Nclex Questions ENDOCRINE

the nurse has just supervised a newly diagnosed DM client self-inject NPH insulin at 7:30am the nurse reviews the time frame for peak insulin action with the client, telling the client to be especially watchful for a hypoglycemic reaction between which time frame?

1:30pm and 7:30pm Rationale: NPH is an intermediate-acting insulin. It begins to work in 1 to 2 hours (onset), peaks in 6 to 12 hours, and lasts for 18 to 24 hours (duration). Hypoglycemic reactions most likely occur during peak time, which is during this time.

a client with DM who takes insulin is seen in the health care clinic. the client tells the nurse that after giving the injection, the insulin seems to leak through the skin. the nurse can appropriately determine the problem by asking the client which?

Are you rotating the injection site Rationale: The client should be instructed that insulin injection sites should be rotated within one anatomical area before moving to another. This rotation process promotes uniform absorption of insulin and reduces the chances of irritation.

the nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's disease. which statement by the student indicates an accurate understanding of this disorder?

Cushing's disease is characterized by an oversecretion of glucocorticoid hormones Rationale: Cushing's syndrome is characterized by an oversecretion of glucocorticoid hormones. Addison's disease is characterized by the failure of the adrenal cortex to produce and secrete adrenocortical hormones.

the nurse is caring for a child with a diagnosis of DI. the nurse anticipates that the HCP will prescribe which medications?

Desmopressin acetate (DDAVP) Rationale: Desmopressin acetate is used to treat diabetes insipidus. Propylthiouracil is used to treat hyperthyroidism. One of the uses for furosemide is to treat syndrome of inappropriate antidiuretic hormone (SIADH). Methimazole is also used to treat hyperthyroidism.

a client is admitted to the hospital with a diagnosis of DKA. the initial serum glucose level was 950 mg/dL. IV insulin was started along with rehydration with IV normal saline. the serum glucose level is now 240 mg/dL. the nurse who is assisting in caring for the client obtains which item anticipating a HCP's prescription?

IV infusion containing 5% dextrose Rationale: During management of DKA, when the blood glucose level falls to 300 mg/dL, the infusion rate is reduced and 5% dextrose is added to maintain a blood glucose level of about 250 mg/dL, or until the client recovers from ketosis. NPH insulin is not used to treat DKA; 50% dextrose is used to treat hypoglycemia. Phenytoin is not a normal treatment measure in DKA.

which client is at risk for developing thyrotoxicosis?

a client with Graves' disease who is having surgery Rationale: Thyrotoxicosis is usually seen in clients with Graves' disease with the symptoms precipitated by a major stressor. This complication typically occurs during periods of severe physiological or psychological stress such as trauma, sepsis, the birth process, or major surgery. It also must be recognized as a potential complication following a thyroidectomy.

the nurse is caring for a client with Addison's disease. the nurse checks the client's vital signs and determines that the client has orthostatic hypotension. the nurse determines that this finding relates to which factor?

a decreased secretion of aldosterone Rationale: A decreased secretion of aldosterone results in a limited reabsorption of sodium and water; therefore, the client experiences fluid volume deficit. A decrease in cortisol, an increase in epinephrine, and an increase in androgen secretion do not result in orthostatic hypotension.

a client has just been admitted with a diagnosis of myxedema coma. if all of the following interventions were prescribed, the nurse should place highest priority on completing which action first?

administering oxygen Rationale: As part of maintaining a patent airway, oxygen would be administered first. This would be quickly followed by fluid replacement, keeping the client warm, monitoring vital signs, and administering thyroid hormones.

the nurse is reviewing the postoperative prescriptions for a client who had a transsphenoidal hypophysectomy. which HCP prescription noted on the record indicates the need for clarification?

apply a loose dressing if any clear drainage is noted Rationale: The nurse should observe for clear nasal drainage; constant swallowing; and a severe, persistent, generalized, or frontal headache. These signs and symptoms indicate cerebrospinal fluid leak into the sinuses. If clear drainage is noted following this procedure, the health care provider needs to be notified immediately.

the nurse is assisting in preparing a plan of care for the client with diabetes mellitus and plans to reinforce the client's understanding regarding the signs/symptoms of hypoglycemia. which signs/symptoms should the nurse review?

elevated pulse; shakiness; and cool, clammy skin rationale Symptoms of mild hypoglycemia include tachycardia; shakiness; and cool, clammy skin.

