage into the adrenal glands from either septicemia or anticoagulant therapy. The primary problems in Addisonian crisis are severe hypotension, circulatory collapse, shock, and coma. Treatment involves rapid intravenous replacement of fluids and glucocorticoids.

Sadie, age 40, has just been given a diagnosis of Graves disease. She has recently lost 25 lb, has palpitations, is very irritable, feels very warm, and has a noticeable bulge on her neck. The most likely cause of her increased thyroid function is: 1. Hyperplasia of the thyroid. 2. An anterior pituitary tumor. 3. A thyroid carcinoma. 4. An autoimmune response.

An autoimmune response. Rationales Option 1: Hyperplasia of the thyroid results from hyperthyroidism; it does not cause it. Option 2: Although pituitary tumors can cause hyperthyroidism, they do not cause Graves disease. Option 3: Although thyroid carcinoma can cause hyperthyroidism, it does not cause Graves disease. Option 4: Graves disease is the result of an autoimmune response wherein antibodies are produced that act against the body's own organs and tissues. Thyroid-stimulating immunoglobulins are found in 95% of people with Graves disease and are evidence of this autoimmune process.

Betty, age 40, has had type 1 diabetes for 20 years and takes a combination of neutral protamine Hagedorn (NPH) and regular insulin every day. She comes to the office because she has developed a severe upper respiratory infection with chills, fever, and production of yellow sputum. Because of her acute infection, you know that Betty is likely to require: 1. A decrease in her daily insulin dosage. 2. An increase in her daily insulin dosage. 3. A high-calorie dietary intake and no insulin change. 4. A change in her insulin from NPH to insulin aspart (NovoLog).

An increase in her daily insulin dosage. Rationales Option 1: Betty is likely to require an increase in her daily insulin dosage. Option 2: For clients with diabetes requiring insulin, an increase in their daily insulin dosage is usually required in the presence of an acute infection. Betty should begin by increasing her regular insulin dose by just 2 units and then monitoring her blood sugar level. Option 3: Betty is likely to require an increase in her daily insulin dosage and no increase in dietary caloric intake. Option 4: At some point, a more physiologic insulin regimen (such as basal-bolus) might be considered.

When teaching Marcy how to use her new insulin pump, you tell her that she needs to monitor her blood glucose level: 1. At least once a day. 2. Only occasionally because glycemic levels are maintained very steadily. 3. At least 4 times a day. 4. On an as needed basis when she feels she needs to give herself an extra dose of insulin.

At least 4 times a day. Rationales Option 1: Marcy needs to monitor her blood glucose level at least 4 times a day because the only insulin used in the pump is rapid-acting. Option 2: Marcy needs to monitor her blood glucose level at least 4 times a day because the only insulin used in the pump is rapid-acting. Option 3: Clients using an insulin pump need to monitor their blood glucose levels at least 4 times a day. Clients can develop diabetic ketoacidosis in as little as 4 hours if there is mechanical failure of the pump because the only insulin used in the pump is rapid-acting. Option 4: Marcy needs to monitor her blood glucose level at least 4 times a day because the only insulin used in the pump is rapid-acting.

Sara, age 40, has diabetes and is now experiencing anhidrosis on the hands and feet, increased sweating on the face and trunk, dysphagia, anorexia, and heartburn. Which complication of diabetes do you suspect? 1. Macrocirculation changes. 2. Microcirculation changes. 3. Peripheral neuropathies. 4. Autonomic neuropathies.

Autonomic neuropathies. Rationales Option 1: Macrocirculation changes include an early onset of atherosclerosis and peripheral vascular insufficiency with claudication, ulcerations, and gangrene of the legs. Option 2: Microcirculation changes include diabetic retinopathy with retinal ischemia and loss of vision and diabetic nephropathy with hypertension, albuminuria, edema, and progressive renal failure. Option 3: Peripheral neuropathies include changes in sensation in the feet and hands; palsy of cranial nerve III with headache, eye pain, and inability to move the eye up, down, or to the middle; pain or loss of cutaneous sensation over the chest; and motor and sensory deficits in the anterior thigh and medial calf. Option 4: Autonomic neuropathies include anhidrosis (absence of sweating) on the hands and feet, increased sweating on the face and trunk, dysphagia, anorexia, heartburn, constricted pupils, nausea and vomiting, constipation, and diabetic diarrhea.

Which class of antihypertensive agents may be problematic for clients with diabetes? 1. Angiotensin-converting enzyme (ACE) inhibitors. 2. Calcium channel blockers. 3. Beta blockers. 4. Alpha blockers.

Beta blockers. Rationales Option 1: ACE inhibitors are the first choice for clients with diabetes who have hypertension because they slow the progression of diabetic nephropathy. Option 2: Calcium channel blockers provide pressure reduction without adverse effects on lipids and glucose control. Option 3: Beta blockers may be problematic in clients with diabetes because they block what is often the first sign of hypoglycemia—tachycardia. Many clients with diabetes have compelling indications (such as coronary artery disease) for the use of beta blockers. In these clients, the need for a beta blocker outweighs any risk that might occur. Decreasing the possibility of low blood sugar by selecting appropriate agents and adjusting dosages may be necessary. If a client with diabetes is on a beta blocker, it is important to explain that instead of tachycardia, he or she will notice other signs of hypoglycemia (such as sweating) that are not affected by beta blockers. Option 4: Alpha blockers provide smooth control and an improved lipid profile.

Marsha, age 24, is preparing for radioactive iodine therapy for her Graves disease. Which test must she undergo first? 1. Beta-human chorionic gonadotropin. 2. Basal metabolism rate. 3. Lithium level. 4. Serum calcium.

Beta-human chorionic gonadotropin. Rationales Option 1: Radioactive iodine therapy is the most commonly used treatment in the United States for Graves disease (hyperthyroidism); however, it is contraindicated during pregnancy. Therefore, for women, a pregnancy test (beta-human chorionic gonadotropin) needs to be performed before initiating therapy. Women of childbearing age should also be told to delay conception for a few months after radioactive iodine therapy. It is also contraindicated in women who are breastfeeding. Older adults or clients at risk of developing cardiac complications may be pretreated with antithyroid drugs (ATDs) before therapy to deplete the thyroid gland of stored hormone, thereby minimizing the risk of exacerbation of hyperthyroidism because of radioactive iodine (131I)-induced thyroiditis. Option 2: Marsha's basal metabolism rate will be affected by her Graves disease but has no bearing on her preparation for radioactive iodine therapy. Option 3: Lithium levels are usually not performed before radioactive iodine therapy. They may be done if lithium is being used to block the release of thyroid hormone from the thyroid gland in clients who are intolerant of antithyroid drugs (ATDs). Option 4: Although parathyroid hormone secretion is dependent on the serum calcium level, it is usually not necessary to obtain a serum calcium level measurement before radioactive iodine therapy.

