Endocrine Success
1. The nurse is teaching a community class to people with Type 2 diabetes mellitus. Which explanation would explain the development of Type 2 diabetes? 1. The islet cells in the pancreas stop producing insulin. 2. The client eats too many foods that are high in sugar. 3. The pituitary gland does not produce vasopressin. 4. The cells become resistant to the circulating insulin.
1. 1. This is the cause of Type 1 diabetes mellitus. 2. This may be a reason for obesity, which may lead to Type 2 diabetes, but eating too much sugar does not cause diabetes. 3. This is the explanation for diabetes insipidus, which should not be confused with diabetes mellitus. >>>4. Normally insulin binds to special receptors sites on the cell and initiates a series of reactions involved in metabolism. In Type 2 diabetes these reactions are diminished primarily as a result of obesity and aging.
71. The nurse is admitting a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which clinical manifestations should be reported to the health-care provider? 1. Serum sodium of 112 mEq/L and a headache. 2. Serum potassium of 5.0 mEq/L and a heightened awareness. 3. Serum calcium of 10 mg/dL and tented tissue turgor. 4. Serum magnesium of 1.2 mg/dL and large urinary output.
1. A serum sodium level of 112 mEq/L is dangerously low, and the client is at risk for seizures. A headache is a symptom of a low-sodium level.
The client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first? 1. Administer 50 % dextrose IVP. 2. Notify the HCP 3. Move the client to the ICU. 4. Check the serum glucose level
1. Administer 50 % dextrose IVP. Rationale: The nurse should assume the client is hypoglycemic and administer IVP dextrose, which will rouse the client immediately. If the collapse is the result of hyperglycemia, this additional dextrose will not further injure the client.
59. The nurse manager of a medical-surgical unit is asked to determine if the unit should adopt a new care delivery system. Which behavior is an example of an autocratic style of leadership? 1. Call a meeting and educate the staff on the new delivery system being used. 2. Organize a committee to investigate the various types of delivery systems. 3. Wait until another unit has implemented the new system and see if it works out. 4. Discuss with the nursing staff if a new delivery system should be adopted.
1. An autocratic style is one in which the person in charge makes the decision with- out consulting anyone else.
The home health nurse is completing the admission assessment for a 76-year-old client diagnosed with type 2 diabetes controlled with 70/30 insulin. Which intervention should be included in the plan of care? 1. Assess the client's ability to read small print. 2. Monitor the client's serum PT level. 3. Teach the client how to perform a hemoglobin A1C test daily. 4. Instruct the client to check the feet weekly.
1. Assess the client's ability to read small print. Rationale: Age-related visual changes and diabetic retinopathy could cause the client to have difficulty in reading and drawing up insulin dosage accurately.
51. The nurse is planning the care of a client diagnosed with Addison's disease. Which intervention should be included? 1. Administer steroid medications. 2. Place the client on fluid restriction. 3. Provide frequent stimulation. 4. Consult physical therapy for gait training.
1. Clients diagnosed with Addison's disease have adrenal gland hypofunction. The hormones normally produced by the gland must be replaced. Steroids and androgens are produced by the adrenal gland.
The patient is diagnosed with hypothyroidism. Which signs/symptoms should the nurse expect the patient to exhibit? 1. Complaints of extreme fatigue and hair loss. 2. Exophthalmos and complaints of nervousness. 3. Complaints of profuse sweating and flushed skin. 4. Tetany and complaints of stiffness of the hands.
1. Complaints of extreme fatigue and hair loss. (A decrease in thyroid hormone causes a decrease in metabolism, which leads to fatigue and hair loss.)
54. The nurse is performing discharge teaching for a client diagnosed with Cushing's disease. Which statement by the client demonstrates an understanding of the instructions? 1. "I will be sure to notify my health-care provider if I start to run a fever." 2. "Before I stop taking the prednisone, I will be taught how to taper it off." 3. "If I get weak and shaky, I need to eat some hard candy or drink some juice." 4. "It is fine if I continue to participate in weekend games of tackle football."
1. Cushing's syndrome/disease predisposes the client to develop infections as a result of the immunosuppressive nature of the disease.
The nurse identifies the patient problem "risk for imbalanced body temperature" for the patient diagnosed with hypothyroidism. Which intervention should be included in the plan of care? 1. Discourage the use of an electric blanket. 2. Assess the patient's temp every 2 hours. 3. Keep the room temp cool. 4. Space activities to promote rest.
1. Discourage the use of an electric blanket. (External heat sources, such as heating pads or electric or warming blankets, should be discouraged because they increase the risk of peripheral vasodilation and vascular collapse.
The nurse administered 28 units of Humulin N, an intermediate-acting insulin to a client diagnosed with type 1 diabetes at 1600. Which intervention should the nurse implement? 1. Ensure the client eats the bedtime snack. 2. Determine how much food the client ate at lunch. 3. Perform a glucometer reading at 0700. 4. Offer the client protein after administering insulin.
1. Ensure the client eats the bedtime snack. Rationale: Humulin N peaks in 6 to 8 hours, making the client at risk for hypoglycemia around midnight, which is why the client should receive a bedtime snack. This snack with prevent nighttime hypoglycemia.
The 68 year old patient diagnosed with hyperthyroidism is being treated with radioactive iodine therapy. Which interventions should the nurse discuss with the patient? 1. Explain it will take up to a month for the symptoms of hyperthyroidism to subside. 2. Teach the iodine therapy will have to be tapered slowly over 1 week. 3. Discuss the patient will have to be hospitalized during the radioactive therapy. 4. Inform the patient after therapy the patient will not have to take any medication.
1. Explain it will take up to a month for the symptoms of the hyperthyroidism to subside. (Radioactive iodine therapy is used to destroy the overactive thyroid cells. After treatment, the patient is followed closely for 3-4 weeks until the euthyroid state is reached.)
68. The nurse is planning the care of a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should be implemented? Select all that apply. 1. Restrict fluids per health-care provider order. 2. Assess level of consciousness every two (2) hours. 3. Provide an atmosphere of stimulation. 4. Monitor urine and serum osmolality. 5. Weigh the client every three (3) days.