the nurse is monitoring a client who has been newly diagnosed with DM for signs of complications. which statement made by the client would indicate hyperglycemia and thus warrant HCP notification?

i am urinating a lot Rationale: The classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia.

the nurse is reinforcing discharge teaching with a client who has Cushing's syndrome. which statement by the client indicates that the instructions related to dietary management were understood?

i can eat foods that contain potassium rationale A diet that is low in calories, carbohydrates, and sodium but ample in protein and potassium content is encouraged for a client with Cushing's syndrome. Such a diet promotes weight loss, the reduction of edema and hypertension, the control of hypokalemia, and the rebuilding of wasted tissue.

the nurse is caring for a client with a diagnosis of hypoparathyroidism. the nurse reviews the client's laboratory results and notes that the calcium level is extremely low. the nurse should expect to note which sign/symptom on data collection.

positive trousseau's sign Rationale: Hypoparathyroidism is related to a lack of parathyroid hormone secretion or to a decreased effectiveness of parathyroid hormone on target tissues. The end result of this disorder is hypocalcemia. When serum calcium levels are critically low, the client may exhibit positive Chvostek's and Trousseau's signs, which indicate potential tetany

the nurse is caring for a client experiencing thyroid storm. which should be a priority concern for this client?

potential for cardiac disturbances rationale Clients in thyroid storm are experiencing a life-threatening event, which is associated with uncontrolled hyperthyroidism. It is characterized by high fever, severe tachycardia, delirium, dehydration, and extreme irritability. The signs and symptoms of the disorder develop quickly, and therefore, emergency measures must be taken to prevent death. These measures include maintaining hemodynamic status and patency of airway and providing adequate ventilation

a client is brought to the ED in an unresponsive state, an a diagnosis of hyperglycemic hyperosmolar state (HHS) is made. the nurse who is assisting with care for the client obtains which item in preparation for the treatment of this syndrome?

IV infusion of normal saline Rationale: The primary goal of treatment is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. IV fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. A nasal cannula for oxygen administration is not necessarily required to treat HHS.

the nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diabetic diet. which statement made by the client indicates the need for further teaching

i need to buy special dietetic foods rationale It is important to emphasize to the client and family that they are not eating a diabetic diet but rather following a balanced meal plan. Adherence to nutrition principles is an important component of diabetic management, and an individualized meal plan should be developed for the client. It is not necessary for the client to purchase special dietetic foods.

the nurse is caring for a postoperative adrenalectomy client. which finding does the nurse specifically monitor for in this client?

signs and symptoms of hypovolemia Rationale: Following adrenalectomy, the client is at risk for hypovolemia. Aldosterone, secreted by the adrenal cortex, plays a major role in fluid volume balance by retaining sodium and water.

a client with hypoparathyroidism has hypocalcemia. the nurse avoids giving the client the prescribed vitamin and calcium supplement with which liquid?

milk Rationale: Milk products are high in phosphates, which should be avoided by a client with hypoparathyroidism. Otherwise, calcium products are best absorbed with milk because the vitamin D in the milk promotes calcium absorption.

which measure should the nurse anticipate being included in the plan of care for a client who has been diagnosed with Graves' disease?

a restful environment Rationale: Because of the hypermetabolic state, the client with Graves' disease needs to be provided with an environment that is restful both physically and mentally. Six full meals a day that are well balanced and high in calories are required because of the accelerated metabolic rate. Foods that increase peristalsis (e.g., high-fiber foods) need to be avoided. These clients suffer from heat intolerance and require a cool environment.

the nurse is reviewing the prescriptions of a client diagnosed with diabetes mellitus who was admitted because of an infected foot ulcer. which HCP's prescription supports the treatment of this condition?

an increased amount of NPH daily insulin Rationale: Infection is a physiological stressor that can cause an increase in the level of epinephrine in the body. An increase in epinephrine causes an increase in blood glucose levels. When the client is under stress, such as when an infection exists, the client will require an increase in the dose of insulin to facilitate the transport of excess glucose into the cells. The client does not necessarily need an adjustment in the daily diet.

the nurse is assisting with preparing a teaching plan for the client with diabetes mellitus regarding proper foot care. which instruction should be included in the plan of care?