Joy has gout. In teaching her about her disease, which food do you tell her is allowed in the diet? 1. Asparagus. 2. Beans. 3. Broccoli. 4. Mushrooms.

Broccoli. Rationales Option 1: Asparagus is high in purine. Option 2: Beans are high in purine. Option 3: Foods high in purine should be avoided by clients with gout. Broccoli is not high in purine. Foods high in purine include all meats and seafood, meat extracts and gravies, yeast and yeast extracts, beans, peas, lentils, oatmeal, spinach, asparagus, cauliflower, and mushrooms. Wine and alcohol in excessive amounts impair the ability of the kidneys to excrete uric acid and should be used in moderation. Option 4: Mushrooms are high in purine.

Mindy is scheduled to have an oral glucose tolerance test (OGTT). She is instructed to discontinue many of her medications for 3 days before the test. Which one is it safe to continue taking? 1. Vitamin C. 2. Aspirin. 3. Calcium. 4. Oral contraceptives.

Calcium. Rationales Option 1: Vitamin C should be discontinued for 3 days before the test. Option 2: Aspirin should be discontinued for 3 days before the test. Option 3: Calcium does not affect an OGTT. The following medications may interfere with the results of an OGTT and should be discontinued for 3 days before the test: vitamin C, aspirin, oral contraceptives, corticosteroids, synthetic estrogens, phenytoin (Dilantin), thiazide diuretics, and nicotinic acid. Option 4: Oral contraceptives should be discontinued for 3 days before the test. Be sure to recommend that clients use another form of birth control for this period of time.

Which of the following is not a risk factor for diabetes mellitus type 2? 1. Body mass index (BMI) greater than 25. 2. History of gestational diabetes. 3. Caucasian race. 4. History of polycystic ovary syndrome (PCOS).

Caucasian race. Rationales Option 1: A BMI greater than 25 is a risk factor for diabetes mellitus type 2. Option 2: A history of gestational diabetes is associated with the development of diabetes mellitus type 2 later in life. Option 3: Caucasians are less likely than African Americans, Asian Americans, Latin Americans, and Native Americans to develop diabetes mellitus type 2. Option 4: Women diagnosed with PCOS are more likely to develop diabetes mellitus type 2.

Jennifer has diabetes mellitus (DM) and is injecting 30 units of Novolin 70/30 with breakfast and 18 units at bedtime. She is complaining that she woke up once in the middle of the night with palpitations and sweating. Based on this information, what do you recommend? 1. Decreasing the am dose of 70/30. 2. Decreasing the pm dose of 70/30. 3. Eating a snack before going to bed. 4. Changing the time of the nighttime insulin injection.

Changing the time of the nighttime insulin injection. Rationales Option 1: Decreasing the morning dose of insulin will not affect her symptoms. Option 2: While decreasing her nighttime dose might have some effect, the Novolin 70/30 must be given 30 minutes prior to the evening meal, not at bedtime. Option 3: While eating a snack before bedtime might have some effect, the Novolin 70/30 must be given 30 minutes prior to the evening meal, not at bedtime. Option 4: The Novolin 70/30 should be given before a meal. Jennifer was not given appropriate instructions on the timing of the injections. She should inject her nighttime dose about 30 minutes prior to the evening meal. Injecting this type of insulin before bed will cause the blood sugar to drop because 30% of the insulin is regular insulin.

A patient presents to your primary care office with abnormal lab results. On physical exam, you tap the patient's facial nerve around the zygomatic arch, just anterior to the earlobe. This describes which of the following tests and is associated with which of the following lab abnormalities? 1. Trousseau sign, hypocalcemia. 2. Chvostek sign, hypocalcemia. 3. Chvostek sign, hypercalcemia. 4. Lachman test, hypercalcemia.

Chvostek sign, hypocalcemia. Rationales Option 1: Trousseau sign is positive in hypocalcemia but is described as spasms of the hand and wrist following inflation of a blood pressure cuff in the arm. Option 2: The test described in the question is positive in someone with hypocalcemia and is called Chvostek sign. Option 3: The test described in the question is consistent with Chvostek sign but is not consistent with hypercalcemia; it is consistent with hypocalcemia. Option 4: A Lachman test is positive in the presence of anterior cruciate ligament tears in the knee.

Mr. Reynolds is on the antithyroid drug (ATD) methimazole (Tapazole), so you make it a point to check his: 1. Glycated hemoglobin (HbA1c). 2. Complete blood count (CBC) and liver transaminases. 3. Uric acid level. 4. Total thyroxine (T4).

Complete blood count (CBC) and liver transaminases. Rationales Option 1: HbA1c is monitored in clients with diabetes. Option 2: ATDs can cause agranulocytosis and hepatic injury; therefore, CBC and liver studies should be done. Option 3: Uric acid is monitored in clients with gout. Option 4: Thyroid function tests are needed in patients taking ATDs; however, thyroid-stimulating hormone (TSH) and free T4 are preferred.

Which of the following would not be ordered on a regular basis to evaluate diabetic patients for end organ damage associated with diabetes? 1. Ophthalmology evaluation. 2. Lipid panel. 3. Urinalysis and basic metabolic panel (BMP). 4. Complete blood count (CBC).

Complete blood count (CBC). Rationales Option 1: The general recommendation for diabetic patients is to evaluate for diabetic retinopathy at diagnosis and at least every 2 years thereafter. Option 2: Hyperlipidemia is common in diabetes, and a lipid panel should be ordered annually. Option 3: A urinalysis and BMP should be ordered regularly for the evaluation of kidney damage associated with diabetes. Option 4: A CBC should be done in all patients at an annual physical, but diabetics don't typically have end organ damage that would be evident on a CBC.

Juanita, age 23, complains of palpitations that started a few weeks ago; they occur 2 to 4 times a day and last 5 to 10 minutes. She feels nervous and is having trouble sleeping. Her stools have been frequent (1-3 per day) and loose. She is taking levothyroxine 150 µg daily. Her labs indicate free thyroxine (T4) 2.28 and thyroid-stimulating hormone (TSH) 0.022. She has a history of Graves disease and had radioactive iodine (RAI) treatment a few months ago. She has been on thyroid replacement for 2 months. Based on these data, you decide to: 1. Increase the levothyroxine dosage. 2. Decrease the levothyroxine dosage. 3. Keep the dosage the same. 4. Start propranolol every 8 hours.

