endocrine

NURSING PROCESS for the Patient with an Endocrine Disorder

The role of the licensed practical nurse/licensed vocational nurse (LPN/LVN) in the nursing process as stated is that the LPN/LVN will: • Participate in planning care for patients based on patient needs • Review patient's care plans and recommend revisions as needed • Review and follow defined prioritization for patient care • Use clinical pathways, care maps, or care plans to guide and review patient care ▪ Assessment Hormones affect every body tissue and system, causing diverse signs and symptoms of endocrine dysfunction. Endocrine disorders may have nonspecific or specific clinical manifestations. Some specific signs of endocrine dysfunction are the classic "polys" (polyuria, polydipsia, and polyphagia) in DM and exophthalmos in hyperthyroidism. Specific signs make the assessment easier, whereas nonspecific signs and symptoms, such as tachycardia, fatigue, and depression, are more problematic. ▪ Nursing Diagnosis Nursing diagnoses are determined from careful examination of patient data. Nursing diagnoses for the patient with an endocrine disorder may include but are not limited to the following: • Deficient knowledge • Risk for situational low self-esteem • Disturbed sensory perception • Risk for deficient fluid volume • Risk for infection • Risk for injury • Sexual dysfunction • Disturbed body image • Ineffective coping • Impaired home maintenance • Noncompliance • Imbalanced nutrition: less than body requirements • Imbalanced nutrition: more than body requirements • Activity intolerance ▪ Expected Outcomes and Planning The plan for management of patients with endocrine disorders must center on education to enable patients to understand their disorders, develop a healthy lifestyle, and prevent complications of their disease. The care plan focuses on accomplishing individual goals and outcomes that relate to the identified nursing diagnoses. Examples of these include the following: Goal 1: Patient will demonstrate safety in selfinjections of insulin. Evaluation: Patient independently administers insulin injection safely and accurately. Goal 2: Patient will demonstrate SMBG. Evaluation: Patient performs SMBG accurately. ▪ Implementation A major nursing responsibility is to help patients gain self-management skills for their chronic endocrine disorder through teaching and counseling. Selfmanagement skills are probably the major factor in controlling the health problem and maintaining an optimal quality of life. Self-management skills are implemented through education in the disease process, the management of medications, the management of nutrition, and the role of exercise; SMBG; hygiene; the prevention of complications; and assistance with psychological adjustment. ▪ Evaluation During and after patient educational teaching on self-management skills, assist in evaluating the success of the teaching by noting patient progress based on stated goals and outcomes. For example, when the patient performs SMBG, observe the patient's skill, correct him or her as necessary, and evaluate the patient's technique to ensure accuracy. When patients are unable to meet expected outcomes, be ready to revise the care plan to promote success.

Ketone bodies

Normal metabolic products, β-hydroxybutyric and aminoacetic acid, from which acetone may spontaneously arise.

Box 51-4 Technique for Insulin Injection

1. Follow the steps in Box 51-3 to prepare the insulin dose. 2. Don disposable gloves. 3. Clean the injection site with a prep swab, using a circular motion. Allow the alcohol to dry. Place the swab between the last two fingers of the hand not used to inject the insulin. 4. Pick up the syringe and remove the needle cover and lay it aside. Hold the syringe like a dart. 5. Using the other hand, gently pinch up at least a 2-inch fold of tissue (not just the skin). 6. Quickly insert the needle into the top (apex) of the fold, entering the subcutaneous tissue. The "soft spot" technique is to insert the needle about 1 inch to the side of the apex of the fold, into softer tissue, entering the pocket. The needle should be inserted at a 90-degree angle unless the patient is very thin and has little subcutaneous tissue. In that case the angle may be reduced by up to 45 degrees to avoid intramuscular injection. 7. Release the skinfold and use that hand to steady the barrel of the syringe. 8. Inject the insulin over a period of 3 to 5 seconds. 9. Place the alcohol swab against the needle hub, at the injection site, and pull the syringe unit straight out in one swift motion. Gently press on the injection site for a few seconds, but do not massage the site. 10. Carefully place the entire unit, uncapped, into the sharps container provided. 11. Record the injection site and insulin dose on a chart, computer, or other documentation sheet. Include the second licensed nurse who witnessed the insulin dose during preparation. Have the nurse witness the dose given. Store insulin and other supplies properly. 12. When instructing patient to self-inject insulin, use the following guidelines (if appropriate): — Aspiration does not need to be done before injection. — The injection site does not need to be cleansed with alcohol. The use of an alcohol swab by the patient on the site before self-injection is no longer recommended. Routine hygiene such as washing with soap and rinsing with water is adequate

Box 51-3 Preparation of Insulin

1. Thoroughly wash hands with warm water and soap. Bring the insulin to room temperature because an injection of cold insulin can be painful. 2. Assemble all equipment needed, such as properly calibrated insulin syringe with a prefitted needle, prep sponge, and insulin. 3. Turn the insulin vial onto its side and gently rotate between the hands several times to be certain it is mixed. The precipitate should be evenly blended. This does not need to be done with regular insulin because it has no precipitate. Never shake insulin vigorously because this creates air bubbles. 4. Clean the rubber stopper on the vial with a prep sponge. 5. Remove the needle cover and draw in the same amount of air as units of insulin to be injected. 6. Insert the needle into the rubber stopper of the vial and then inject air. Invert the bottle with the syringe unit attached, making sure the tip of the needle is below the level of the insulin so that air will not be drawn into the syringe. 7. Pull back slowly on the plunger, a few units past the desired dose of insulin. 8. Inspect for air bubbles in the syringe; if any are seen, gently tap the barrel until they rise to the top, then push back into the vial with plunger to the level of the desired dose of insulin. 9. Holding on to the barrel and plunger, remove the syringe unit and put the needle cover back on. Always check insulin dose with a second licensed nurse. Proceed with injection procedure. TWO INSULINS 1. Follow steps 1 through 5 above. 2. Insert the desired amount of air into the vial of the longer-acting insulin first. Do not mix insulin glargine (Lantus) or detemir (Levemir) with any other insulin or solution. 3. Inject the desired amount of air into the shorter-acting insulin vial; leave the syringe unit in this vial; invert, and proceed through steps 6 through 9, but do not inject yet. Set the vial of shorter-acting insulin out of reach to prevent accidental reuse. 4. Insert the needle into the vial of longer-acting insulin, being careful to hold on to the plunger so that none of the insulin in the syringe enters that vial. 5. Slowly pull the plunger to the level of the combined total of both types of insulin desired (such as regular 10 units, NPH 30 units, totaling 40 units). Do not pull extra units into the syringe. Take special care not to get any air bubbles into the syringe because they will displace some of the insulin and make the dose incorrect. If this happens, discard the whole syringe and start all over again. Check insulin dose with a second licensed nurse. 6. If the dose is correct, proceed with the injection procedure.