apply a moisturizing lotion to dry feet, but not between the toes rationale The client should use a moisturizing lotion on his or her feet, but should avoid applying the lotion between the toes. The client should also be instructed not to soak the feet and to avoid hot water to prevent burns. The client may cut the toenails straight across and even with the toe itself, but he or she should consult a podiatrist if the toenails are thick or hard to cut or if his or her vision is poor. The client should be instructed to wash the feet daily with a mild soap.

the nurse is collecting data on a client with hyperparathyroidism. which question would elicit accurate information about this condition from the client?

are you experiencing pain in your joints Rationale: Hyperparathyroidism causes an oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain, and pathological fractures.

the nurse caring for a client who has had a subtotal thyroidectomy reviews the plan of care and determines which problem is the priority for this client in the immediate postoperative period?

bleeding Rationale: Hemorrhage is one of the most severe complications that can occur following thyroidectomy. The nurse must frequently check the neck dressing for bleeding and monitor vital signs to detect early signs of hemorrhage, which could lead to shock. T3 and T4 do not regulate fluid volumes in the body. Infection is a concern for any postoperative client but is not the priority in the immediate postoperative period. Urinary retention can occur in postoperative clients as a result of medication and anesthesia but is not the priority from the options provided.

the wife of a client with DM who takes insulin calls the nurse in a HCP's office about her husband. she states that her husband is sleepy and that his skin is warm and flushed. she adds that his breathing is faster than normal and his pulse rate seems fast. which action should the nurse tell the wife to do first?

check his blood glucose level Rationale: The client's signs and symptoms are consistent with hyperglycemia. The wife should first obtain a blood glucose reading, which the nurse should then report to the health care provider.

the nurse working on an endocrine nursing unit understands that which correct concept is used in planning care?

clients who have hyperparathyroidism should be protected against falls Rationale: Hyperparathyroidism is a disease that involves excess secretion of parathyroid hormone (PTH). Elevation of PTH causes excess calcium to be removed from the bones. There is a decline in bone mass, which may cause a fracture if a fall occurs. Cushing's syndrome is likely to cause hypertension. Clients with hypothyroidism must be monitored for weight gain and clients with hyperthyroidism must be monitored for weight loss. Clients who have diabetes insipidus should be assessed for fluid deficit.

a client with DM demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. which intervention would be appropriate to decrease the clients anxiety?

convey empathy, trust, and respect toward the client Rationale: The appropriate intervention is to address the client's feelings related to the anxiety and to convey empathy, trust, and respect toward the client. Administering a sedative is not the most appropriate intervention. The nurse should not ignore the client's anxious feelings. A client will not relate to medical terms, particularly when anxiety exists.

the nurse is assisting in preparing a care plan for a client with diabetes mellitus who has hyperglycemia. the nurse should focus on which potential problem for this client?

dehydration rationale Increased blood glucose will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis that leads to dehydration. This fluid loss must be replaced when it becomes severe.

a client with a diagnosis of DKA is being treated in the ED. which finding should the nurse expect to note as confirming this diagnosis?

elevated blood glucose and low plasma bicarbonate Rationale: In DKA, the arterial pH is less than 7.35, plasma bicarbonate is less than 15 mEq/L, the blood glucose level is higher than 250 mg/dL, and ketones are present in the blood and urine. The client would be experiencing polyuria and Kussmaul's respirations. Coma may occur if DKA is not treated, but coma would not confirm the diagnosis.

a client has a blood glucose level drawn for suspected hyperglycemia. after interviewing the client, the nurse determines that the client ate lunch approximately 2 hours before the blood specimen was drawn. the lab reports the blood glucose to be 180 mg/dL and the nurse analyzes this result as indicative of which interpretation?

elevated from the normal value Rationale: Normal fasting blood glucose values range from 70 to 110 mg/dL. A 2-hour postprandial blood glucose level should be less than 140 mg/dL. In this situation, the blood glucose value was 180 mg/dL 2 hours after the client ate, which is an elevated value as compared with normal. Although the result may be reported to the health care provider, it is not a dangerously high one.

a nursing student notes in the medical record that a client with Cushing's syndrome is experiencing body image disturbances. the need for additional education regarding this problem is identified when the nursing student suggests which nursing intervention?

evaluating the client's understanding that the body changes need to be dealt with Rationale: Evaluating the client's understanding that the body changes that occur in this disorder need to be dealt with is an inappropriate nursing intervention. This option does not address the client's feelings.