Decrease the levothyroxine dosage. Rationales Option 1: A lower dosage of levothyroxine will probably correct Juanita's symptoms. Option 2: It appears that she may be overcorrected. The usual dosage of thyroid replacement is 1.6 µg/kg/d. She could skip a dose and then resume at a lower dosage of 125 to 137 µg per day. In an older individual, the lower dose would be preferred because overcorrection can lead to atrial fibrillation. She should take the levothyroxine on an empty stomach with a full glass of water and wait 30 minutes before eating for maximum absorption. Option 3: A lower dosage of levothyroxine will probably correct Juanita's symptoms. Option 4: Propranolol, which may help palpitations in some patients, is not necessary here, as the correct dosage of levothyroxine will probably correct Juanita's symptoms.

A client with diabetes on a sulfonylurea and metformin with a glycated hemoglobin (HbA1c) of 6.5% is complaining of episodes of low blood sugar. Which of the following changes would be the most appropriate? 1. Decreasing the dosage of the metformin. 2. Discontinuing the metformin. 3. Increasing carbohydrate intake. 4. Decreasing the dosage of the sulfonylurea.

Decreasing the dosage of the sulfonylurea. Rationales Option 1: There is less risk of hypoglycemia with metformin than with sulfonylureas. Option 2: There is less risk of hypoglycemia with metformin than with sulfonylureas. Option 3: Increasing the carbohydrate intake is never a good choice in a patient with diabetes. Option 4: Metformin, dipeptidyl peptidase-4 (DPP4) inhibitors such as sitagliptin (Januvia), and incretin mimetics such as exenatide (Byetta) are gaining favor over sulfonylureas because the risk of hypoglycemia is less than with sulfonylureas.

You suspect that Sharon has hypoparathyroidism because, in addition to her other signs and symptoms, she has: 1. Elevated serum phosphate levels. 2. Elevated serum calcium levels. 3. Decreased neuromuscular activity. 4. Increased bone resorption, as implied by her bone density test.

Elevated serum phosphate levels. Rationales Option 1: Signs of hypoparathyroidism include elevated serum phosphate levels; decreased serum calcium levels; increased neuromuscular activity, which may progress to tetany; decreased bone resorption; hypocalciuria; and hypophosphatemia. Option 2: Signs of hypoparathyroidism include decreased serum calcium levels. Option 3: Signs of hypoparathyroidism include increased neuromuscular activity. Option 4: Signs of hypoparathyroidism include decreased bone resorption.

You suspect that Sharon has hypoparathyroidism because, in addition to her other signs and symptoms, she has: 1. Elevated serum phosphate levels. 2. Elevated serum calcium levels. 3. Decreased neuromuscular activity. 4. Increased bone resorption, as implied by her bone density test.

Elevated serum phosphate levels. Rationales Option 1: Signs of hypoparathyroidism include elevated serum phosphate levels; decreased serum calcium levels; increased neuromuscular activity, which may progress to tetany; decreased bone resorption; hypocalciuria; and hypophosphatemia. Option 2: Signs of hypoparathyroidism include decreased serum calcium levels. Option 3: Signs of hypoparathyroidism include increased neuromuscular activity. Option 4: Signs of hypoparathyroidism include decreased bone resorption.

The major risk factor for thyroid cancer is: 1. Inadequate iodine intake. 2. Presence of a goiter. 3. Exposure to radiation. 4. Smoking.

Exposure to radiation. Rationales Option 1: There is an increased incidence of thyroid cancer in areas where iodine deficiency is more common. Option 2: There is an increased incidence of thyroid cancer in areas where goiter is more common. Option 3: The major risk factor for thyroid cancer is exposure to radiation, usually from treatment to the head and neck. Until 1950, radiation treatments were given to children for an enlarged thymus, enlarged tonsils, and acne. Several million children were exposed in this manner. It may also occur in individuals who have had radiation therapy to the face or upper chest. Option 4: Cigarette smoking is a risk factor for bladder and lung cancer but not thyroid cancer.

The American Diabetes Association (ADA) recommends which of the following quarterly blood tests be performed on all clients with diabetes? 1. Thyroid-stimulating hormone (TSH). 2. Liver function studies. 3. Glycated hemoglobin. 4. Serum glucose.

Glycated hemoglobin. Rationales Option 1: The American Thyroid Association recommends measuring thyroid function in all adults beginning at age 35 and every 5 years thereafter. Option 2: Liver function studies should be done on an annual basis as part of a routine examination. Option 3: The ADA recommends that the glycated hemoglobin (HbA1c) test be performed quarterly because it reports the serum glucose concentration of the previous 3 months. HbA1c can now be used for diagnosis of diabetes (greater than 6.5%). The ADA also recommends an annual urine test to assess for urine protein, which might be an early sign of kidney damage. Option 4: Although a serum glucose test is an excellent test for clients with diabetes, it reports only the serum glucose of that day.

The most common cause of hyperthyroidism is: 1. Graves disease. 2. A toxic uninodular goiter. 3. Subacute thyroiditis. 4. A pituitary tumor.

Graves disease. Rationales Option 1: The most common cause of hyperthyroidism is an autoimmune condition known as Graves disease, which accounts for 90% of hyperthyroid conditions in young adults. Option 2: A toxic uninodular goiter is the second most common cause of hyperthyroidism. Option 3: Subacute thyroiditis is a less common cause of hyperthyroidism. Option 4: A pituitary tumor is a less common cause of hyperthyroidism.

Harriet, age 62, has type 1 diabetes that is well controlled by insulin. Recently, she has been having marital difficulties that have left her emotionally upset. As a result of this stress, it is possible that she will: 1. Have an insulin reaction more readily than usual. 2. Have an increased blood sugar level. 3. Need less daily insulin. 4. Need more carbohydrates.

Have an increased blood sugar level. Rationales Option 1: Harriet will not have an insulin reaction (such as hypoglycemia) more readily than usual. Option 2: Stress causes the adrenal glands to secrete more cortisol, which leads to gluconeogenesis and insulin antagonism, raising the blood sugar. It is possible, then, that Harriet will have an increased blood sugar level. She will not need less daily insulin or more carbohydrates and will not have an insulin reaction (such as hypoglycemia) more readily than usual. Harriet may, in fact, need to increase her insulin use. Option 3: She will not need less daily insulin; she may need to increase her insulin use. Option 4: She will not need more carbohydrates; it is possible she will have an increased blood sugar level.