508. A nurse is caring for a client after thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to: 1. Treat thyroid storm. 2. Prevent cardiac irritability. 3. Treat hypocalcemic tetany. 4. Stimulate the release of parathyroid hormone.

508. 3 Rationale: Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed or injured during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips, or toes or muscle spasms or twitching, the physician is notified immediately. Calcium gluconate should be kept at the bedside. Test-Taking Strategy: Noting the name of the medication (calcium gluconate) should easily direct you to option 3. Calcium is given if hypocalcemic tetany occurs. Review calcium gluconate if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology

509. A 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? 1. Check for signs of bleeding. 2. Administer calcium gluconate. 3. Notify the registered nurse immediately. 4. Reassure the client that this is usually a temporary condition.

509. 4 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 registered nurse immediately. These signs do not indicate bleeding or the need to administer calcium gluconate. Test-Taking Strategy: Use the process of elimination. Options 1 and 2 can easily be eliminated, because they are unrelated to the signs presented in the question. From the remaining options, recall that these signs indicate a temporary condition. Review the expected findings after thyroidectomy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine

510. A client is admitted to the emergency department, and a diagnosis of myxedema coma is made. Which nursing action would the nurse prepare to carry out initially? 1. Warm the client. 2. Maintain a patent airway. 3. Infuse intravenous fluids. 4. Administer thyroid hormone.

510. 2 Rationale: The initial nursing action would be to maintain a patent airway. Oxygen would be administered, followed by fluid replacement. The nurse would also keep the client warm, monitor the vital signs, and administer thyroid hormones. Test-Taking Strategy: Note the strategic words "carry out initially." All of the options are appropriate interventions, but the use of the ABCs—airway, breathing, and circulation—will direct you to option 2. Review the care of the client with myxedema coma if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing

511. A 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? 1. Soak the feet in hot water. 2. Avoid using soap to wash the feet. 3. Apply a moisturizing lotion to dry feet, but not between the toes. 4. Always have a podiatrist cut your toenails; never cut them yourself.

511. 3 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 to not soak the feet and to avoid hot water to prevent burns. The client may cut the toenails straight 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. Test-Taking Strategy: Use the process of elimination. Eliminate option 4 first because of the word "always," and eliminate option 1 because of the word "hot." From the remaining options, recalling the concern related to skin infection will assist you with eliminating option 2. Review diabetic foot care instructions if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine

512. A nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diabetic diet. Which statement, if made by the client, indicates the need for further teaching? 1. "I'll eat a balanced meal plan." 2. "I need to drink diet soft drinks." 3. "I need to buy special dietetic foods." 4. "I will snack on fruit instead of cake."

512. 3 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. Test-Taking Strategy: Note the strategic words "indicates the need for further teaching." These words indicate a negative event query and ask you to select an option that is an incorrect statement. Basic principles related to the diabetic diet will direct you to option 3. Review these principles if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health/Endocrine

513. A client who has been newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. Which information should the nurse teach when carrying out plans for discharge? 1. Keep insulin vials refrigerated at all times. 2. Rotate the insulin injection sites systematically. 3. Increase the amount of insulin before unusual exercise. 4. Monitor the urine acetone level to determine the insulin dosage.

513. 2 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 to then change to another site. This prevents dramatic changes in daily insulin absorption. Test-Taking Strategy: Use the process of elimination. Eliminate option 1 first because of the words "at all times." Knowledge regarding insulin administration and the significance of acetone in the urine will assist you with eliminating options 3 and 4. Review insulin management if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology

514. A 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? 1. Polyuria 2. Shakiness 3. Blurred vision 4. Fruity breath odor

514. 2 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. Test-Taking Strategy: Knowledge regarding the signs and symptoms of hypoglycemia and hyperglycemia is required to answer this question. Remember that shakiness is a sign of hypoglycemia. Review the signs and symptoms of hypoglycemia and hyperglycemia if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Endocrine

515. When the nurse is teaching a client who has been newly diagnosed with type 1 diabetes mellitus, which statement by the client would indicate that teaching has been effective? 1. "I will stop taking my insulin if I'm too sick to eat." 2. "I will decrease my insulin dose during times of illness." 3. "I will adjust my insulin dose according to the level of glucose in my urine." 4. "I will notify my physician if my blood glucose level is greater than 250 mg/dL."

515. 4 Rationale: During illness, the client should monitor the blood glucose level, and he or she should notify the physician 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 physician's advice. Test-Taking Strategy: Use the process of elimination. Note that options 1, 2, and 3 all relate to the adjustment of insulin doses; therefore, eliminate these options. Review diabetic management during illness if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Endocrine

516. A nurse is monitoring a client who has been newly diagnosed with diabetes mellitus for sign of complications. Which of the following, if exhibited by the client, would indicate hyperglycemia and thus warrant physician notification? 1. Polyuria 2. Bradycardia 3. Diaphoresis 4. Hypertension

516. 1 Rationale: The classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Options 2, 3, and 4 are not signs of hyperglycemia. Test-Taking Strategy: Focus on the subject of hyperglycemia. Remember the 3 Ps—polyuria, polydipsia, polyphagia. Review the signs of hyperglycemia if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection

517. A nurse is reinforcing instructions with a client with diabetes mellitus who is recovering from diabetic ketoacidosis (DKA) regarding measures to prevent a recurrence. Which instruction is important for the nurse to emphasize? 1. Eat six small meals daily. 2. Test the urine ketone levels. 3. Monitor blood glucose levels frequently. 4. Receive appropriate follow-up health care.