after several diagnostic tests, a client is diagnosed with DI. the nurse understands that which signs/symptoms are indicative of this disorder?

excessive thirst and urine output Rationale: Excessive thirst (polydipsia) and excessive urine output (polyuria) are classic symptoms of diabetes insipidus. The urine is pale in color, and its specific gravity is low. Anorexia and weight loss occur. Diarrhea and blurred vision are not manifestations of the disorder. Weight gain and increased urine specific gravity are associated with syndrome of inappropriate antidiuretic hormone (SIADH).

a client scheduled for a thyroidectomy says to the nurse, "i am so scared to get cut in my neck." based on the client's statement, the nurse determines that the client is experiencing which problem?

fear about impending surgery Rationale: The client is having a difficult time coping with the scheduled surgery. The client is able to express fears but is scared.

the nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). which signs and symptoms noted in the client should alert the nurse to the presence of this crisis? select all that apply.

fever, sweating, agitation Rationale: Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body's tolerance to a chronic excess of thyroid hormones. The clinical signs/symptoms include fever greater than 100° F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur.

a comatose client with an admitting diagnosis of DKA has a blood glucose value of 368 mg/dL arterial pH of 7.2, arterial bicarbonate of 14 mEq/L, and is positive for serum ketones. the diagnosis is supported by which noted data?

fruity breath odor rationale Diabetic ketoacidotic coma is usually identified with a fruity breath odor, dry cracked mucous membranes, hypotension, and rapid deep breathing.

the nurse is caring for a client with pheochromocytoma. the client asks for a snack and something warm to drink. which is the appropriate choice for this client to meet nutritional needs?

graham crackers and warm milk Rationale: The client with pheochromocytoma needs to be provided with a diet that is high in vitamins, minerals, and calories. Of particular importance is that food or beverages that contain caffeine (e.g., chocolate, coffee, tea, and cola) are prohibited.

the nurse is preparing to reinforce instructions to a client with Addison's disease regarding diet therapy. the nurse understands that which diet should be prescribed for this client?

high-sodium, high-carbohydrate diet Rationale: A high-sodium, high-complex carbohydrate, and high-protein diet will be prescribed for the client with Addison's disease. To prevent excess fluid and sodium loss, the client is instructed to maintain an adequate salt intake of up to 8 g of sodium daily and to increase salt intake during hot weather; before strenuous exercise; and in response to fever, vomiting, or diarrhea.

which signs/symptoms should the nurse expect to note when collecting data on a client with Addison's disease?

hypotension and vomiting rationale Common manifestations of Addison's disease include postural hypotension from fluid loss, syncope, muscle weakness, anorexia, nausea, vomiting, abdominal cramps, weight loss, depression, and irritability. The manifestations in the remaining options are not associated with Addison's disease.

the nurse is monitoring a client who has been newly diagnosed with diabetes mellitus for signs of complications. which statement made by the client would indicate hyperglycemia and thus warrant HCP notification?

i am urinating a lot rationale The classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia.

a client with type 1 DM takes NPH insulin every morning and checks the blood glucose level four times per day. the client tells the nurse that yesterday the late afternoon blood glucose was 60 mg/dL and that she "felt funny" which statement by the client indicates an understanding of this occurrence?

i forgot to take my usual mid-afternoon snack yesterday Rationale: Hypoglycemia is a blood glucose level of 60 mg/dL or less. The causes are multiple, but in this case, omitting the afternoon snack is the cause. Fatigue and self-adjustment of dose are incorrect options. Recommended blood glucose testing for the client with type 1 diabetes mellitus is at least four times a day.

the nurse is caring for a postoperative parathyroidectomy client. which would require the nurse's immediate attention?

laryngeal stridor Rationale: During the postoperative period, the nurse carefully observes the client for signs of hemorrhage, which causes swelling and the compression of adjacent tissue. Laryngeal stridor is a harsh, high-pitched sound heard on inspiration and expiration that is caused by the compression of the trachea and that leads to respiratory distress. It is an acute emergency situation that requires immediate attention to avoid the complete obstruction of the airway.

the nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. which statement by the client indicates a need for further teaching? select all that apply.

i need to limit playing football to only the weekends // i should exercise in the evenings to encourage a good sleep pattern Rationale: The client should be instructed to avoid high-impact activity or contact sports such as football. Exercising late in the evening may interfere with restful sleep. The client with hyperparathyroidism should pace activities throughout the day and plan for periods of uninterrupted rest. The client should plan for at least 30 minutes of walking each day to support calcium movement into the bones. The client should be instructed to use energy level as a guide to activity.