Marie, age 50, has type 1 diabetes and checks her blood glucose level several times every day. Her blood glucose level ranges from 250 to 280 mg/dL in the morning and is usually about 140 at lunch, about 120 at dinner, and about 100 at bedtime. In the morning, she takes 30 units of neutral protamine Hagedorn (NPH) insulin and 4 units of regular insulin, and before dinner she takes 18 units of NPH insulin and 4 units of regular insulin. Although she has had her insulin dose adjusted several times in the past month, it has had no effect on her high morning blood glucose level. What is your next course of action? 1. Increase the evening NPH insulin dose by 2 more units. 2. Have her check her blood glucose level between 2 am and 4 am for the next several days. 3. Increase the morning regular insulin dose by 2 units. 4. Order a fasting blood sugar test.

Have her check her blood glucose level between 2 am and 4 am for the next several days. Rationales Option 1: If Marie's blood glucose level from 2 am to 4 am is greater than 70 mg/dL, the evening dose of NPH insulin should be increased and changed from before dinner to before bedtime. Option 2: Marie is experiencing the Somogyi phenomenon (rebound hyperglycemia). If her blood glucose level from 2 am to 4 am is greater than 70 mg/dL, the evening dose of NPH insulin should be increased and changed from before dinner to before bedtime. This should prevent most cases of nocturnal hypoglycemia, which results in morning hyperglycemia. Many providers prefer the longer acting insulins, such as insulin glargine (Lantus) and insulin detemir (Levemir), because they are mostly "peakless" and have less risk of hypoglycemia than NPH. Option 3: Marie's morning hyperglycemia is caused by her nocturnal hypoglycemia, so it is the evening dose that may need to be adjusted. Option 4: A fasting blood sugar test will not confirm the Somogyi phenomenon. The blood sugar level needs to be checked during the night to "catch" the Somogyi phenomenon.

A 35-year-old male presents to your office complaining of fatigue, weight loss, nausea, and abdominal pain. On physical exam, you notice he has orthostatic hypotension and hyperpigmented skin. You do a morning cortisol level, which is low. The plasma adrenocorticotropic hormone (ACTH) is elevated. How would you treat this patient? 1. Oral prednisone. 2. Hydrocortisone. 3. Androgen replacement. 4. Fludrocortisone.

Hydrocortisone. Rationales Option 1: This is reserved for patients that don't respond well to hydrocortisone. Option 2: Hydrocortisone is the treatment of choice for primary adrenal insufficiency (Addison disease). Option 3: This is supplemental in the treatment of primary adrenal insufficiency. Option 4: This is reserved for patients with electrolyte disturbances associated with primary adrenal insufficiency.

A patient presents to your primary care office complaining of polydipsia, polyuria, and polyphagia. Which of the following diagnoses would not be in your differential diagnosis? 1. Diabetes mellitus (DM). 2. Diabetes insipidus (DI). 3. Psychiatric disorders. 4. Hyperthyroidism.

Hyperthyroidism. Rationales Option 1: Polydipsia, polyuria, and polyphagia are common presenting complaints in DM. Option 2: Polydipsia, polyuria, and polyphagia are common presenting complaints in DI. Option 3: Many psychiatric disorders can have polydipsia, polyuria, and polyphagia as presenting symptoms. Option 4: Symptoms of hyperthyroidism could include polyphagia due to increased metabolism, but symptoms generally are weight loss, tachycardia, and other physical manifestations of increased metabolism.

When you inspect the integumentary system of clients with endocrine disorders, a finding of coarse hair may be an indicator of: 1. Addison disease. 2. Diabetes mellitus. 3. Cushing syndrome. 4. Hypothyroidism.

Hypothyroidism. Rationales Option 1: Indicators of Addison disease include hyperpigmentation. Option 2: Indicators of diabetes mellitus include hypopigmentation. Option 3: Indicators of Cushing syndrome include hirsutism, hyperpigmentation, purple striae over the abdomen, and bruising. Option 4: During inspection of the integumentary system of clients with endocrine disorders, a finding of coarse hair may be an indicator of hypothyroidism. Fine hair is seen in clients with hyperthyroidism; hirsutism with Cushing syndrome; hyperpigmentation with both Addison disease and Cushing syndrome; hypopigmentation with diabetes mellitus, hyperthyroidism, and hypothyroidism; and purple striae over the abdomen and bruising with Cushing syndrome.

Your client with diabetes asks you about insulin glargine (Lantus). You tell her that: 1. It may be administered subcutaneously at home or intravenously in the hospital if need be. 2. The onset of action is 15 minutes. 3. Insulin glargine (Lantus) stays in your system for 24 hours. 4. It can be mixed with any other insulin.

Insulin glargine (Lantus) stays in your system for 24 hours. Rationales Option 1: Insulin glargine (Lantus) must be administered subcutaneously, not intravenously. Regular insulin may be administered by the intravenous route. The newer insulin analogues, such as insulin aspart (NovoLog), are also approved for intravenous use. Option 2: Insulin glargine (Lantus) has an onset of action of just over 1 hour. Option 3: Insulin glargine (Lantus) has an onset of action of just over 1 hour and stays in the system for 24 hours. Option 4: Insulin glargine (Lantus) and insulin detemir (Levemir) may not be mixed with any other insulin.

Mark has type 1 diabetes and has mild hyperglycemia. What effect does physical activity (exercise) have on his blood glucose level? 1. It may cause it to vary a little. 2. It may decrease it. 3. It may elevate it. 4. It may fluctuate greatly either way.

It may decrease it. Rationales Option 1: For individuals without diabetes, the blood glucose level generally varies little during physical activity unless the activity is intense and of very long duration, such as marathon running. Option 2: Clients with insulin-dependent diabetes mellitus (IDDM)—ie, type 1 diabetes—who have mild hyperglycemia may experience a drop in their blood glucose level during physical activity, whereas those with marked hyperglycemia may experience a rise in their blood glucose level. Clients with IDDM should check their blood glucose level before exercising and refrain from exercising if their level is too high (greater than 300 mg/dL). Option 3: Clients with marked hyperglycemia may experience a rise in their blood glucose level during physical activity. Option 4: Since Mark has mild hyperglycemia, his blood glucose level may drop during physical activity.

A 55-year-old Asian male presents with a history of severe left great toe pain. He states he cannot even touch the toe with a sheet without it causing pain. He denies trauma but states he cannot ambulate without pain. He admits to drinking alcohol but not to excess. On physical exam, he has normal vital signs, and you note erythema of the great toe at the interphalangeal (IP) joint. Which of the following is the gold standard for diagnosis of this problem? 1. Joint aspiration with crystal analysis. 2. Serum uric acid level. 3. X-ray. 4. Diagnosis is made with physical exam only.