517. 3 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. Test-Taking Strategy: Focus on the subject of preventing DKA. Recall that the treatment of DKA focuses on the maintenance of an appropriate blood glucose level. Option 1 is not an accurate component of diabetic care. Option 4 will not prevent DKA. Option 2 does not prevent DKA but rather confirms the diagnosis. Review DKA if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Adult Health/Endocrine

518. A nurse is reviewing 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? 1. "I can eat foods that contain potassium." 2. "I will need to limit the amount of protein in my diet." 3. "I am fortunate that I can eat all the salty foods I enjoy." 4. "I am fortunate that I do not need to follow any special diet."

518. 1 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. Test-Taking Strategy: Note the strategic words "instructions related to dietary management were understood." Eliminate option 4, because it indicates that no dietary change is necessary. Eliminate option 2 next, because protein is usually only limited with renal disorders. Excess sodium is not healthy in general, so eliminate option 3. Review the dietary management of Cushing's syndrome if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Endocrine

519. A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia. Which statement by the client indicates a correct understanding of NPH insulin and exercise? 1. "I should not exercise after lunch." 2. "I should not exercise after breakfast." 3. "I should not exercise in the late evening." 4. "I should not exercise in the late afternoon."

519. 4 Rationale: A hypoglycemic reaction may occur in response to increased exercise. Clients should avoid exercise during the peak time of insulin. NPH insulin peaks at 6 to 14 hours; therefore, late afternoon exercise would occur during the peak of the medication. Test-Taking Strategy: Use the process of elimination, and note the strategic words "a correct understanding." Recalling the peak time of insulin will direct you to option 4. Review the measures to prevent hypoglycemia if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Endocrine

520. A nurse is caring for a postoperative parathyroidectomy client. Which of the following would require the nurse's immediate attention? 1. Incisional pain 2. Laryngeal stridor 3. Difficulty voiding 4. Abdominal cramps

520. 2 Rationale: During the postoperative period, the nurse carefully observes the client for signs of hemorrhage, which cause 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. Test-Taking Strategy: Consider the anatomical location of the surgical procedure, and use the ABCs—airway, breathing, and circulation—to select the correct option. Options 1, 3, and 4 are usual postoperative problems that are not life threatening. Option 2 addresses the airway. Review the care of the client after parathyroidectomy if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine

521. When a nurse notes that a client with type 1 diabetes mellitus has lipodystrophy on both upper thighs, what information should the nurse obtain from the client? 1. Plan of injection rotation 2. Consistency of aspiration 3. Preparation of the injection site 4. Angle at which the medication is administered

521. 1 Rationale: Lipodystrophy (i.e., the hypertrophy of subcutaneous tissue at the injection site) occurs in some diabetic clients when the same injection sites are used for prolonged periods of time. Thus, clients are instructed to adhere to a rotating injection site plan to avoid tissue changes. Preparation of the site, aspiration, and the angle of insulin administration do not produce tissue damage. Test-Taking Strategy: Recalling the definition of lipodystrophy will direct you to the correct option. Remember that lipodystrophy is the hypertrophy of subcutaneous tissue at the injection site. Review this potential complication of insulin therapy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine

522. Which client complaint would alert the nurse to a possible hypoglycemic reaction? 1. Tremors 2. Anorexia 3. Hot, dry skin 4. Muscle cramps

522. 1 Rationale: Decreased blood glucose levels produce automatic nervous system symptoms, which are classically manifested as nervousness, irritability, and tremors. Option 3 is more likely to occur with hyperglycemia. Options 2 and 4 are unrelated to the signs of hypoglycemia. Test-Taking Strategy: Focus on the subject of a hypoglycemic reaction. Recalling the signs associated with this reaction will direct you to option 1. Review hypoglycemia if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine

523. Which nursing action would be appropriate to implement when a client has a diagnosis of pheochromocytoma? 1. Weigh the client. 2. Test the client's urine for glucose. 3. Monitor the client's blood pressure. 4. Palpate the client's skin to determine warmth.

523. 3 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 clinical manifestations of pheochromocytoma, but hypertension is the major symptom. Test-Taking Strategy: Use the principles associated with prioritizing and the ABCs—airway, breathing, and circulation. A method of assessing circulation is to take the blood pressure. Review the manifestations of pheochromocytoma if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine

524. A nurse is caring for a client with pheochromocytoma. The client is scheduled for an adrenalectomy. During the preoperative period, the priority nursing action would be to monitor: 1. The vital signs 2. The intake and output 3. The blood urea nitrogen level 4. The urine for glucose and acetone

524. 1 Rationale: Hypertension is the hallmark of pheochromocytoma. Severe hypertension can precipitate a brain attack (stroke) accident or sudden blindness. Although all of the options are accurate nursing interventions for the client with pheochromocytoma, the priority nursing action is to monitor the vital signs, particularly the blood pressure. Test-Taking Strategy: Note the strategic words "priority nursing action." Monitoring the vital signs is the nursing action that would assess the ABCs—airway, breathing, and circulation. In addition, note that options 2, 3, and 4 all refer to the assessment of the renal system. Review the care of the client with pheochromocytoma if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing

525. A nurse is caring for a client with pheochromocytoma. The client asks for a snack and something warm to drink. The appropriate choice for this client to meet nutritional needs would be which of the following? 1. Crackers with cheese and tea 2. Graham crackers and warm milk 3. Toast with peanut butter and cocoa 4. Vanilla wafers and coffee with cream and sugar

525. 2 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, cola) are prohibited. Test-Taking Strategy: Use the process of elimination. Eliminate options 1, 3, and 4, because they are comparable or alike and include food items that contain caffeine. Review dietary measures for the client with pheochromocytoma if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine

526. A nurse is caring for a client with pheochromocytoma. Which data would indicate a potential complication associated with this disorder? 1. A urinary output of 50 mL/hour 2. A coagulation time of 5 minutes 3. Congestion heard on auscultation of the lungs 4. A blood urea nitrogen (BUN) level of 20 mg/dL