the nurse is assigned to care for a client at home who has a diagnosis of type 1 DM. when the nurse arrives to care for the client, the client tells the nurse that she has been vomiting and has diarrhea. which additional statement by the client indicates a need for further teaching?

i need to stop my insulin Rationale: When a client with diabetes is unable to eat normally because of illness, the client should still take the prescribed insulin or oral medication. Additional fluids should be consumed and a call placed to the health care provider. The client should monitor the blood glucose levels every 4 to 6 hours.

a client with type 1 DM calls the nurse to report recurrent episodes of hypoglycemia. which statement by the client indicates a correct understanding of Humulin N insulin and exercise?

i should not exercise in the late afternoon Rationale: A hypoglycemic reaction may occur in response to increased exercise. Clients should avoid exercise during the peak time of insulin. Humulin N insulin peaks at 12 to 14 hours; therefore, late-afternoon exercise would occur during the peak of the medication.

the nurse is instructing a client with Addison's disease about a newly prescribed medication fludrocortisone acetate (Florinef). which statement by the client indicates a need for further teaching?

i will be glad to gain weight Rationale: The client should notify the health care provider of weight gain. The client should take oral drugs with food or milk. The client should wear a Medic-Alert bracelet. Fludrocortisone acetate (Florinef) should not be stopped abruptly but should be tapered down

when the nurse is reinforcing instructions to a client who has been newly diagnosed with type 1 diabetes mellitus, which statement by the client would indicate that teaching has been effective?

i will notify my HCP if my blood glucose level is consistently greater than 250 mg/dL rationale During illness, the client should monitor the blood glucose level, and he or she should notify the health care provider (HCP) if the level is greater than 250 mg/dL. Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the HCP's advice.

the nurse is providing instructions to a client newly diagnosed with diabetes mellitus. the nurse gives the client a list of the signs of hyperglycemia. which specific signs of this complication should be included on the list?

increased thirst rationale The classic signs of hyperglycemia include polydipsia, polyuria, and polyphagia. Profuse sweating and shakiness would be noted in a hypoglycemic condition.

a client with Cushing's disease is being admitted to the hospital after a stab would to the abdomen. the nurse plans care and places highest priority on which potential problem?

infection Rationale: The client with a stab wound has a break in the body's first line of defense against infection. The client with Cushing's disease is at great risk for infection because of excess cortisol secretion and subsequent impaired antibody function and decreased proliferation of lymphocytes. The client may also have a potential for the problems listed in the other options, but these are not the highest priority at this time.

the nurse is collecting data on a client admitted to the hospital with a diagnosis of myxedema. which data collection technique would provide data necessary to support the admitting diagnosis?

inspection of facial features Rationale: Inspection of facial features will reveal the characteristic coarse features, presence of edema around the eyes and face, and a blank expression that are characteristic of myxedema. The techniques in the remaining options will not reveal any data that would support the diagnosis of myxedema.

the nurse should expect to note which interventions in the plan of care for a client with hypothyroidism? select all that apply.

instruct the client about thyroid replacement therapy // encourage the client to consume fluids and high-fiber foods in the diet // instruct the client to contact the HCP if episodes of chest pain occur Rationale: The clinical manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormone. Interventions are aimed at replacement of the hormones and providing measures to support the signs and symptoms related to a decreased metabolism. The nurse encourages the client to consume a well-balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to prevent constipation. The client often has cold intolerance and requires a warm environment. The client would notify the health care provider if chest pain occurs because it could be an indication of overreplacement of thyroid hormone. Iodine preparations are used to treat hyperthyroidism. These medications decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone.

the nurse is reinforcing dietary instructions to a client newly diagnosed with DM. the nurse accurately instructs the client with which statement?

it is best to eat meals at approximately the same time each day Rationale: Mealtimes must be approximately the same time each day to maintain a stable blood glucose level. The client should not be instructed that mealtimes are varied, depending on blood glucose levels or insulin administration. Mealtimes should not be adjusted based on blood glucose levels or snacks.

a client with myxedema has changes in intellectual function such as impaired memory, decreased attention span and lethargy. the client's husband is upset and shares his concerns with the nurse. which statement by the nurse is helpful to the client's husband?