Joint aspiration with crystal analysis. Rationales Option 1: This is the gold standard diagnostic test for diagnosis of gout. Option 2: Hyperuricemia supports a diagnosis of gout but is not in itself diagnostic. Option 3: X-rays are not diagnostic of gout. Option 4: When you have a clinical suspicion of gout, you can treat the patient, but aspiration of the affected joint with crystal analysis is the gold standard for diagnosing gout.

Ben, a client with type 1 diabetes, is hospitalized with an admitting diagnosis of diabetic ketoacidosis (DKA). Which of the following signs and symptoms would be consistent with this condition? 1. Hypoglycemia and glycosuria. 2. Decreased respiratory rate with shallow respirations. 3. Polydipsia and an increased blood pH. 4. Ketonuria and polyuria.

Ketonuria and polyuria. Rationales Option 1: Hyperglycemia, not hypoglycemia, is a symptom of DKA. Option 2: Very deep, not shallow, respirations are a symptom of DKA. Option 3: A decreased, not increased, blood pH is a symptom of DKA. Option 4: Signs and symptoms of diabetic ketoacidosis include Kussmaul breathing (very de

A client with newly diagnosed diabetes who has a glycated hemoglobin (HbA1c) of 7.5 is started on therapeutic lifestyle changes (TLCs) and medical nutrition therapy (MNT). Which oral antidiabetic agent is recommended as monotherapy? 1. Glipizide (Glucotrol). 2. Sitagliptin (Januvia). 3. Exenatide (Byetta). 4. Metformin (Glucophage).

Metformin (Glucophage). Rationales Option 1: Insulin secretagogues such as sulfonylureas can cause hypoglycemia and are often added as a second, cost-effective choice. Option 2: The dipeptidyl peptidase-4 (DPP4) inhibitors such as sitagliptin (Januvia) increase insulin secretion, suppress glucagon secretion, and suppress hepatic glucose production and peripheral glucose uptake and metabolism. Option 3: An injectable agent, exenatide (Byetta), is an incretin mimetic that often induces weight loss. Both sitagliptin and exenatide have a lower risk of hypoglycemia, making them a good choice over a sulfonylurea as dual therapy. The cost of both of these newer agents may be prohibitive for many clients, and evidence for long-term reduction of morbidity and mortality is lacking. There is also a risk of pancreatitis with oral and injectable incretin-like drugs. Option 4: Because of its safety, efficacy, and cost, metformin is the cornerstone of monotherapy unless there is a contraindication, such as renal disease, hepatic disease, gastrointestinal intolerance, or risk of lactic acidosis. Metformin often has beneficial effects on components of metabolic syndrome, including mild to moderate weight loss, improvement of the lipid profile, and improved fibrinolysis. It improves the effectiveness of insulin in suppressing excess hepatic glucose production and increases insulin sensitivity in peripheral tissues. The risk of hypoglycemia with metformin is low. Gastrointestinal side effects can be diminished by starting at the lowest dose of 500 mg daily and gradually increasing as needed to a maximum dose of 2000 mg per day. Use of metformin with alcohol can increase the risk of lactic acidosis.

Jay has had diabetes for 10 years. He recently had a physical and was told he has some evidence of nephropathy. What is the first manifestation of this condition? 1. Microalbuminuria. 2. Development of Kimmelstiel-Wilson nodules. 3. Decreased serum urea nitrogen levels. 4. Decreased serum creatinine levels.

Microalbuminuria. Rationales Option 1: Microalbuminuria is the first symptom indicative of nephropathy in clients who have had diabetes for about 10 years (although some studies suggest 5 years). There is increased permeability of the capillaries, with resultant leakage of albumin into the glomerular filtrate, causing microalbuminuria. Option 2: The development of Kimmelstiel-Wilson nodules occurs in people with type 1 diabetes but does not necessarily precede microalbuminuria. Option 3: As renal function deteriorates, serum urea nitrogen levels increase. Option 4: As renal function deteriorates, serum creatinine levels increase.

Lynne has Cushing syndrome. You would expect her to have or develop: 1. Onychomycosis. 2. Generalized increased pigmentation of the skin. 3. Hair loss. 4. Excitability and nervousness.

Onychomycosis. Rationales Option 1: Cushing syndrome results in an excessive amount of adrenocorticotropic hormone, which stimulates the secretion of glucocorticoids, mineralocorticoids, and androgenic steroids from the adrenal cortex. In the presence of excessive cortisol, fungal infections of the skin, nails, and oral mucosa, such as onychomycosis and tinea versicolor, are common and skin wounds heal very slowly. Option 2: Addison disease, which is a deficiency in the secretion of adrenocortical hormones, usually results in increased pigmentation of the skin in its entirety. Option 3: Other symptoms of Cushing syndrome include excessive hair growth (not hair loss). Option 4: Other symptoms of Cushing syndrome include fatigue and weakness (not excitability and nervousness).

A low thyroid-stimulating hormone (TSH) can lead to: 1. Osteoporosis. 2. Weight gain. 3. Bradycardia. 4. Brittle hair.

Osteoporosis. Rationales Option 1: Hyperthyroidism presents with a suppressed TSH and elevated free thyroxine (T4). Manifestations include weight loss, tachycardia, diarrhea, anxiety, and warm, silky skin. The increased metabolic state of hyperthyroidism can cause cardiac dysrhythmias and osteoporosis. The clinical manifestations can also occur when there is excessive thyroid replacement. Option 2: Manifestations of hyperthyroidism include weight loss (not weight gain). Option 3: Manifestations of hyperthyroidism include tachycardia (not bradycardia). Option 4: Manifestations of hyperthyroidism include warm, silky skin (not brittle hair).

Which is the only curative treatment option for primary hyperparathyroidism (PHPT)? 1. Type II calcimimetic cinacalcet. 2. Hormone therapy. 3. Parathyroidectomy. 4. Bisphosphonates.

Parathyroidectomy. Rationales Option 1: The type II calcimimetic cinacalcet treats the underlying cause of PHPT by binding to the calcium-sensing receptor on the surface of the parathyroid glands, which increases the sensitivity to extracellular calcium, which then reduces the excess secretion of parathyroid hormone (PTH). It is used for the treatment of secondary hyperparathyroidism but not for PHPT. Option 2: Hormone therapy is not used by itself. Low doses of estrogen have been shown to reduce calcium, prevent bone loss, and improve bone density. Option 3: The only curative treatment option for PHPT is a parathyroidectomy. It is successful in 90% to 98% of cases. Option 4: Although the first generation of bisphosphonates was found to be ineffective for treatment of the skeletal manifestations of PHPT, the newer bisphosphonates, such as alendronate (Fosamax), increase bone density a little, but they do not affect parathyroid hormone (PTH) secretion and thus will not reduce serum calcium.