526. 3 Rationale: The complications associated with pheochromocytoma include hypertensive retinopathy and nephropathy, myocarditis, congestive heart failure (CHF), increased platelet aggregation, and stroke. Death can occur from shock, stroke, renal failure, dysrhythmias, or dissecting aortic aneurysm. Congestion heard on auscultation of the lungs is indicative of CHF. A urinary output of 50 mL/hour is an appropriate output; the nurse would become concerned if the output was less than 30 mL/hour. A BUN level of 20 mg/dL is a normal finding. A coagulation time of 5 minutes is normal. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation. Congestion heard on auscultation of the lungs is associated with the airway. In addition, if you know the normal hourly urinary output, the normal laboratory values for coagulation time, and the BUN level, you can determine that option 3 is correct by the process of elimination. Review the complications associated with pheochromocytoma if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine

527. A nurse is caring for a client after thyroidectomy and monitoring for signs of thyroid storm. The nurse understands that which of the following is a manifestation associated with this disorder? 1. Bradycardia 2. Hypotension 3. Constipation 4. Hypothermia

527. 2 Rationale: Clinical manifestations associated with thyroid storm include a fever as high as 106° F (41.1° C), severe tachycardia, profuse diarrhea, extreme vasodilation, hypotension, atrial fibrillation, hyperreflexia, abdominal pain, diarrhea, and dehydration. With this disorder, the client's condition can rapidly progress to coma and cardiovascular collapse. Test-Taking Strategy: Knowledge regarding the manifestations associated with thyroid storm is required to answer the question. Remember that this condition is a rare but potentially fatal hypermetabolic state. Review thyroid storm if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine

528. When caring for a client who is having clear drainage from his nares after transsphenoidal hypophysectomy, which action by the nurse is appropriate? 1. Lower the head of the bed. 2. Test the drainage for glucose. 3. Obtain a culture of the drainage. 4. Continue to observe the drainage.

528. 2 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. Test-Taking Strategy: Use the process of elimination. Option 1can be eliminated first. Option 3 can be eliminated, because the drainage is clear. Because an action is required, eliminate option 4. Review the complications after hypophysectomy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine

529. After several diagnostic tests, a client is diagnosed with diabetes insipidus. The nurse understands that which symptom is indicative of this disorder? 1. Diarrhea 2. Polydipsia 3. Weight gain 4. Blurred vision

529. 2 Rationale: Polydipsia and polyuria are classic symptoms of diabetes insipidus. The urine is pale in color, and its specific gravity is low. Anorexia and weight loss occur. Test-Taking Strategy: Use the process of elimination and your knowledge of the manifestations of diabetes insipidus. Remember that polydipsia and polyuria are classic symptoms. Review the clinical manifestations associated with diabetes insipidus if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine

530. Which clinical manifestation should the nurse expect to note when assessing a client with Addison's disease? 1. Edema 2. Obesity 3. Hirsutism 4. Hypotension

530. 4 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. Test-Taking Strategy: Knowledge regarding the clinical manifestations associated with Addison's disease is required to answer this question. Remember that hypotension occurs with Addison's disease. Review Addison's disease if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine

531. What would the nurse anticipate being included in the plan of care for a client who has been diagnosed with Graves' disease? 1. Provide a high-fiber diet. 2. Provide a restful environment. 3. Provide three small meals per day. 4. Provide the client with extra blankets.

531. 2 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. Test-Taking Strategy: The strategic concept to bear in mind when answering this question is that clients with Graves' disease experience an accelerated metabolic rate. This concept should assist you with eliminating options 1, 3, and 4. Review the care of the client with Graves' disease if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine

532. A hospitalized client with type 1 diabetes mellitus received NPH and regular insulin 2 hours ago at 7:30 AM. The client calls the nurse and reports that he is feeling hungry, shaky, and weak. The client ate breakfast at 8:00 and is due to eat lunch at noon. List, in order of priority, the actions that the nurse would take. (Number 1 is the first action.) ___ Take the client's vital signs. ___ Retest the client's blood glucose level. ___ Check the client's blood glucose level. ___ Give the client half a cup of fruit juice to drink. ___ Give the client a small snack of carbohydrate and protein. ___ Document the client's complaints, the actions taken, and the outcome.

532. 3, 4, 1, 2, 5, 6 Rationale: The client is experiencing symptoms of mild hypoglycemia. If symptoms such as hunger, irritability, shakiness, or weakness occur, the nurse first would check the client's blood glucose level to verify that the client is experiencing hypoglycemia. After this is verified, the nurse would give the client 10 to 15 g of carbohydrates and then retest the blood glucose level in 15 minutes. In the meantime, the nurse would check the client's vital signs. The nurse would give the client another food item containing 10 to 15 g of carbohydrate if the client's symptoms do not resolve. Otherwise, the nurse would provide a small snack of carbohydrates and protein if the client's next scheduled meal is more than an hour away from the time of the occurrence. After treatment and the resolution of the hypoglycemic event, the nurse would document the occurrence, the actions taken, and the outcome. Test-Taking Strategy: Focus on the client's symptoms. Noting that the client is hospitalized will assist you with determining that the first action would be to check the client's blood glucose level. After this has been done, treating the hypoglycemia is necessary. Recalling that an outcome cannot be determined until treatment has been instituted will assist you with selecting the documentation action as the last action. From the remaining three actions, select taking the vital signs as the third action. The nurse would not give the client a carbohydrate and protein item immediately after giving the client a 10- to 15-g carbohydrate item or before retesting the blood glucose level. Review the management of hypoglycemia if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing

533. A nurse provides instructions to the client taking fludrocortisone (Florinef). The nurse tells the client to notify the physician if which of the following occurs? 1. Nausea 2. Fatigue 3. Weight loss 4. Swelling of the feet

533. 4 Rationale: Excessive doses of fludrocortisone cause retention of sodium and water and excessive excretion of potassium, resulting in expansion of blood volume, hypertension, cardiac enlargement, edema, and hypokalemia. The client needs to be informed about the signs of sodium and water retention, such as unusual weight gain or swelling of the feet or lower legs. If these signs occur, the physician needs to be notified. Test-Taking Strategy: Use the process of elimination. Recalling that fludrocortisone can cause water retention will direct you to option 4. If you are unfamiliar with the adverse effects associated with this medication, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology

534. Calcitriol (Rocaltrol) is prescribed for the client with hypocalcemia, and the nurse provides dietary instructions to the client. Which food item would the nurse instruct the client to avoid while taking this medication? 1. Milk 2. Oysters 3. Sardines 4. Whole-grain cereals

534. 4 Rationale: The client taking an antihypocalcemic medication should be instructed to avoid eating foods that can suppress calcium absorption. These foods include Swiss chard, beets, bran, and whole-grain cereals. Test-Taking Strategy: Use the process of elimination. Note that the client's diagnosis is "hypocalcemia" and note the strategic word "avoid." Eliminate options 2 and 3 first because they are comparable or alike. From the remaining options, recalling the food items that can suppress calcium absorption will direct you to option 4. Review these foods if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology

535. A daily dose of prednisone (Deltasone) is prescribed for a client. A nurse provides instructions to the client regarding administration of the medication and tells the client that the best time to take this medication is: 1. At noon 2. At bedtime 3. Early morning 4. Any time, at the same time, each day

535. 3 Rationale: Glucocorticoids should be administered before 9:00 AM, and the client should be instructed to do so. Administration at this time helps minimize adrenal insufficiency and mimics the burst of glucocorticoids released naturally by the adrenals each morning. Test-Taking Strategy: Knowledge regarding the administration of glucocorticoids is required to answer this question. Remember, glucocorticoids should be administered before 9:00 AM. If you had difficulty with this question, review the guidelines associated with administering glucocorticoids. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology

536. Sildenafil citrate (Viagra) is prescribed to treat a client with erectile dysfunction. A nurse reviews the client's medical record and would question the prescription if which of the following is noted in the client's history? 1. Insomnia 2. Neuralgia 3. Use of nitroglycerin 4. Use of multivitamins

536. 3 Rationale: Sildenafil citrate (Viagra) enhances the vasodilation effect of nitric oxide in the corpus cavernosus of the penis, thus sustaining an erection. Because of the effect of the medication, it is contraindicated with concurrent use of organic nitrates and nitroglycerin. It is not contraindicated with the use of vitamins. Neuralgia and insomnia are side effects of the medication. Test-Taking Strategy: Use the process of elimination and note the strategic words "would question the prescription." Recalling the action of the medication will direct you to option 3. If you had difficulty with this question, review the contraindications associated with the use of this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology

537. A nurse is teaching the client how to mix regular insulin and NPH insulin in the same syringe. Which of the following actions, if performed by the client, would indicate the need for further teaching? 1. Withdraws the NPH insulin first 2. Withdraws the regular insulin first 3. Injects air into the NPH insulin vial first 4. Injects the amount of air equal to the desired dose of insulin into the vial

537. 1 Rationale: When preparing a mixture of regular insulin with another insulin preparation, the regular insulin should be drawn into the syringe first. This sequence will avoid contaminating the vial of regular insulin with insulin of another type. Options 2, 3, and 4 are correct. Test-Taking Strategy: Use the process of elimination and note the strategic words "need for further teaching." These words indicate a negative event query and the need to select the incorrect client statement. Recalling the appropriate method of preparing insulin for injection will direct you to option 1. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology

538. A nurse is reinforcing home care instructions to a client recently diagnosed with diabetes mellitus. The client is taking NPH insulin daily and asks the nurse how to store the unopened vials of insulin. The nurse tells the client to: 1. Freeze the insulin 2. Refrigerate the insulin 3. Keep the insulin in a dark, dry place 4. Keep the insulin at room temperature

538. 2 Rationale: Unopened vials of insulin should be stored under refrigeration until needed. Vials should not be frozen. Open vials in use may be kept at room temperature and should be kept away from heat and direct light. Test-Taking Strategy: Use the process of elimination and note the strategic word "store" in the question. Remembering that insulin should not be frozen will assist in eliminating option 1. Eliminate options 3 and 4 next because they are comparable or alike. Review client teaching points related to insulin if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology

539. A client with diabetes mellitus is self-administering NPH insulin from a vial that is kept at room temperature. The client asks the nurse about the length of time an unrefrigerated vial of insulin will maintain its potency. The appropriate response is which of the following? 1. Two weeks 2. Six months 3. One month 4. Two months

539. 3 Rationale: An unrefrigerated insulin vial will maintain its potency for up to 1 month. Direct sunlight and heat must be avoided. Test-Taking Strategy: Note the strategic word "unrefrigerated" to assist in directing you to the correct option. Review the concepts related to insulin stability if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology

540. Lispro insulin (Humalog), a rapid-acting form of insulin, is prescribed for a client. The nurse instructs the client to administer the insulin: 1. 30 minutes before eating 2. 45 minutes before eating 3. 60 minutes before eating 4. Immediately before eating

540. 4 Rationale: The effect of lispro insulin begins within 5 minutes of subcutaneous injection and persists for 2 to 4 hours. Lispro insulin acts more rapidly than regular insulin but has a shorter duration of action. Because of its rapid onset, it can be administered immediately before eating. In contrast, regular insulin is generally administered 30 minutes before meals. Test-Taking Strategy: Use the process of elimination. Noting the strategic words "rapid-acting" will assist in eliminating options 2 and 3. From the remaining options, remember that the question is asking about lispro, not regular, insulin. Review this type of insulin if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology

541. Tolbutamide (Orinase) is prescribed for the client with diabetes mellitus. The nurse instructs the client to avoid which of the following while taking this medication? 1. Alcohol 2. Organ meats 3. Whole-grain cereals 4. Carbonated beverages

541. 1 Rationale: When alcohol is combined with tolbutamide, a disulfiram-like reaction may occur. This syndrome includes flushing, palpitations, and nausea. Also, alcohol can potentiate the hypoglycemic effects of tolbutamide. Clients must be warned about alcohol consumption while taking this medication. Test-Taking Strategy: Use the process of elimination. Eliminate options 2, 3, and 4 because these food items are allowed in a diabetic diet. From the remaining options, remembering that alcohol can affect the action of many medications will assist in directing you to option 1. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology

542. A nurse is monitoring a client receiving desmopressin (DDAVP). Which of the following, if noted in the client, would indicate an adverse effect of the medication? 1. Insomnia 2. Drowsiness 3. Weight loss 4. Increased urination

542. 2 Rationale: Water intoxication or hyponatremia is an adverse reaction to DDAVP. Early signs include drowsiness, listlessness, and headache. Decreased urination, rapid weight gain, confusion, seizures, and coma may also occur in overhydration. Test-Taking Strategy: Use the process of elimination. Knowledge that this medication is used in the treatment of diabetes insipidus will assist in eliminating options 3 and 4. Recalling the action of the medication will assist you in determining that water intoxication is an adverse reaction. This thought process will assist in directing you to option 2. Review the adverse effects related to this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology

543. A nurse provides instructions to a client taking levothyroxine (Synthroid). The nurse determines that the teaching was effective if the client states that he or she will take the medication: 1. At bedtime 2. At lunch time 3. Two hours after a meal 4. One hour before breakfast

543. 4 Rationale: Oral doses of levothyroxine should be taken on an empty stomach to enhance absorption. The medication should be taken in the morning before breakfast. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 3 first because they are comparable or alike. From the remaining options, recalling the purpose of the medication and that it is administered in the morning will direct you to option 4. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology

544. A nurse reinforces medication instructions to a client taking levothyroxine (Synthroid). The nurse should instruct the client to notify the doctor if which problem occurs? 1. Fatigue 2. Tremors 3. Cold intolerance 4. Excessively dry skin

544. 2 Rationale: Excessive doses of levothyroxine can produce signs and symptoms of hyperthyroidism (thyrotoxicosis). These include tachycardia, angina, tremors, nervousness, insomnia, hyperthermia, heat intolerance, and sweating. The client should be instructed to notify the physician if these occur. Options 1, 3, and 4 are signs of hypothyroidism. Test-Taking Strategy: Use the process of elimination, recalling the symptoms associated with hypothyroidism, the purpose of administering levothyroxine, and the effects of the medication. Options 1, 3, and 4 are symptoms related to hypothyroidism. Review the adverse effects of the medication if you are unfamiliar with it. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology

545. A nurse reviews the health record of a client seen in the physician's office and noted that the client is taking propylthiouracil (PTU) daily. The nurse suspects that the client is taking the medication for which condition? 1. Myxedema 2. Acromegaly 3. Graves' disease 4. Addison's disease

545. 3 Rationale: PTU inhibits thyroid hormone synthesis and is used to treat hyperthyroidism or Graves' disease. Myxedema indicates hypothyroidism. Cushing's syndrome and Addison's disease are disorders related to adrenal function. Test-Taking Strategy: Knowledge regarding the action of the medication and the treatment measures for Graves' disease is required to answer the question. Remember that PTU inhibits thyroid hormone synthesis and is used to treat hyperthyroidism or Graves' disease. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology

546. Propylthiouracil (PTU) is prescribed for a client with hyperthyroidism, and the nurse provides instructions to the client regarding the medication. The nurse informs the client to notify the physician if which of the following signs occur? 1. Polyuria 2. Dry mouth 3. Sore throat 4. Drowsiness

546. 3 Rationale: An adverse effect of PTU is agranulocytosis. The client needs to be informed of the early signs of this adverse effect, which include fever or sore throat. Drowsiness is an occasional side effect of the medication. Polyuria and dry mouth are unrelated to this medication. Test-Taking Strategy: Use the process of elimination. Recalling that agranulocytosis is an adverse effect of PTU will direct you to option 3. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology

547. A client with diabetes mellitus is preparing for discharge from the hospital and tells the nurse that syringes prefilled with NPH and regular insulin will be prepared by a home care nurse who will be visiting the client. The client asks the nurse how often the home care nurse will need to visit to fill syringes. Considering the stability of insulin, the nurse tells the client that how many prefilled syringes can be prepared by the home care nurse? Answer: _____________

547. 7 Rationale: Mixtures of insulin in prefilled syringes should be stored in a refrigerator, where they will be stable for 1 week. The syringe should be stored vertically, with the needle pointing up, to avoid clogging the needle. Prior to administration, the syringe should be agitated gently to resuspend the insulin. Test-Taking Strategy: It is necessary to know the concepts related to insulin stability and storage to answer this question. Remember that mixtures of insulin in prefilled syringes are stable for 1 week. Review these concepts if you are unfamiliar with the principles related to prefilling insulin syringes. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology

Table 51-8 Comparison of Types of Diabetic Coma

ASSESSMENT HYPERGLYCEMIC REACTION, DIABETIC KETOACIDOSIS HYPOGLYCEMIC REACTION HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC COMA Type of diabetes Type 1 Type 1 or type 2 Type 2 Cause Inadequate insulin Too much insulin or oral hypoglycemic agent Inadequate insulin or oral hypoglycemic agent Patient history Omitted or insufficient dose of insulin, physical or emotional stress, gastrointestinal upsets, dietary noncompliance Reduced food intake, delayed meal, too much exercise Reduced fluid or food intake with increased urinary output, resulting in severe dehydration Onset of symptoms Hours to days Minutes to hours Days Previous diagnosis of having diabetes Almost always Yes; on medication Usually type 2, on hypoglycemic agent Age of patient Usually younger patient Usually younger patient Usually older adult patient Appearance of skin Hot, dry, flushed Cool, moist Hot, dry; body temperature elevated Breath Fruity (from ketones) Normal Normal Mucous membranes Dry Moist Very dry Respirations Deep; may have Kussmaul's respirations (air hunger) as a result of metabolic acidosis Rapid, shallow Normal Neurosensory Drowsiness to coma Irritability, tremors, impaired consciousness, personality changes; may lose consciousness Lethargy, decreased consciousness; may lose consciousness Blood pressure Low Normal Decreased Glycosuria and ketonuria Present Absent Glycosuria present; no ketonuria Polyuria and polydipsia Present Absent Present Hunger Absent; may have nausea and vomiting Present; may be nauseated Absent Blood glucose level Usually 300-800 mg/dL Usually <50 mg/dL 600-2000 mg/dL; serum osmolality greatly increased Emergency treatment Insulin, usually regular Glucose (oral or IV) or glucagon (subQ, IM, or IV) Large amounts of intravenous fluids; regular insulin

Chvostek's sign

Abnormal spasm of the facial muscles elicited by light taps on the facial nerve in patients who are hypocalcemic; seen in tetany.