it seems that you are concerned about your wife's condition, but the symptoms may improve with continued therapy Rationale: Using therapeutic communication techniques, the nurse acknowledges the husband's concerns and conveys that the client's symptoms are common with myxedema. With thyroid hormone therapy, these symptoms should decrease, and cognitive function often returns to normal. Option 1 is not appropriate and offers false reassurance. Option 2 is pessimistic and untrue.

the nurse is reinforcing instructions with a client with diabetes mellitus who is recovering from DKA regarding measures to prevent a recurrence. which instruction is important for the nurse to emphasize?

monitor blood glucose levels frequently rationale Client education after DKA should emphasize the need for home glucose monitoring four to five times per day. It is also important to instruct the client to notify the health care provider when illness occurs. The presence of urinary ketones indicates that DKA has already occurred. The client should eat well-balanced meals with snacks, as prescribed.

the nurse reviews a plan of care for a postoperative client following a thyroidectomy and notes that the client is at risk for breathing difficulty. which nursing intervention should the nurse include in the plan of care?

monitor neck circumference frequently Rationale: Following a thyroidectomy, the client should be placed in an upright position to facilitate air exchange. The nurse should assist the client with deep breathing exercises, but coughing is minimized to prevent tissue damage and stress to the incision. A pressure dressing is not placed on the operative site because it could affect breathing. The nurse should monitor the dressing closely and should loosen the dressing if necessary. Neck circumference is monitored at least every 4 hours to assess for postoperative edema.

which nursing action would be appropriate to implement when a client has a diagnosis of pheochromocytoma?

monitor the client's blood pressure Rationale: Hypertension is the major symptom that is associated with pheochromocytoma. The blood pressure status is monitored by taking the client's blood pressure. Glycosuria, weight loss, and diaphoresis are also signs/symptoms of pheochromocytoma, but hypertension is the major symptom.

the nurse notes in the medical record that a client with Cushing's syndrome is experiencing fluid overload. which intervention should be included in the plan of care? select all that apply.

monitoring daily weight // monitoring intake and output // maintaining a low-sodium diet // monitoring extremities for edema Rationale: The client with Cushing's syndrome experiencing fluid overload should be maintained on a high-potassium and low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water. Monitoring weight, intake, output, and extremities for edema are all appropriate interventions for such a nursing diagnosis.

the nurse is reviewing a plan of care for a client with Addison's disease. the nurse notes that the client is at risk for dehydration and suggests nursing interventions that will prevent this occurrence. which nursing intervention is an appropriate component of the plan of care? select all that apply.

monitoring intake and output // monitoring changes in mental status // encouraging fluid intake of at least 3000 mL/day Rationale: The client at risk for deficient fluid volume should be encouraged to eat regular meals and snacks and to increase the intake of sodium, protein, and complex carbohydrates. Oral replacement of sodium losses is necessary, and maintenance of adequate blood glucose levels is required.

which nursing measure would be effective in preventing complications in a client with Addison's disease?

monitoring the blood glucose Rationale: The decrease in cortisol secretion that characterizes Addison's disease can result in hypoglycemia. Therefore, monitoring the blood glucose would detect the presence of hypoglycemia so that it can be treated early to prevent complications. Fluid intake should be encouraged to compensate for dehydration. Potassium intake should be restricted because of hyperkalemia.

the nurse is reviewing a HCP's prescriptions for a client with newly diagnosed, untreated hypothyroidism. which medication prescribed for the client should the nurse question and verify?

morphine sulfate rationale The client with hypothyroidism experiences fatigue, lethargy, and increased somnolence. The decreased metabolism and oxygen consumption is manifested by a slow heart rate, decreased cardiac output, and decreased blood pressure. Levothyroxine, a thyroid hormone, is a component of therapy. Stool softeners such as docusate sodium are prescribed to promote defecation. Morphine sulfate would further depress bodily functions. Atenolol is used with caution in clients with hyperthyroidism.

the nurse in an outpatient diabetes clinic is assisting in caring for a client on insulin pump therapy. which statement by the client indicates that a need for teaching regarding insulin pump therapy?