1. Fluids are restricted to 500 to 600mL per 24 hours. 2. Orientation to person, place, and time should be assessed every two (2) hours or more often. 4. Urine and serum osmolality are moni- tored to determine fluid volume status.
The elderly client is admitted to the intensive care department diagnosed with severe HHNS. Which collaborative intervention should the nurse include in the plan of care? 1. Infuse 0.9% NS intravenously 2. Administer intermediate-acting insulin 3. Peroform blood glucometer checks daily 4. Monitor arterial blood gas results
1. Infuse 0.9% NS intravenously Rationale: The initial fluid replacement is 0.9% normal saline (an isotonic solution) intravenously, followed by a 0.45% saline. The rate depends on the client's fluid volume status and physical health, especially of the heart.
The client is admitted to the ICU diagnosed with DKA. Which interventions should the nurse implement? Select all that apply 1. Maintain adequate ventilation 2. Assess fluid volume status 3. Administer intravenous potassium 4. Check for urinary ketones 5. Monitor intake and output
1. Maintain adequate ventilation 2. Assess fluid volume status 3. Administer intravenous potassium 4. Check for urinary ketones 5. Monitor intake and output
The diabetic educator is teaching a class on diabetes type 1 and is discussing sick-day rules. Which interventions should the diabetes educator include in the discussion? Select all that apply. 1. Take diabetic medication even if unable to eat the client's normal diabetic diet. 2. If unable to eat, drink liquids equal to the client's normal caloric intake. 3. It is not necessary to notify the HCP if ketones are in the urine. 4. Test blood glucose levels and test urine ketones once a day and keep a record. 5. Call the HCP if glucose levels are higher than 180 mg/dL
1. Take diabetic medication even if unable to eat the client's normal diabetic diet. 2. If unable to eat, drink liquids equal to the client's normal caloric intake. 5. Call the HCP if glucose levels are higher than 180 mg/dL Rationales: 1. The most important issue to teach clients is to take insulin even if they are unable to eat. Glucose levels are increased with illness and stress. 2. The client should drink liquids such as regular cola or orange juice or eat regular gelatin, which provide enough glucose to prevent hypoglycemia when receiving insulin. 5. The HCP should be notified if the blood glucose level is this high. Regular insulin may need to be prescribed to keep the blood glucose level within acceptable range.
57. The client diagnosed with Addison's disease is admitted to the emergency department after a day at the lake. The client is lethargic, forgetful, and weak. Which intervention should the nurse implement? 1. Start an IV with an 18-gauge needle and infuse NS rapidly. 2. Have the client wait in the waiting room until a bed is available. 3. Obtain a permit for the client to receive a blood transfusion. 4. Collect urinalysis and blood samples for a CBC and calcium level.
1. The client was exposed to wind and sun at the lake during the hours prior to being admitted to the emergency depart- ment. This predisposes the client to dehydration and an addisonian crisis. Rapid IV fluid replacement is necessary.
The nurse is developing a care plan for the client diagnosed with type 1 diabetes. The nurse identifies the problem "high risk for hyperglycemia related to noncompliance with the medication regimen." Which statement is an appropriate short term goal for the client? 1. The client will have a blood glucose level between 90 and 140 mg/dL. 2. The client will demonstrate appropriate insulin injection technique 3. The nurse will monitor the client's blood glucose levels four times a day. 4. The client will maintain normal kidney function with 30 mL/hr urine output.
1. The client will have a blood glucose level between 90 and 140 mg/dL. Rationale: The short-term goal must address the response part of the nursing diagnosis, which is "high risk for hyperglycemia," and this blood glucose level is within acceptable ranges for a client who is noncompliant.
63. Which laboratory value should be monitored by the nurse for the client diagnosed with diabetes insipidus? 1. Serum sodium. 2. Serum calcium 3. Urine glucose. 4. Urine white blood cells.
1. The client will have an elevated sodium level as a result of low circulating blood volume. The fluid is being lost through the urine. Diabetes means "to pass through" in Greek, indicating polyuria, a symptom shared with diabetes mellitus. Diabetes in- sipidus is a totally separate disease process.
10. The nurse is admitting a client to rule out aldosteronism. Which assessment data should the nurse monitor that supports the client's diagnosis? 1. Temperature. 2. Pulse. 3. Respirations. 4. Blood pressure.
10. 1. The temperature is not affected by aldostero nism. 2. The pulse is not affected by this disorder. 3. The respirations are not affected by this disorder. >>>4. Blood pressure is affected by aldostero nism, with hypertension being the most prominent and universal sign of aldostero nism.
11. Which client history would be most significant in the development of symptoms for a client who has iatrogenic Cushing's disease? 1. Long-term use of anabolic steroids. 2. Extended use of inhaled steroids for asthma. 3. History of long-term glucocorticoid use. 4. Family history of increased cortisol production.
11. 1. Anabolic steroids are used by individuals to build muscle mass. Long-term use can lead to psychosis or heart attacks. 2. Inhaled steroids do not have systemic effects, which is described by iatrogenic Cushing's disease. >>>3. Iatrogenic Cushing's disease is Cushing's disease caused by medical treatment—in this case, by taking excessive steroids that result in the symptoms of moon face, buffalo hump, and other associated symp toms. 4. Family history does not cause iatrogenic prob lems.
12. The client is one (1) hour postoperative thyroidectomy. Which intervention should the nurse implement? 1. Check the posterior neck for bleeding. 2. Assess the client for the Chvostek's sign. 3. Monitor the client's serum calcium level. 4. Change the client's surgical dressing.
12. >>>1. The incision for a thyroidectomy allows the blood to drain dependently by gravity to the back of the client's neck. Therefore, the nurse should check this area for hemor rhaging, which is a possible complication of any surgery. 2. The Chvostek's sign indicates hypocalcemia, which is too early to assess for in this client. 3. Accidental removal or damage to the parathy roid glands will not decrease calcium level for at least 24 hours. 4. Surgeons prefer to change the surgical dress ing for the first time.
13. Which signs/symptoms would indicate that the client with hypothyroidism is not taking enough thyroid hormone? 1. Complaints of weight loss and fine tremors. 2. Complaints of excessive thirst and urination. 3. Complaints of constipation and being cold. 4. Complaints of delayed wound healing and belching.