Box 51-2 Diagnostic Tests for Diabetes Mellitus

Box 51-2 Diagnostic Tests for Diabetes Mellitus • Fasting blood glucose (FBG): After an 8-hour fast, blood is drawn. Normal is 60 to 110 mg/dL of venous blood; 126 mg/dL or greater is considered abnormal. • Oral glucose tolerance test (OGTT): When patient shows overt signs and symptoms of hyperglycemia, polyuria, polydipsia, and polyphagia, together with FBG levels of 126 mg/dL or greater, further OGTTs are usually not warranted. However, whenever OGTTs are used, the accuracy depends on adequate patient preparation and attention to the many factors that may influence the outcome of such tests. • Serum insulin: Absent in type 1 diabetes mellitus (DM); normal to high in type 2 DM. • Postprandial (after a meal) blood glucose (PPBG): Give a fasting patient a measured amount of carbohydrate solution orally, or have the patient eat a measured amount of foods containing carbohydrates, fats, and proteins. Draw a blood sample 2 hours after completion of the meal. Elevated plasma glucose over 160 mg/dL may indicate the presence of DM. • Patient self-monitoring of blood glucose (SMBG): A blood sample is obtained by the fingerstick method, by either the patient or the nurse, and tested using a blood glucose-monitoring device. • Glycosylated hemoglobin (HbAlc): This blood test measures the amount of glucose that has become incorporated into the hemoglobin within an erythrocyte; these levels are reported as a percentage of the total hemoglobin. Because glycosylation occurs constantly during the 120-day life span of the erythrocyte, this test reveals the effectiveness of diabetes therapy for the preceding 8 to 12 weeks. Glycosylated hemoglobin levels remain more stable than plasma glucose levels and are evaluated by a venipuncture every 6 to 8 weeks. Normal HbAlc is approximately 4% to 6% of the total. There is an urgent need to reduce HbAlc values to below 7% to reduce complications. A result greater than 8% represents an average blood glucose level of approximately 200 mg/dL and signals a need for changes in treatment. • C-peptide test: The production of insulin by the beta cells of the pancreas begins with proinsulin with an A chain of amino acids and a B chain of amino acids with a connecting peptide or C-peptide. The C-peptide allows the A and B proinsulin to fold and cleave together, creating the structure of insulin. After the connection has been made, the fusion occurs, creating insulin and a C-peptide by-product. C-peptide then gets secreted into the bloodstream by the pancreas along with insulin. The C-peptide level may be measured in a patient with type 2 DM to see if any insulin is being produced by the body. A newly diagnosed diabetic patient will often use this test to determine whether he or she has type 1 or type 2 DM. Normal values are 0.5 to 2 ng/mL. The patient with type 1 diabetes is unable to produce insulin and therefore has decreased levels of C-peptide; C-peptide levels in type 2 diabetic patients are normal or higher than normal. In type 2 diabetics, the problem seems to be an abnormal resistance to insulin action.

Cultural Considerations

Chronic Conditions • When dealing with a patient with a chronic condition, identification of the patient's cultural background, values, and beliefs can assist the health care team in identifying appropriate regimens. This is particularly important in a condition such as diabetes mellitus, which may require major lifestyle changes for successful management. • In assessing patients, it is important to consider the best way to communicate across cultures. For example, Asian and Mexican cultures consider asking a direct question and expecting a direct answer to be ill mannered and rude. Phrasing questions in a more indirect way will foster more effective communication.

Home Care Considerations

Diabetes Mellitus • Considering the day of short hospitalization or no hospitalization and the overwhelming amount of information to be learned, home care is a high priority for people with diabetes mellitus. • Frequently, older adults have difficulty with mobility and changes in vision that may hamper the drawing up of insulin. • Often there is missing information as to why control cannot be obtained; that missing link may be found during a home visit. • Diabetes caregivers and home care agencies often team up to provide good care for the older adult. • Home care personnel network with other community resources to improve the older adult's quality of life or help deal with economic issues. • Diabetic management should include education in: — Motivation — Self-monitoring of blood glucose — Exercise — Nutrition therapy — Medications — Written treatment plan

Dysphagia

Difficulty swallowing.

Complementary & Alternative Therapies

Endocrine Disorders • Herbal medicines used in the treatment of type 2 diabetes mellitus include aloe vera juice, beans (Phaseolus species), bitter gourd, karela (Momordica charantia), black tea (Camellia sinensis), fenugreek (Trigonella foenum-graecum), gurmar (Gymnema sylvestre), macadamia nut, and Madagascar periwinkle (Catharanthus roseus). Effects of these herbs include lowering of blood pressure (fenugreek), boosting of insulin production (gurmar), and increased use of available insulin (black tea). • Kelp (Fucus vesiculosus) may help with weight loss in hypothyroid disorders. Milk thistle (Silybum marianum) is used for treatment and prophylaxis of chronic hepatotoxicity, inflammatory liver disorders, and certain types of cirrhosis. • Yoga may help the patient with diabetes mellitus with diet control and may improve pancreatic function.

Evidence-Based Practice Changes in Diabetes Self-Care Behaviors

Evidence Summary Diabetes self-management is critical, complex, and demanding. In a comparison between diabetes Treatment as Usual (TAU) with the Pathways to Change (PTC) intervention, the PTC group received stage-matched personalized assessment reports, self-help manuals, and newsletters. In addition, individual phone counseling helped determine readiness for self-monitoring of blood glucose (SMBG), healthy eating, and/or smoking cessation. Those in the PTC group were more likely to move into the action stages of those self-care behaviors, such as performing SMBG as instructed, eating more fruits and vegetables, and quitting smoking in order to manage their diabetes. Application to Nursing Practice As health care professionals, we need to help patients move through the stages of behavior change. It is important to assess and determine the patient's readiness for change and target messages appropriately. When a patient is not even beginning to think about eating more fruits and vegetables in his or her diet, it is unrealistic to tell the patient to eat at least five fruits and vegetables every day. It would be more appropriate to inform the patient why this is important, have the patient identify a favorite fruit or vegetable, and give one or two simple suggestions as to how to incorporate the fruits or vegetables into his or her diet. By helping patients through the change process, we can reduce long-term complications of diabetes.