now that i have this pump, i don't have to worry about insulin reactions or ketoacidosis occurring again Rationale: All of the statements are correct in regard to insulin pump therapy, except the one that mentions insulin reactions and ketoacidosis. Hypoglycemic reactions can occur if there is an error in calculating the insulin dose or if the pump malfunctions. Ketoacidosis can occur if too little insulin is used or if there is an increase in metabolic need. The pump does not have a built-in blood glucose monitoring feedback system, so the client is subject to the usual complications associated with insulin administration without the use of a pump.

a client with Graves' disease has exophthalmos and is experiencing photophobia. which intervention would best assist the client with this problem?

obtaining dark glasses for the client Rationale: Because photophobia (light intolerance) accompanies this disorder, dark glasses are helpful in alleviating the symptom. Medical therapy for Graves' disease does not help alleviate the clinical symptom of exophthalmos. Other interventions may be used to relieve the drying that occurs from not being able to completely close the eyes; however, the question is asking what the nurse can do for photophobia. Tap water, which is hypotonic, could actually cause more swelling to the eye because it could pull fluid into the interstitial space. In addition, the client is at risk for developing an eye infection because the solution is not sterile. There is no need to prevent straining with exophthalmos.

the nurse is collecting data from a client who is being admitted to the hospital for a diagnostic workup for primary hyperparathyroidism. the nurse understands that which client complaint would be characteristic of this disorder?

polyuria Rationale: Hypercalcemia is the hallmark of hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis (polyuria). This diuresis leads to dehydration and the client would lose weight. Options 1, 3, and 4 are gastrointestinal (GI) symptoms but are not associated with the common GI symptoms typical of hyperparathyroidism (nausea, vomiting, anorexia, constipation).

the nurse is monitoring the results of periodic serum lab studies drawn on a client with DKA receiving an insulin infusion. the nurse determines that which value needs to be reported?

potassium 3.1 mEq/L Rationale: The client with diabetic ketoacidosis initially becomes hyperkalemic as potassium leaves the cells in response to lowered pH. Once fluid replacement and insulin therapy are started, the potassium level drops quickly. This occurs because potassium is carried into the cells along with glucose and insulin and because potassium is excreted in the urine once rehydration has occurred. Thus, the nurse carefully monitors the results of serum potassium levels and reports hypokalemia promptly.

a client with DM visits the health care clinic. the client previously had been well controlled with glyburide (DiaBeta), but recently, the fasting blood glucose has been running 180 to 200 mg/dL. which medication, if added to the client's regimen, may be contributing to the hyperglycemia?

prednisone Rationale: Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements. Option 3, a β-blocker, and option 2, a monoamine oxidase inhibitor, have their own intrinsic hypoglycemic activity. Option 4 decreases urinary excretion of sulfonylurea agents, causing increased levels of the oral medications, which can lead to hypoglycemia.

the nurse is collecting data regarding a client after a thyroidectomy and notes that the client has developed hoarseness and a weak voice. which nursing action is appropriate?

reassure the client that this is usually a temporary condition rationale weakness and hoarseness of the voice can occur as a result of trauma of the laryngeal nerve. if this develops, the client should be reassured that the problem will subside in a few days. unnecessary talking should be discouraged. it is not necessary to notify the RN immediately. these signs do not indicate bleeding or the need to administer calcium gluconate

a client who has been newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. which teaching information should the nurse reinforce upon discharge?

rotate the insulin injection sites systematically rationale Insulin dosages should not be adjusted or increased before unusual exercise. If acetone is found in the urine, it may possibly indicate the need for additional insulin. To minimize the discomfort associated with insulin injections, the insulin should be administered at room temperature. Injection sites should be systematically rotated from one area to another. The client should be instructed to give injections in one area, about 1 inch apart, until the whole area has been used and then to change to another site. This prevents dramatic changes in daily insulin absorption.

the nurse reinforces teaching with a client with DM regarding differentiating between hypoglycemia and ketoacidosis. the client demonstrates an understanding of the teaching by stating that glucose will be taken if which symptom develops?

shakiness Rationale: Shakiness is a sign of hypoglycemia, and it would indicate the need for food or glucose. Fruity breath odor, blurred vision, and polyuria are signs of hyperglycemia.

the nurse reinforces teaching with a client with diabetes mellitus regarding differentiating between hypoglycemia and ketoacidosis. the client demonstrates an understanding of the teaching by stating that glucose will be taken if which symptom develops?

shakiness rationale Shakiness is a sign of hypoglycemia, and it would indicate the need for food or glucose. Fruity breath odor, blurred vision, and polyuria are signs of hyperglycemia.