13. 1. Weight loss and fine tremors would make the nurse suspect the client is taking too much thyroid hormone because these are symptoms of hyperthyroidism. 2. Excessive thirst and urination are symptoms of diabetes. >>>3. If the client were not taking enough thyroid hormone, then the client would exhibit symptoms of hypothyroidism such as constipation and being cold. 4. This would indicate Cushing's disease.
14. Which client problem is the nurse's priority concern for the client diagnosed with acute pancreatitis? 1. Impaired nutrition. 2. Skin integrity. 3. Anxiety. 4. Pain relief.
14. 1. The client would be NPO and can live without food for a number of days as long as he or she receives fluids. 2. The client is not on strict bed rest and can move about in the bed; therefore, skin integrity would not be a priority problem. In pancreati tis, the tissue damage is internal. 3. The client may be anxious, but psychosocial problems are not priority. >>>4. The client with pancreatitis is in excruciat ing pain because the enzymes are autodi gesting the pancreas; severe abdominal pain is the hallmark symptom of pancreatitis.
15. Which laboratory data indicate the client's pancreatitis is improving? 1. The amylase and lipase serum levels are decreased. 2. The white blood cell count (WBC) is decreased. 3. The conjugated and unconjugated bilirubin levels are decreased. 4. The blood urea nitrogen (BUN) serum level is decreased.
15.>>> 1. These laboratory data are used to diagnose and monitor pancreatitis because amylase and lipase are the enzymes produced by the pancreas. 2. Pancreatitis is not an infection of the pancreas resulting from bacteria; such an infection would cause an elevation in the WBCs. 3. Bilirubin is used to monitor liver problems. 4. BUN monitors kidney function.
16. The client diagnosed with acute pancreatitis has developed a pseudocyst that ruptures. Which procedure should the nurse anticipate the HCP ordering? 1. Paracentesis. 2. Chest tube insertion. 3. Lumbar puncture. 4. Biopsy of the pancreas.
16. 1. A paracentesis is used to remove fluid from the abdominal cavity. >>>2. The pancreas lies immediately below the diaphragm. When the cyst ruptures alka line substances in the abdomen cause fluid leaks at the esophageal diaphragmatic opening into the thorax. The fluid must be removed to prevent lung collapse. 3. Lumbar puncture is used to diagnose meningi tis. 4. Biopsies are performed to confirm a diagnosis; they are not used for treatment.
17. Which signs/symptoms would the nurse expect to find in the client diagnosed with an insulinoma? 1. Nervousness, jitteriness, and diaphoresis. 2. Flushed skin, dry mouth, and tented skin turgor. 3. Polyuria, polydipsia, and polyphagia. 4. Hypertension, tachycardia, and feeling hot.
17.>>> 1. Insulinoma is a tumor of the islet cells of the pancreas that produces insulin. The signs/symptoms of an insulinoma are signs of hypoglycemia. 2. These are signs/symptoms of hyperglycemia. 3. These are signs/symptoms of hyperglycemia. 4. These are signs/symptoms of hyperthyroidism.
18. Which risk factor would the nurse expect to find in the client diagnosed with pancre atic cancer? 1. Chewing tobacco. 2. Low-fat diet. 3. Chronic alcoholism. 4. Exposure to industrial chemicals.
18. 1. A history of smoking cigarettes would be perti nent, but a history of chewing tobacco is not. 2. A diet high in fat, not low in fat, would be a risk factor. 3. Chronic alcoholism is not a risk factor, but chronic pancreatitis is a risk factor. >>>4. Exposure to industrial chemicals or envi ronmental toxins is a risk factor for pancre atic cancer.
19. The nurse is aware that epinephrine and norepinephrine are secreted by which endocrine gland? 1. The pancreas. 2. The adrenal cortex. 3. The adrenal medulla. 4. The anterior pituitary gland.
19. 1. The endocrine function of the pancreas is the secretion of insulin and amylin. 2. The adrenal cortex secretes mineralocorti coids, glucocorticoids, and gonadotrophins. >>>3. The adrenal medulla secretes the catecho lamines epinephrine and norepinephrine. 4. The anterior pituitary gland secretes the growth hormone.
2. The nurse is teaching the client diagnosed with Type 2 diabetes mellitus about diet. Which diet selection indicates the client understands the teaching? 1. A submarine sandwich, potato chips, and diet cola. 2. Four (4) slices of a supreme thin-crust pizza and milk. 3. Smoked turkey sandwich, celery sticks, and unsweetened tea. 4. A roast beef sandwich, fried onion rings, and a cola.
2. 1. A submarine sandwich is on a bun-type bread and is usually 6 to 12 inches long and potato chips add fat and more carbohydrates to the meal. 2. Four (4) slices of pizza would contain excessive numbers of carbohydrates, plus cheese and meats, and whole milk is high in fat. >>>3. Turkey is a low-fat meat. A sandwich usu ally means normal slices of bread and the client needs at least 50% carbohydrates in each meal. Celery sticks are not counted as carbohydrates. 4. The roast beef sandwich is high in carbohy drates, fried onion rings are high in fat, and a regular coke is high in carbohydrates.
The nurse at a freestanding health care clinic is caring for a 56-year-old male client who is homeless and is a type 2 diabetic controlled with insulin. Which action is an example of client advocacy? 1. Ask the client if he has somewhere he can go and live. 2. Arrange for someone to give him insulin at a local homeless shelter. 3. Notify Adult Protective Services about the client's situation. 4. Ask the HCP to take the client off insulin because he is homeless.
2. Arrange for someone to give him insulin at a local homeless shelter. Rationale: Client advocacy focuses support on the client's autonomy. Even if the nurse disagrees with his living on the street, it is the client's right. Arranging for someone to give him his insulin provides for his needs and allows his choices.
61. The client diagnosed with a pituitary tumor developed syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should the nurse implement? 1. Assess for dehydration and monitor blood glucose levels. 2. Assess for nausea and vomiting and weigh daily. 3. Monitor potassium levels and encourage fluid intake. 4. Administer vasopressin IV and conduct a fluid deprivation test.