Jason, age 14, appears with tender discoid breast tissue enlargement (2-3 cm in diameter) beneath the areolae. Your next action would be to: 1. Perform watchful waiting for 1 year. 2. Order an ultrasound. 3. Obtain laboratory tests. 4. Refer Jason to an endocrinologist.

Perform watchful waiting for 1 year. Rationales Option 1: Pubertal gynecomastia is common and is characterized by tender discoid breast tissue enlargement of about 2 to 3 cm in diameter beneath the areolae. The swelling usually subsides spontaneously within a year, and watchful waiting along with reassurance is recommended for that time period. Option 2: Because this condition is fairly common, there is no need to order an ultrasound. Option 3: Because this condition is fairly common, there is no need to obtain laboratory tests. Option 4: Because this condition is fairly common, there is no need to refer Jason to an endocrinologist.

What is the most common cause of Cushing disease? 1. Pituitary adenoma. 2. Prednisone use. 3. Adrenal tumor. 4. Nonpituitary tumor.

Pituitary adenoma. Rationales Option 1: Pituitary adenomas are the cause of 70% of cases of Cushing disease; they secrete excessive adrenocorticotropic hormone (ACTH). Option 2: Exogenous glucocorticoids are the second most common cause of Cushing disease. Option 3: Adrenal tumors can cause Cushing disease but are responsible for only 30% of adrenocorticotropic hormone (ACTH)-independent cases. ACTH-independent Cushing disease is less common than ACTH-dependent Cushing disease. Option 4: Nonpituitary tumors that secrete adrenocorticotropic hormone (ACTH) are rare.

Sandra, age 28, has secondary obesity. Which of the following may have caused this? 1. Taking in more calories than are expended. 2. Polycystic ovary syndrome. 3. Antihypertensive medications. 4. A sedentary lifestyle.

Polycystic ovary syndrome. Rationales Option 1: Essential obesity is the most prevalent type of obesity and is the result of taking in more calories than are expended. This type of obesity results from the multiple interactions of genetic and environmental factors (cultural, metabolic, social, and psychological). Option 2: Secondary obesity is rare; possible causes include Cushing disease, polycystic ovary syndrome, hypothalamic disease, hypothyroidism, and insulinoma. Some medications associated with weight gain include glucocorticoids, tricyclic antidepressants, and phenothiazines. Option 3: Antihypertensive medications do not lead to obesity. Option 4: A sedentary lifestyle may lead to primary, not secondary, obesity.

Which of the following conditions is a common pathological cause of hirsutism? 1. Polycystic ovary syndrome. 2. Addison disease. 3. Hyperthyroidism. 4. Alopecia.

Polycystic ovary syndrome. Rationales Option 1: Ninety percent of people with polycystic ovary syndrome have associated hirsutism. Option 2: Addison disease is associated with hair loss. Option 3: Hyperthyroidism is associated with hair loss, not excessive hair growth. Option 4: Alopecia is the loss of hair on the body.

What is the most common cause of gynecomastia? 1. Puberty. 2. Drug use. 3. Testicular failure. 4. Malnutrition.

Puberty. Rationales Option 1: Puberty is the most common cause of gynecomastia; most of these cases are self-limiting. Option 2: Drug use is a less common cause of gynecomastia. Option 3: Testicular failure is a less common cause of gynecomastia. Option 4: Malnutrition is a less common cause of gynecomastia.

To reduce the incidence of flares, foods high in what amino acid need to be limited in the diets of patients with gout? 1. Purine. 2. Glutamine. 3. Phenylalanine. 4. Alanine.

Purine. Rationales Option 1: High-purine foods need to be avoided in order to reduce the risk of gout flares. High-purine foods include fish, red meat, and beans. Beer is also rich in purine. Option 2: Purine-rich foods need to be limited in order to reduce the risk of gout. Option 3: Purine-rich foods need to be limited in order to reduce the risk of gout. Option 4: Purine-rich foods need to be limited in order to reduce the risk of gout.

Which of the following would not confirm a diagnosis of diabetes? 1. Glycated hemoglobin (HbA1c) of 7.0. 2. Fasting glucose of 155. 3. Random glucose of 198. 4. Oral glucose tolerance test with a plasma glucose of 250.

Random glucose of 198. Rationales Option 1: An HbA1c greater than 6.5 is diagnostic of diabetes. Option 2: A fasting glucose greater than 126 is diagnostic of diabetes. Option 3: A random glucose greater than 200, with associated symptoms such as weight loss, polyuria, and polydipsia, is diagnostic of diabetes. Option 4: An oral glucose tolerance test with a plasma glucose greater than 200 is diagnostic of diabetes.

Jeffrey, age 17, has gynecomastia. You should also assess him for: 1. Obesity. 2. Endocrine abnormalities. 3. Testicular cancer. 4. Tuberculosis.

Testicular cancer. Rationales Option 1: While Jeffrey may be obese, which would probably accentuate his gynecomastia, it is the more serious problem of testicular cancer that needs to be addressed. Option 2: Gynecomastia can occur secondary to hyperthyroidism and other endocrine imbalances. Option 3: Gynecomastia may be the first sign of testicular cancer. It is also associated with breast, adrenal, pituitary, lung, and hepatic malignancies. Hypogonadism produces low testosterone levels in men with normal estrogen levels. Alteration in breast tissue responsiveness to hormonal activity can result in gynecomastia. Gynecomastia can occur secondary to cirrhosis, chronic obstructive lung disease, malnutrition, hyperthyroidism and other endocrine imbalances, tuberculosis, and chronic renal disease. Option 4: Gynecomastia can occur secondary to tuberculosis.

A client with hyperthyroidism presents with a complaint of a "gritty" feeling in her eyes. Over the past week, her visual acuity has diminished, and her ability to see colors has changed. She also has a feeling of pressure behind her eyes. The next step for the nurse practitioner is to: 1. Order a thyroid ultrasound. 2. Refer the client for immediate evaluation by an ophthalmologist. 3. Order a total thyroxine (T4). 4. Prescribe a beta-adrenergic blocker.