a HCP has prescribed propylthiouracil (PTU) for a client with hyperthyroidism, and the nurse assists in developing a plan of care for the client. which nursing measure would be included in the plan of care regarding this medication?

signs/symptoms of hypothyroidism Rationale: Excessive dosing with propylthiouracil may convert the client from a hyperthyroid state to a hypothyroid state. If this occurs, the dosage should be reduced. Temporary administration of thyroid hormone may be required. Propylthiouracil is not used for pain and does not cause hyperglycemia or renal toxicity

a client with type 1 DM is to being an exercise program, and the nurse is reinforcing instructions to the client regarding the program. which should the nurse include in the instructions?

take a blood glucose test before exercising Rationale: A blood glucose test performed before exercising provides information to the client regarding the need to eat a snack first. Exercising during the peak times of insulin effect or before mealtime places the client at risk for hypoglycemia. Insulin should be administered as prescribed.

when caring for a client who is having clear drainage from his nares after transsphenoidal hypophysectomy, which action by the nurse is essential?

test the drainage for glucose Rationale: After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid (CSF) leak. If this occurs, the drainage should be collected and tested for glucose, indicating the presence of CSF. The head of the bed should not be lowered to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication.

the nurse is collecting data from a client newly diagnosed with diabetes mellitus regarding the clients learning readiness. which client behavior indicates to the nurse that the client is not ready to learn?

the client complains of fatigue whenever the nurse plans a teaching session rationale Physical symptoms can interfere with an individual's ability to learn and can indicate to the teacher that the learner lacks motivation to learn if the symptoms repeatedly recur when teaching is initiated.

a client with DM is being discharged following treatment for hyperglycemic hyperosmolar state (HHS) precipitated by acute illness. the client states to the nurse, "i will call the doctor next time i can't eat more than a day or so." the nurse plans care, understanding that which statement accurately reflects the client's level of knowledge?

the client needs immediate education before discharge Rationale: If the client becomes ill and cannot retain fluids or food for a period of 4 hours, the health care provider should be notified. The client's statement in this question indicates a need for immediate education to prevent HHS, a life-threatening emergency situation

the nurse is collecting data from a client with type 2 DM. which statement by the client indicates an understanding of the medication regimen?

the medication that i am taking helps release the insulin i already make Rationale: Clients with type 2 diabetes mellitus have decreased or impaired insulin secretion. Oral hypoglycemic agents are given to these clients to facilitate glucose use and need to be taken on a regular schedule as prescribed. To maintain normal blood glucose levels throughout the day, oral hypoglycemic agents such as metformin are not taken on an as-needed basis depending on the blood glucose levels. Insulin injections may be given during times of stress-induced hyperglycemia. Oral insulin is not available or effective because of the breakdown of the insulin by digestion.

the nurse is discussing foot care with a diabetic client and the spouse. the nurse indicates which instruction during this informational session?

the toenails should be cut straight across Rationale: The client should be instructed to cut the toenails straight across. The client should not soak the feet in hot water, to prevent burns. The client should be instructed to wash the feet daily using a mild soap. Moisturizing lotion can be applied to the feet but should not be placed between the toes.

glucagon hydrochloride injection would most likely be prescribed for which disorder?

type 1 DM Rationale: Glucagon hydrochloride is a medication that can be administered subcutaneously or intramuscularly. It is prescribed to stimulate the liver to release glucose when a client is experiencing hypoglycemia and unable to take oral glucose replacement. It is important to teach a person other than the client how to administer the medication because the client's symptoms may prevent self-injection.

during data collection on a postoperative client who has undergone hypophysectomy, the client complains of thirst and frequent urination. knowing the expected complication of this surgery, the nurse should check which parameter next?

urine specific gravity Rationale: Following hypophysectomy, diabetes insipidus can occur temporarily because of antidiuretic hormone (ADH) deficiency. This deficiency is related to surgical manipulation. The nurse should assess specific gravity and notify the registered nurse if the results are less than 1.005.

the nurse has reinforced dietary instructions to a client with a diagnosis of hypoparathyroidism. the nurse instructs the client to include which item in the client?

vegetables Rationale: The client with hypoparathyroidism is instructed to follow a calcium-rich diet and to restrict the amount of phosphorus in the diet. The client should limit meat, poultry, fish, eggs, cheese, and cereals. Vegetables are allowed in the diet.