2. Early signs and symptoms are nausea and vomiting. The client has the syndrome of inappropriate secretion of antidiuretic (against allowing the body to urinate) hor- mone. In other words, the client is pro- ducing a hormone that will not allow the client to urinate.
The client with type 2 diabetes controlled with biguanide oral diabetic medication is scheduled for a computed tomography (CT) scan with contrast of the abdomen to evaluate pancreatic function. Which intervention should the nurse implement? 1. Provide a high-fat diet 24 hours prior to test. 2. Hold the biguanide medication for 48 hours prior to test. 3. Obtain an informed consent form for the test. 4. Administer pancreatic enzymes prior to the test.
2. Hold the biguanide medication for 48 hours prior to test. Rationale: Biguanide medication must be held for a tests with contrast medium because it increases the risk of lactic acidosis, which leads to renal problems.
Which signs/symptoms should make the nurse suspect the patient is experiencing a thyroid storm? 1. Obstipation and hypoactive bowel sounds. 2. Hyperpyrexia and extreme tachycardia. 3. Hypotension and bradycardia. 4. Decreased respiration and hypoxia.
2. Hyperpyrexia and extreme tachycardia. (Hyperpyrexia, high fever, and heart rate above 130 bpm are signs of thyroid storm, a severely exaggerate hyperthyroidism.)
64. The nurse is discharging a client diagnosed with diabetes insipidus. Which statement made by the client warrants further intervention? 1. "I will keep a list of my medications in my wallet and wear a Medic Alert bracelet." 2. "I should take my medication in the morning and leave it refrigerated at home." 3. "I should weigh myself every morning and record any weight gain." 4. "If I develop a tightness in my chest, I will call my health-care provider."
2. Medication for DI is usually taken every eight (8) to 12 hours, depending on the client. The client should keep the medica- tion close at hand.
The UAP on the medical floor tells the nurse the client diagnosed with DKA wants something else to eat for lunch. Which intervention should the nurse implement? 1. Instruct the UAP to get the client additional food. 2. Notify the dietitian about the client's request. 3. Request the HCP increase the client's caloric intake 4. Tell the UAP the client cannot have anything else
2. Notify the dietitian about the client's request. Rationale: The client will not be compliant with the diet if he or she is still hungry. Therefore, the nurse should request the dietitian to talk to the client to try to adjust the meals so the client will adhere to the diet.
Which electrolyte replacement should the nurse anticipate being ordered by the health-care provider in the client diagnosed with DKA who has just been admitted to the ICU? 1. Glucose 2. Potassium 3. Calcium 4. Sodium
2. Potassium Rationale: The client in DKA loses potassium from increased urinary output, acidosis, catabolic state, and vomiting. Replacement is essential for preventing cardiac dysrhythmias secondary to hypokalemia.
The patient is admitted to the ICU with myxedema coma. Which assessment data warrant immediate intervention by the nurse? 1. Serum blood glucose level of 74. 2. Pulse ox of 90%. 3. Telemetry reading showing sinus bradycardia. 4. The patient is lethargic and sleeps all the time.
2. Pulse ox of 90%. (A pulse ox of less than 93% is significant. A 90% pulse ox reading indicates a PaO2 of approx 60 on an arterial blood gas test; this is severe hypoxemia and requires immediate
52. The client is admitted to rule out Cushing's syndrome. Which laboratory tests should the nurse anticipate being ordered? 1. Plasma drug levels of quinidine, digoxin, and hydralazine. 2. Plasma levels of ACTH and cortisol. 3. A 24-hour urine for metanephrine and catecholamine. 4. Spot urine for creatinine and white blood cells (WBCs).
2. The adrenal gland secretes cortisol and the pituitary gland secretes adrenocorti- cotropic hormone (ACTH), a hormone used by the body to stimulate the produc- tion of cortisol.
Which assessment data indicate the client diagnosed with DKA is responding to the medical treatment? 1. The clinet has tented skin turgor and dry mucous membranes. 2. The client is alert and oriented to date, time, and place. 3. The client's ABG results are pH 7.29, PaCO2 44, HCO3 15. 4. The client's serum potassium level is 3.3 mEq/L
2. The client is alert and oriented to date, time, and place. Rationale: The client's level of consciousness can be altered because of dehydration and acidosis. If the client's sensorium is intact the client is getting better and responding to the medical treatment.
62. The nurse is admitting a client to the neurological intensive care unit who is postoperative transsphenoidal hypophysectomy. Which data warrant immediate intervention? 1. The client is alert to name but is unable to tell the nurse the location. 2. The client has an output of 2,500 mL since surgery and an intake of 1,000 mL. 3. The client's vital signs are T 97.6oF, P 88, R 20, and BP 130/80. 4. The client has a 3-cm amount of dark-red drainage on the turban dressing.
2. The output is more than double the intake in a short time. This client could be developing diabetes insipidus, a complica- tion of trauma to the head.
An 18-year-old female client, 5'4" tall, weighing 113 kg, comes to the clinic for a nonhealing wound on her lower leg, which she has had for two weeks. Which disease process should the nurse suspect the client has developed? 1. Type 1 diabetes 2. Type 2 diabetes 3. Gestational diabetes 4. Acanthosis nigricans
2. Type 2 diabetes Rationale: Type 2 diabetes is a disorder usually occurring around the age of 40, but it is now being detected in children and young adults as a result of obesity and sedentary lifestyles. Nonhealing wounds are a hallmark sign of type 2 diabetes.
53. The client has developed iatrogenic Cushing's disease. Which statement is the scientific rationale for the development of this diagnosis? 1. The client has an autoimmune problem causing the destruction of the adrenal cortex. 2. The client has been taking steroid medications for an extended period for another disease process. 3. The client has a pituitary gland tumor causing the adrenal glands to produce too much cortisol. 4. The client has developed an adrenal gland problem for which the health-care provider does not have an explanation.
2."Iatrogenic" means a problem has been caused by a medical treatment or procedure—in this case, treatment with steroids for another problem. Clients taking steroids over a period of time develop the clinical manifestations of Cushing's disease. Disease processes for which long-term steroids are prescribed include chronic obstructive pulmonary disease, cancer, and arthritis.