Refer the client for immediate evaluation by an ophthalmologist. Rationales Option 1: This course of action would prolong treatment and does not address the client's need to seek an immediate evaluation by an ophthalmologist. Option 2: The practitioner should refer the client for an immediate evaluation by an ophthalmologist. Clinically recognized Graves ophthalmopathy occurs in about 50% of cases of Graves disease. A client with Graves orbitopathy with these complaints is at risk of blindness if there is compression of the optic nerve. Additional symptoms include photophobia and diplopia. Autoantibodies present in Graves disease can cause increased muscle thickness in the eye, leading to edema and compression of the optic nerve. Fundal exam may reveal disk swelling. This is an emergency situation that may require hospitalization and treatment with prednisone to diminish the inflammation. Artificial tears are also helpful. In 75% of clients, the onset of Graves orbitopathy occurs within a year before or after the diagnosis of thyrotoxicosis but can sometimes precede or follow thyrotoxicosis by several years. Option 3: This course of action would prolong treatment and does not address the client's need to seek an immediate evaluation by an ophthalmologist. Option 4: This course of action would prolong treatment and does not address the client's need to seek an immediate evaluation by an ophthalmologist.

Jenny, age 46, has hypertension that has been controlled with hydrochlorothiazide 50 mg every day for the past 3 years. She is 5 ft 8 in tall and weighs 220 lb. Her fasting blood sugar (FBS) is 300 mg/dL, serum cholesterol level is 250 mg/dL, serum potassium level is 3.4 mEq, and she has 4+ glucosuria. Your next course of action would be to: 1. Discontinue her hydrochlorothiazide. 2. Order a glucose tolerance test (GTT). 3. Repeat her FBS and do a glycated hemoglobin (HbA1c). 4. Start insulin therapy.

Repeat her FBS and do a glycated hemoglobin (HbA1c). Rationales Option 1: Hyperglycemia can be an adverse reaction to high doses of hydrochlorothiazide, but the first action would be to repeat the FBS. If it is still high on a second reading, the diuretic should be reduced. Option 2: A GTT to confirm a diagnosis of diabetes is usually not needed. Diabetes is not usually diagnosed with a single high glucose reading unless symptoms of polyphagia, polydipsia, and polyuria are present. Option 3: Jenny's FBS should be repeated along with an HbA1c. An HbA1c of greater than 6.5% can now be used to diagnosis diabetes. Option 4: Insulin therapy would not be started until Jenny was given a positive diagnosis, and even then oral antidiabetic agents would be considered first.

Morris has had type 1 diabetes for 10 years. Several recent urinalysis reports have shown microalbuminuria. Your next step would be to: 1. Order a 24-hour urinalysis. 2. Start him on an angiotensin-converting enzyme (ACE) inhibitor. 3. Stress the importance of strict blood sugar control. 4. Send him to a dietitian because he obviously has not been following his diet.

Start him on an angiotensin-converting enzyme (ACE) inhibitor. Rationales Option 1: Ordering a 24-hour urinalysis will not give you any additional information. Option 2: Morris should be started on an ACE inhibitor such as enalapril (Vasotec). ACE inhibitors offer renoprotective effects by reducing intraglomerular pressure. They do this by inhibiting the renin-angiotensin system, which causes efferent dilation, and by improving glomerular permeability, which causes a reduction of glomerulosclerosis. ACE inhibitors also have this beneficial effect on clients with diabetes who are normotensive and even hypotensive. Diabetic nephropathy is the leading cause of end-stage renal disease in the United States. Monitoring for microalbuminuria is one method for identifying early nephropathy. Option 3: You do want to stress tight glycemic control, but Morris needs to be started on an angiotensin-converting enzyme (ACE) inhibitor now because he is already exhibiting microalbuminuria. Option 4: You may possibly send Morris to a dietitian, but he needs to be started on an angiotensin-converting enzyme (ACE) inhibitor now because he is already exhibiting microalbuminuria.

A 35-year-old female presents to your primary care office for review of her laboratory results. Her physical exam shows a blood pressure (BP) of 140/90, pulse (P) of 105, oxygen saturation of 97%, and temperature of 98.6°F. She has complaints of palpitations, weight loss, hair loss, and anxiety. Her labs are all normal except for a low thyroid-stimulating hormone (TSH) and an elevated thyroxine (T4). What would your next course of treatment be? 1. Start metoprolol and propylthiouracil (PTU). 2. Refer the patient to psychiatry for treatment of anorexia. 3. Refer the patient for radioactive iodine treatment. 4. Refer the patient for thyroidectomy.

Start metoprolol and propylthiouracil (PTU). Rationales Option 1: This is the presentation of a patient with hyperthyroidism. A beta blocker would help treat her tachycardia and hypertension and PTU would help normalize her thyroid hormones. Option 2: The patient's physical complaints of palpitations, weight loss, and hair loss can be present in anorexia as well as hyperthyroidism; however, thyroid hormone levels would likely be normal in anorexia. Option 3: Radioactive iodine treatment is reserved for patients that have failed medical management of hyperthyroidism. Option 4: Thyroidectomy is reserved for patients with compressive goiter, symptoms of which would include stridor and hoarseness.

Jeffrey, age 17, has gynecomastia. You should also assess him for: 1. Obesity. 2. Endocrine abnormalities. 3. Testicular cancer. 4. Tuberculosis.

Testicular cancer. Rationales Option 1: While Jeffrey may be obese, which would probably accentuate his gynecomastia, it is the more serious problem of testicular cancer that needs to be addressed. Option 2: Gynecomastia can occur secondary to hyperthyroidism and other endocrine imbalances. Option 3: Gynecomastia may be the first sign of testicular cancer. It is also associated with breast, adrenal, pituitary, lung, and hepatic malignancies. Hypogonadism produces low testosterone levels in men with normal estrogen levels. Alteration in breast tissue responsiveness to hormonal activity can result in gynecomastia. Gynecomastia can occur secondary to cirrhosis, chronic obstructive lung disease, malnutrition, hyperthyroidism and other endocrine imbalances, tuberculosis, and chronic renal disease. Option 4: Gynecomastia can occur secondary to tuberculosis.

Leah, age 70, has had diabetes for many years. When teaching her about foot care, you want to stress: 1. That her calluses will protect her from infection. 2. The need to assess the bottom of her feet carefully after walking barefoot. 3. That painless ulcerations might occur and feet should be examined with a mirror. 4. That mild pain is to be expected because of neuropathy.

That painless ulcerations might occur and feet should be examined with a mirror. Rationales Option 1: She should try to avoid the development of calluses because preparations used to remove them are very caustic. Option 2: Leah should not be walking barefoot because her sensation is probably decreased as a result of neuropathy. Option 3: Painless ulcerations are very common in clients with diabetes, and the only way to assess for them in the feet is for clients to use a mirror to examine the bottoms of their feet. Option 4: Sensation may be decreased as a result of neuropathy.