20. Which question should the nurse ask when assessing the client for an endocrine dysfunction? 1. "Have you noticed any pain in your legs when walking?" 2. "Have you had any unexplained weight loss?" 3. "Have you noticed any change in your bowel movements?" 4. "Have you experienced any joint pain or discomfort?"
20. 1. Leg pain when walking would indicate inter mittent claudication, which occurs with peri pheral vascular disease. >>>2. Weight loss with normal appetite may indi cate hyperthyroidism. 3. Changes in bowel movements may indicate colon cancer. 4. Joint pain would indicate a musculoskeletal or degenerative joint disease.
21. Which nursing instruction should the nurse discuss with the client who is receiving glucocorticoids for Addison's disease? 1. Discuss the importance of tapering medications when discontinuing medication. 2. Explain that the dose will need to be decreased during times of stress or infection. 3. Instruct the client to take medication on an empty stomach with a glass of water. 4. Encourage the client to wear a Medic Alert bracelet and carry a card in the wallet.
21. 1. The client will have to receive this medication the rest of his or her life so this should not be discussed with the client. 2. The dose will need to be increased, not de creased, in times of stress, infection, or dental work. 3. The medication should be taken with food to minimize its ulcerogenic effect. >>>4. If the client does not receive these medica tions consistently, death (from Addisonian crisis) can occur. The dose needs to be increased during times of physical and emotional stress. Because this medication masks infection and affects other medica tions, the client should wear a Medic Alert bracelet and carry a Medic Alert card to make sure all HCPs are aware of the client's condition and medications taken.
22. The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client? 1. Deep tendon reflexes. 2. Arterial blood gases. 3. Skin turgor. 4. Capillary refill time.
22. >>>1. If deep tendon reflexes are hypoactive or absent, the nurse should hold the magne sium and notify the health-care provider. 2. The arterial blood gases are not affected by the serum magnesium level. 3. The client's skin turgor will not be affected by the client's serum magnesium level. 4. The client's capillary refill time is not affected by the client's serum magnesium level.
23. Which endocrine disorder would the nurse assess for in the client who has a closed head injury with increased intracranial pressure? 1. Pheochromocytoma. 2. Diabetes insipidus. 3. Hashimoto's disease. 4. Gynecomastia.
23. 1. This is a tumor of the adrenal medulla. >>>2. Diabetes insipidus can be caused by brain tumors or infections, pituitary surgery, cerebrovascular accidents, or renal and organ failure, or it may be a complication of a closed head injury with increased intracranial pressure. Diabetes insipidus is a result of antidiuretic hormone (ADH) insufficiency. 3. Hashimoto's thyroiditis causes hypothyroidism. 4. Gynecomastia is abnormal enlargement of breast tissue in men
24. Which sign/symptom would the nurse expect in the client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)? 1. Excessive thirst. 2. Orthopnea. 3. Ascites. 4. Concentrated urine output.
24. 1. Excessive thirst is a symptom of diabetes insipidus, which is a deficiency of antidiuretic (ADH) hormone. 2. Orthopnea is difficulty breathing when in the supine position, which is not a sign/symptom of SIADH. 3. Ascites is excess fluid in the peritoneal cavity, which is not a sign/symptom of SIADH. >>>4. Excess antidiuretic hormone (ADH) causes SIADH, which causes increased water reabsorption and leads to increased fluid volume and scant, concentrated urine.
25. In which area should the nurse administer the regular insulin to ensure the best absorption of the medication? 1. A 2. B 3. C 4. D
25. 1. The anterior thigh is an appropriate area, but it does not provide the best absorption. >>>2. The abdominal area allows for the most rapid absorption of insulin and is the recommended site. 3. The deltoid is an appropriate area, but it does not provide the most rapid absorption. 4. The gluteal buttocks area is primarily the best area for intramuscular injections.
26. The client diagnosed with Type 1 diabetes mellitus received regular insulin two (2) hours ago. The client is complaining of being jittery and nervous. Which interventions should the nurse implement? List in order of priority. 1. Call the laboratory to confirm blood glucose level. 2. Administer a quick-acting carbohydrate. 3. Have the client eat a bologna sandwich. 4. Check the client's blood glucose level at the bedside. 5. Determine if the client has had anything to eat.
26. In order of performance: 5, 4, 1, 2, 3 5. Regular insulin peaks in 2-4 hours; there fore the nurse should suspect a hypo glycemic reaction if the client has not eaten anything. 4. The nurse should obtain the client's blood glucose level as soon as possible; this can be done with a glucometer at the bedside. 1. Most hospitals require a confirmatory serum blood glucose level. Do not wait for results to give food. 2. The antidote for insulin is glucose; there fore the nurse should give the client some type of quick-acting food source. 3. A source of long-acting carbohydrate and protein should be given to prevent a reoc currence of hypoglycemia.
3. The nurse is preparing to administer sliding scale insulin to a client with Type 2 diabetes. The Medication Administration Record is as follows: At 1130, the client has a blood glucometer level of 322. Which action should the nurse implement? 1. Notify the health-care provider. 2. Administer ten (10) units of regular insulin. 3. Administer five (5) units of Humalog insulin. 4. Administer ten (10) units of intermediate-acting insulin.
3. 1. The client's blood glucose level does not war rant notifying the HCP. >>>2. According to the sliding scale, any blood glucose reading between 301 and 450 re quires 10 units of regular insulin, which is fast-acting insulin. 3. Humalog is rapid-acting insulin, but the order reads regular insulin. 4. Intermediate-acting insulin, NPH or Humulin N, is not regular insulin.
56. The nurse writes a problem of "altered body image" for a 34-year-old client diagnosed with Cushing's disease. Which intervention should be implemented? 1. Monitor blood glucose levels prior to meals and at bedtime. 2. Perform a head-to-toe assessment on the client every shift. 3. Use therapeutic communication to allow the client to discuss feelings. 4. Assess bowel sounds and temperature every four (4) hours.
3. Allowing the client to ventilate feelings about the altered body image is the most appropriate intervention. The nurse cannot do anything to help the client's buffalo hump or moon face.
49. The nurse is admitting a client diagnosed with primary adrenal cortex insufficiency (Addison's disease). Which clinical manifestations should the nurse expect to assess? 1. Moon face, buffalo hump, and hyperglycemia. 2. Hirsutism, fever, and irritability. 3. Bronze pigmentation, hypotension, and anorexia. 4. Tachycardia, bulging eyes, and goiter.
3. Bronze pigmentation of the skin, particu- larly of the knuckles and other areas of skin creases, occurs in Addison's disease. Hypotension and anorexia also occur with Addison's disease.
The client diagnosed with type 2 diabetes is admitted to the intensive care unit with hyperosmolar hyperglycemic nonketonic syndrome (HHNS) coma. Which assessment data should the nurse expect the client to exhibit? 1. Kussmaul's respirations. 2. Diarrhea and epigastric pain. 3. Dry mucous membranes. 4. Ketone breath odor.
3. Dry mucous membranes. Rationale: Dry mucous membranes are a result of the hyperglycemia and occur with both HHNS and DKA.
The client received 10 units of Humulin R, a fast-acting insulin, at 0700. At 1030 the unlicensed assistive personnel (UAP) tells the nurse the client has a headache and is really acting "funny." Which intervention should the nurse implement first? 1. Instruct the UAP to obtain the blood glucose level. 2. Have the client drink eight ounces of orange juice. 3. Go to the client's room and assess the client for hypoglycemia. 4. Prepare to administer one ampule 50% dextrose intravenously.
3. Go to the client's room and assess the client for hypoglycemia. Rationale: Regular insulin peaks in 2 to 4 hours. Therefore, the nurse should think about the possibility the client is having a hypoglycemic reaction and should assess the client. The nurse should not delegate nursing tasks to a UAP if the client is unstable.
The emergency department nurse is caring for a client diagnosed with HHNS who has a blood glucose of 680 mg/dL. Which question should the nurse ask the client to determine the cause of this acute complication? 1. When is the last time you took your insulin? 2. When did you have your last meal? 3. Have you had some type of infection lately? 4. How long have you had diabetes?
3. Have you had some type of infection lately? Rationale: The most common precipitating factor is infection. The manifestation may be slow to appear, with onset ranging from 24 hours to 2 weeks.
66. The nurse is caring for clients on a medical floor. Which client should be assessed first? 1. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who has a weight gain of 1.5 pounds since yesterday. 2. The client diagnosed with a pituitary tumor who has developed diabetes insipidus (DI) and has an intake of 1,500 mL and an output of 1,600 mL in the last 8 hours. 3. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who is having muscle twitching. 4. The client diagnosed with diabetes insipidus (DI) who is complaining of feeling tired after having to get up at night.
3. Muscle twitching is a sign of early sodium imbalance. If an immediate intervention is not made, the client could begin to seize.
60. The client diagnosed with Cushing's disease has undergone a unilateral adrenalectomy. Which discharge instructions should the nurse discuss with the client? 1. Instruct the client to take the glucocorticoid and mineralocorticoid medications as prescribed. 2. Teach the client regarding sexual functioning and androgen replacement therapy. 3. Explain the signs and symptoms of infection and when to call the health-care provider. 4. Demonstrate turn, cough, and deep-breathing exercises the client should perform every two (2) hours.
3. Notifying the HCP if signs/symptoms of infection develop is an instruction given to all surgical clients on discharge.
Which medication order should the nurse question in the patient diagnosed with untreated hypothyroidism? 1. Thyroid Hormones 2. Oxygen 3. Sedatives 4. Laxatives
3. Sedatives (Untreated hypothyroidism is characterized by an increased susceptibility to the effects of the most hypnotic and sedative agents; therefore, the nurse should question this medication.)
The nurse is discussing ways to prevent DKA with the client diagnosed with type 1 diabetes. Which instruction is most important to discuss with the client? 1. Refer the client to the American Diabetes Association 2. Do not take any over-the-counter medications 3. Take the prescribed insulin even when unable to eat because of illness 4. Explain the need to get the annual flu and pneumonia vaccines
3. Take the prescribed insulin even when unable to eat because of illness Rationale: Illness increases blood glucose levels; therefore, the client must take insulin and consume high-carbohydrate foods such as regular Jell-O, regular popsicles, and orange juice.
The nurse is assessing the feet of a client with long-term type 2 diabetes. Which assessment data warrant immediate intervention by the nurse? 1. The client has crumbling toenails. 2. The client has athlete's foot. 3. The client has a necrotic big toe. 4. The client has thickened toenails.
3. The client has a necrotic big toe. Rationale: A necrotic big toe indicates "dead" tissue. The client does not feel pain, does not realize the injury, and does not seek treatment. Increased blood glucose levels decrease the oxygen supply needed to heal the wound and increase the risk for developing an infection.
65. The client is admitted to the medical unit with a diagnosis of rule-out diabetes insipidus (DI). Which instructions should the nurse teach regarding a fluid deprivation test? 1. The client will be asked to drink 100 mL of fluid as rapidly as possible and then will not be allowed fluid for 24 hours. 2. The client will be administered an injection of antidiuretic hormone (ADH), and urine output will be measured for four (4) to six (6) hours. 3. The client will have nothing by mouth (NPO), and vital signs and weights will be done hourly until the end of the test. 4. An IV will be started with normal saline, and the client will be asked to try to hold the urine in the bladder until a sonogram can be done.
3. The client is deprived of all fluids, and if the client has DI the urine production will not diminish. Vital signs and weights are taken every hour to determine circulatory status. If a marked decrease in weight or vital signs occurs, the test is immediately terminated.
The charge nurse is making clinet assignments in the ICU. Which client should be assigned to the most experienced nurse? 1. The client with type 2 diabetes who has a blood glucose level of 358 mg/dL. 2. The client diagnosed with type 1 diabetes who is experiencing hypoglycemia. 3. The client with DKA who has multifocal premature ventricular contractions 4. The client with HHNS who has a plasma osmolarity of 290 mOsm/L
3. The client with DKA who has multifocal premature ventricular contractions Rationale: Multifocal PVCs, which are secondary to hypokalemia and can occur in clients with DKA, are a potentially life-threatening emergency. This client needs an experienced nurse.