Eunice, age 32, has type 2 diabetes. She said she heard she should take an aspirin a day after she reaches menopause for its cardioprotective action. She does not have coronary artery disease, but her father does. How do you respond? 1. "You're right. Your hormones protect you against coronary artery disease until menopause; then you should start on aspirin therapy." 2. "The American Diabetes Association recommends that you start on low-dose aspirin therapy now." 3. "Aspirin therapy is recommended for all patients over age 55 as a precautionary measure." 4. "If you maintain good glycemic control, you don't need aspirin therapy."

The American Diabetes Association recommends that you start on low-dose aspirin therapy now." Rationales Option 1: The American Diabetes Association (ADA) recommends aspirin therapy as a primary prevention strategy in high-risk men and women with diabetes who have a family history of coronary heart disease. Option 2: The American Diabetes Association's position statement on aspirin therapy in patients with diabetes recommends low-dose (81 mg) aspirin use as a secondary prevention strategy in men and women with diabetes who have evidence of large-vessel disease, such as a history of myocardial infarction, vascular bypass procedures, and stroke, and have no contraindications for the use of aspirin. They also recommend aspirin therapy as a primary prevention strategy in high-risk men and women with type 1 or type 2 diabetes who have a family history of coronary heart disease and for individuals who smoke, are hypertensive or obese, or who have albuminuria, cholesterol levels greater than 200 mg/dL, low-density lipoprotein cholesterol levels greater than 130 mg/dL, high-density lipoprotein cholesterol levels less than 40 mg/dL, and triglyceride levels greater than 250 mg/dL. Option 3: Aspirin therapy is not recommended as a precautionary measure in all patients over age 55. Option 4: The American Diabetes Association (ADA) recommends aspirin therapy as a primary prevention strategy in high-risk men and women with diabetes who have a family history of coronary heart disease.

After an oral cholecystogram, Sam complains of burning on urination. This is because of: 1. A mild reaction to the contrast medium. 2. Biliary obstruction. 3. Contraction of the gallbladder. 4. The presence of dye in the urine.

The presence of dye in the urine. Rationales Option 1: A reaction to the contrast medium would produce symptoms such as urticaria, nausea, vomiting, and dyspnea. Option 2: An oral cholecystogram is done to assess for biliary obstruction. Option 3: To obtain a better reading during a cholecystogram, contraction of the gallbladder may be desirable and may be accomplished by having the client consume a high-fat meal during the procedure. Option 4: After an oral cholecystogram, some people experience burning on urination because of the presence of dye in the urine. This is helped by forcing fluids.

Which of the following statements about hypothyroidism is not true? 1. The most common worldwide cause of hypothyroidism is iodine deficiency. 2. The most common cause of autoimmune hypothyroidism is Hashimoto thyroiditis. 3. The rate of hypothyroidism decreases with age. 4. Lithium use is a risk factor for hypothyroidism.

The rate of hypothyroidism decreases with age. Rationales Option 1: This is true; hypothyroidism is less common in the United States due to access to iodinated salt. Option 2: This is true; Hashimoto thyroiditis is the most common cause of autoimmune hypothyroidism. Option 3: This is not true; hypothyroidism becomes more common as we age. Option 4: This is true; lithium and amiodarone are 2 drugs that can cause hypothyroidism.

Sigrid, age 48, appears with a 3-month history of heat intolerance, increased sweating, palpitations, tachycardia, nervousness, irritability, fatigue, and muscle weakness. Which test would you order first? 1. A blood chemistry panel. 2. Thyroid-stimulating hormone (TSH) level. 3. Liver function studies. 4. Electrocardiogram.

Thyroid-stimulating hormone (TSH) level. Rationales Option 1: If antithyroid drugs are used, a complete blood count (CBC) will need to be performed. Option 2: For a client with the symptoms experienced by Sigrid, a TSH level should be ordered first because the symptoms suggest hyperthyroidism. The TSH level is the best screening test for hyperthyroidism. Other laboratory and isotope tests for hyperthyroidism include a free triiodothyronine (T3) or thyroxine (T4) level, T3 resin uptake, and thyroid autoantibodies, including thyrotropin receptor antibody (TRAb). Tests not routinely performed but that may be helpful include radioactive iodine uptake and a thyroid scan (with iodine-123 [123I] or technetium-99m), which help to determine the etiology of the hyperthyroidism and assess the functional status of any palpable thyroid irregularities or nodules associated with a toxic goiter. Option 3: If antithyroid drugs are used, liver function tests will need to be performed. Option 4: An electrocardiogram may be ordered because of the palpitations, but once the thyroid is stabilized, the cardiac rhythm usually returns to normal.

An elderly client presents with atrial fibrillation. Which of the following lab tests is important in forming the diagnosis? 1. Complete blood count (CBC). 2. C-reactive protein (CRP). 3. Comprehensive metabolic panel (CMP). 4. Thyroid-stimulating hormone (TSH).

Thyroid-stimulating hormone (TSH). Rationales Option 1: A CBC is not specific. Option 2: A CRP will detect inflammation and the possibility of heart disease but not atrial fibrillation. Option 3: A CMP is not specific. Option 4: Atrial fibrillation is a common presentation in elderly clients with hyperthyroidism. If the TSH is suppressed, a free thyroxine (T4) and triiodothyronine (T3) should be drawn.

Mason, age 52, has diabetes mellitus (DM) and is overweight. You now find that he is hypertensive. How should you treat his hypertension? 1. You should treat it the same as in a client without diabetes. 2. Because insulin affects most antihypertensive drugs, you should try diet and exercise first before ordering any antihypertensives. 3. You should treat it very aggressively, preferably with angiotensin-converting enzyme (ACE) inhibitors. 4. You should initiate therapy when the blood pressure is 5 to 10 mm Hg more than the conventional therapeutic guidelines.

You should treat it very aggressively, preferably with angiotensin-converting enzyme (ACE) inhibitors. Rationales Option 1: Because hypertension is implicated in accelerating the microangiopathy of diabetes (especially retinopathy and nephropathy), according to the Eighth Joint National Committee (JNC 8) therapy should be initiated when the patient has a blood pressure at or above 140/90 mm Hg. Other organizations recommend the lower goal of 130/80 in clients with DM. Option 2: Owing to the beneficial effects of reducing albuminuria and glomerular pressure, angiotensin-converting enzyme (ACE) inhibitors are the drugs of choice in clients with DM with hypertension. Option 3: ACE inhibitors should be initiated in patients with diabetes and an elevated blood pressure and are recommended in normotensive patients with albuminuria. Option 4: Depending on the guidelines, therapy should be initiated when blood pressure reaches levels equal to or 10 mm Hg less than conventional therapeutic guidelines.