70. The unlicensed assistive personnel (UAP) complains to the nurse she has filled the water pitcher four (4) times during the shift for a client diagnosed with a closed head injury and the client has asked for the pitcher to be filled again. Which intervention should the nurse implement first? 1. Tell the UAP to fill the pitcher with ice cold water. 2. Instruct the UAP to start measuring the client's I&O. 3. Assess the client for polyuria and polydipsia. 4. Check the client's BUN and creatinine levels.
3. The first action should be to determine if the client is experiencing polyuria and polydipsia as a result of developing diabe- tes insipidus, a complication of the head trauma.
The nurse is preparing to administer the following meds. Which med should the nurse question administering? 1. The thyroid hormone to the patient who does not have a T3, T4 level. 2. Regular insulin to the patient with the blood glucose of 210. 3. The loop diuretic to the patient with a potassium level of 3.3mEq/L. 4. The cardiac glycoside to the patient who has a digoxin level of 1.4mg/dL.
3. The loop diuretic to the patient with a potassium level of 3.3mEq/L. (This potassium level is below normal, which is 3.5-5.5. Therefore, the nurse should question administering this med because loop diuretics can cause potassium loss in the urine.)
The patient diagnosed with hypothyroidism is prescribed the levothyroxine (Synthroid). Which assessment data indicate the medication has been effective? 1. The patient has a 3 pound weight gain. 2. The patient has a decrease pulse rate. 3. The patient's temp is WNL. 4. The patient denies any diaphoresis.
3. The patient's temp is WNL. (The patient with hypothyroidism frequently has subnormal temps, so a temp WNL indicates the med is effective.)
55. The charge nurse of an intensive care unit is making assignments for the night shift. Which client should be assigned to the most experienced intensive care nurse? 1. The client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation. 2. The client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, Pao2 88, Paco2 44, and HCO3 22. 3. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45, P 124, and R 28. 4. The client diagnosed with hyperthyroidism who has undergone a thyroidectomy two (2) days ago and has a negative Trousseau's sign.
3. This client has a low blood pressure and tachycardia. This client may be experi- encing an addisonian crisis, a potentially life-threatening condition. The most expe- rienced nurse should care for this client.
72. The male client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) secondary to cancer of the lung tells the nurse he wants to discontinue the fluid restriction and does not care if he dies. Which action by thenurse is an example of the ethical principle of autonomy? 1. Discuss the information the client told the nurse with the health-care provider and significant other. 2. Explain it is possible the client could have a seizure if he drank fluid beyond the restrictions. 3. Notify the health-care provider of the client's wishes and give the client fluids as desired. 4. Allow the client an extra drink of water and explain the nurse could get into trouble if the client tells the health-care provider.
3. This is an example of autonomy (the client has the right to decide for himself).
The client diagnosed with type 1 diabetes has a glycosylated hemoglobin (A1C) of 8.1%. Which interpretation should the nurse make based on this result? 1. This result is below normal levels. 2. This result is within acceptable levels. 3. This result is above recommended levels. 4. This result is dangerously high
3. This result is above recommended levels. Rationale: This result parallels a serum blood glucose level of approximately 180 to 200 mg/dL. An A1C is a blood test reflecting average blood glucose levels over a period of three months; clients with elevated blood glucose levels are at risk for developing long-term complications.
Which statement made by the patient makes the nurse suspect the patient is experiencing hyperthyroidism? 1. "I just don't seem to have any appetite anymore." 2. "I have a bowel movement about every 3-4 days." 3. "My skin is becoming really dry and coarse." 4. "I have noticed all my collars are getting tighter."
4. "I have noticed all my collars are getting tighter." (The thyroid gland enlarges as a result of the increased need for thyroid hormone production; an enlarged gland is called a goiter.)
The nurse is providing an in-service on thyroid disorders. One of the attendees asks the nurse, "Why don't people in the US get goiters as often?" Which statement by the nurse is the best response? 1. "It's because of one of the screening techniques used in the US." 2. "It's a genetic predisposition rare in North Americans." 3. "The meds available in the US decrease goiters." 4. "Iodized salt helps prevent the development of goiters in the US."
4. "Iodized salt helps prevent the development of goiters in the US." (Almost all of the iodine entering the body is retained in the thyroid gland. A deficiency in iodine will cause the thyroid gland to work hard and enlarge, which is called a goiter. Goiters are commonly seen in geographical regions having an iodine deficiency. Most table salt in the US has iodine added.)
4. When assessing a 31-year-old client who has a sustained release of growth hormone (GH), what signs/symptoms would the nurse expect to find? 1. An enlarged forehead, maxilla, and face. 2. A six (6)-inch increase in height of the client. 3. The client complaining of a severe headache. 4. A systolic blood pressure of 200 to 300 mm Hg.
4. >>>1. Acromegaly, enlarged extremities, occurs when sustained GH hypersecretion begins during adulthood, most commonly because of a pituitary tumor. 2. Gigantism occurs when GH hypersecretion begins before puberty when the closure of the epiphyseal plates occurs. Note the age of the client. 3. This is not a symptom of acromegaly. 4. This is a sign of pheochromocytoma.
50. The nurse is developing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (AIDS) who has developed an infection in the adrenal gland. Which client problem is highest priority? 1. Altered body image. 2. Activity intolerance. 3. Impaired coping. 4. Fluid volume deficit.
4. Fluid volume deficit (dehydration) can lead to circulatory impairment and hyperkalemia.
The client diagnosed with HHNS was admitted yesterday with a blood glucose level of 780 mg/dL. The client's blood glucose level is now 300 mg/dL. Which intervention should the nurse implement? 1. Increase the regular insulin IV drip 2. Check the client's urine for ketones 3. Provide the client with a therapeutic diabetic meal. 4. Notify the HCP to obtain an order to decrease insulin
4. Notify the HCP to obtain an order to decrease insulin Rationale: When the glucose level is decreased to around 300 mg/dL, the regular insulin infusion therapy is decreased. Subcutaneous insulin will be administered per sliding scale.
The nurse is discussing the importance of exercising with a client diagnosed with type 2 diabetes whose diabetes is well controlled with diet and exercise. Which information should the nurse include in the teaching about diabetes? 1. Eat a simple carbohydrate snack before exercising. 2. Carry peanut butter crackers when exercising. 3. Encourage the client to walk 20 minutes three times a week. 4. Perform warm-up and cool-down exercises.
4. Perform warm-up and cool-down exercises. Rationale: All clients who exercise should perform warmup and cool-down exercises to help prevent muscle strain and injury.
Which nursing intervention should be included in the plan of care for the patient diagnosed with hyperthyroidism? 1. Increase the amount of fiber in the diet. 2. Encourage a low-calorie, low-protein diet. 3. Decrease the patient's fluid intake to 1,000mL/day. 4. Provide 6 small, well-balanced meals a day.
4. Provide 6 small, well-balanced meals a day. (The patient with hyperthyroidism has an increased appetite; therefore, well-balanced meals served several times throughout the day will help with the patient's constant hunger.)
69. The nurse is caring for a client diagnosed with diabetes insipidus (DI). Which intervention should be implemented? 1. Administer sliding-scale insulin as ordered. 2. Restrict caffeinated beverages. 3. Check urine ketones if blood glucose is >250. 4. Assess tissue turgor every four (4) hours.
4. The client is excreting large amounts of dilute urine. If the client is unable to drink enough fluids, the client will quickly become dehydrated, so tissue turgor should be assessed frequently.
Which arterial blood gas results should the nurse expect in the client diagnosed with DKA? 1. pH 7.34, PaO2 99, PaCO2 48, HCO3 24. 2. pH 7.38, PaO2 95, PaCO2 40, HCO3 22. 3. pH 7.46, PaO2 85, PaCO2 30, HCO3 26. 4. pH 7.30, PaO2 90, PaCO2 30, HCO3 18.
4. pH 7.30, PaO2 90, PaCO2 30, HCO3 18. Rationale: This ABG indicates metabolic acidosis, which is expected in a client diagnosed with DKA. Normal ABGs are pH 7.35-7.45, PaO2 80-100, PaCO2 35-45, and HCO3 22-26.
5. Which sign/symptom would indicate to the nurse that the client is experiencing hyper parathyroidism? 1. A negative Trousseau's sign. 2. A positive Chvostek's sign. 3. Nocturnal muscle cramps. 4. Tented skin turgor.
5. 1. A carpopedal spasm occurs when the blood flow to the arm is decreased for three (3) minutes with a blood pressure cuff; a positive Trousseau's sign indicates hypocalcemia, which is a sign of hyperparathyroidism. >>>2. When a sharp tapping over the facial nerve elicits a spasm or twitching of the mouth, nose, or eyes, the client is hypocalcemic, which occurs in clients with hyperparathyroidism. This is known as a positive Chvostek's sign. 3. This would make the nurse suspect hypokalemia (low potassium). 4. This would make the nurse suspect dehydration that occurs with hypernatremia.
6. Which laboratory data would make the nurse suspect that the client with primary hyperparathyroidism is experiencing a complication? 1. A serum creatinine level of 2.8 mg/dL. 2. A calcium level of 9.2 mg/dL. 3. A serum triglyceride level of 130 mg/dL. 4. A sodium level of 135 mEq/L.
6. >>>1. A serum creatinine level of 2.8 mg/dL would indicate the client is in renal failure, which is a complication of hyperparathy roidism. The formation of stones in the kidneys related to the increased urinary excretion of calcium and phosphorus occurs in about 55% of clients with primary hyper parathyroidism and can lead to renal failure. 2. This calcium level is within the normal range of 9.0-10.5 mg/dL. 3. This serum triglyceride level is within the normal range of 40-150 mg/dL in males and 30-140 mg/dL for females. 4. This sodium level is within the normal range of 135-145 mEq/L.
7. Which information is a risk factor for developing pheochromocytoma? 1. A history of skin cancer. 2. A history of high blood pressure. 3. A family history of adrenal tumors. 4. A family history of migraine headaches.
7. 1. A history of skin cancer is not a risk factor for pheochromocytoma. 2. A history of high blood pressure is a sign of this disease, not a risk factor for developing it. >>>3. There is a high incidence of pheochromo cytomas in family members with adrenal tumors, and the von Hippel-Lindau gene is thought to be a primary cause. 4. Headaches are a symptom of this disease but not a risk factor for it.
8. The client is three (3) days postoperative unilateral adrenalectomy. Which discharge instructions should the nurse teach? 1. Discuss the need for lifelong steroid replacement. 2. Instruct the client on administration of vasopressin. 3. Teach the client to care for the suprapubic Foley catheter. 4. Tell the client to notify the HCP of a temperature greater than 101F.
8. 1. Because the client has one adrenal gland remaining, the client may not need lifelong supplemental steroids. 2. Vasopressin is administered to clients with diabetes insipidus. 3. The client does not have a suprapubic catheter during this procedure. >>>4. Any temperature greater than 101F would indicate an infection and the client will need to receive antibiotics, so the HCP must be notified.
9. Which psychosocial problem should be included in the plan of care for a female client diagnosed with Cushing's syndrome? 1. Altered glucose metabolism. 2. Body image disturbance. 3. Risk for suicide. 4. Impaired wound healing.
9. 1. This is not a psychosocial problem; it is a phys iological problem that does occur in clients diagnosed with Cushing's syndrome. >>>2. The client with Cushing's syndrome has body changes, including moon face, buffalo hump, truncal obesity, hirsutism, and striae and bruising, all of which affect the client's body image. 3. This is a psychosocial problem, but it is not one that occurs commonly in clients diagnosed with Cushing's syndrome. 4. This is not a psychosocial problem; it is a phys iological problem that does occur in clients diagnosed with Cushing's syndrome.
The client diagnosed with type 1 diabetes is receiving Humalog, a rapid-acting insulin, by sliding scale. The order reads blood glucose level: <150, zero units; 151 to 200, three units; 201 to 250, six units; >251, contact HCP. The unlicensed assistive personnel (UAP) reports to the nurse the client's glucometer reading is 189. How much insulin should the nurse administer to the client?
Three Rationale: The client's result is 189 which is between 151 and 200, so the nurse should administer 3 units of Humalog insulin subcutaneously.