Hirsutism

Excessive body hair in a masculine distribution.

Table 51-4 Comparison of Type 1 and Type 2 Diabetes Mellitus

FACTOR TYPE 1 TYPE 2 Age at onset Usually 30 years or younger, but can occur at any age Usually age 35 years or older, but can occur at any age Incidence is increasing in children Body weight Normal or underweight 80% are overweight Symptoms at onset Sudden; polyphagia, polydipsia, polyuria, weight loss, weakness, fatigue; glycosuria, hyperglycemia; acidosis, progressing to DKA Gradual; may be asymptomatic at onset; later, may develop signs and symptoms of type 1; others include slow wound healing, blurred vision, pruritus, boils or other skin infections; vaginal infections in women Treatment Diet, exercise, and insulin; may add subcutaneous insulin-enhancing drug (pramlintide [Symlin]) Diet and exercise; or diet, exercise, and oral hypoglycemic agents; or diet, exercise, oral hypoglycemic agents, and insulin during times of illness or stress; may add a subcutaneous insulin-enhancing agent such as exenatide (Byetta) or pramlintide Incidence of complications Frequent Frequent Psychosocial and sexual concerns Irritability; disturbed body image; mood swings, depression; menstrual irregularities; decreased libido Disturbed body image; amenorrhea; decreased libido; poor tolerance to stress

Safety Alert! Emergency Care for Hypoglycemic Reaction

IMMEDIATE TREATMENT: IF CONSCIOUS • Give patient 10 to 20 g of quick-acting carbohydrate in some form, such as 4 to 6 oz of orange juice or a regular soft drink (not a diet drink); half of a candy bar; commercially prepared concentrated dextrose tablets or glucose paste; one tube Cake Mate icing gel (small); 2 tsp sugar or honey; six jelly beans or gumdrops; five or six LifeSavers or other roll candy; four animal crackers; or one granola bar. Offer another 5 to 20 g of quick-acting carbohydrate in 15 minutes if no relief is obtained. • Give patient additional food, a longer-acting carbohydrate (e.g., slice of bread, crackers with peanut butter), after symptoms subside. IMMEDIATE TREATMENT: IF UNCONSCIOUS • Squeeze one tube of glucagon gel between teeth and gums, in buccal space, or give glucagon 0.5 to 1 mg subQ or IM; get patient to hospital. Hospitalized patients may receive IV bolus of 20 mL of 50% glucose or 50 mL of 20% glucose; glucagon may be given intravenously. Patient may need IV 10% or 20% glucose at 100 mL/hr to follow. NURSING INTERVENTIONS DURING AND AFTER HYPOGLYCEMIC EPISODE • Stay with the patient; check vital signs and do fingerstick blood glucose levels. • Monitor for worsening of condition or relief of symptoms. • If patient becomes unconscious, administer glucagon buccally, subcutaneously, intramuscularly, or intravenously. • Be certain patient ingests food such as milk, six crackers with peanut butter, or one slice cheese and six crackers after symptoms end. • Observe closely for 1 to 2 hours after cessation of symptoms. • Notify physician about the hypoglycemic reaction. • Assess reason the reaction may have occurred.

Idiopathic hyperplasia

Increase, without any known cause, in the number of cells.

Nursing Care Plan 51-1 The Patient with Diabetes Mellitus

Ms. Thompson is an obese, 52-year-old married patient with type 2 diabetes mellitus (DM) diagnosed 3 years ago. She was referred to a short-term ambulatory diabetes education program by her physician for instruction on insulin administration because she has not achieved blood glucose control with dietary measures. Objective data included blood glucose 220 mg/dL, weight 200 pounds, and blood pressure 134/84 mm Hg. Collaborative nursing actions include teaching Ms. Thompson measures that will help her control blood glucose (insulin, diet, and exercise) and how to detect, prevent, and treat hypoglycemic reactions. The nurse reported Ms. Thompson's work schedule to the physician and asked for insulin dosage alterations on weekends. The physician was unaware of her work schedule and stated that blood glucose control could not be optimum with this schedule. NURSING DIAGNOSIS Deficient knowledge: self-injections, SMBG, related to lack of exposure Patient Goals and Expected Outcomes Nursing Interventions Evaluation Patient will independently self-administer insulin Patient will perform SMBG accurately Patient will use measurements obtained by SMBG to achieve blood glucose less than 126 mg/dL Patient will be able to detect and treat hypoglycemia Support patient as necessary to self-inject insulin. Observe patient's skill in SMBG; correct as necessary. Review with patient the effect of activity, dietary intake, and insulin on blood glucose. Instruct patient on frequency and timing of SMBG. Review with patient signs and symptoms and treatment measures. Refer to dietitian for modification of diet necessary with insulin and for verification of diet knowledge. Patient demonstrates safety in drawing up and self-administering insulin. Patient demonstrates accuracy in SMBG. Patient can verbalize the effect of activity, diet, and insulin on blood glucose. Patient can recite signs and symptoms of hypoglycemia and the correct immediate treatment to pursue. NURSING DIAGNOSIS Ineffective health maintenance, related to ineffective coping skills Patient Goals and Expected Outcomes Nursing Interventions Evaluation Patient will state at least one change that will improve blood glucose control Teach patient effects of stress, lack of exercise, and activity pattern on blood glucose. Explore with patient willingness and ability to change behaviors: sleep-activity, coping, and exercise. Engage patient in mutual problem solving; refrain from prescribing. Explore sources for long-term support in learning more effective coping skills; suggest support groups: • For patients with DM • For weight loss and maintaining weight loss • Available at work in health service program Suggest to patient that she seek a trial period on day shift on weekends. Patient has enrolled in an exercise and weight-reduction program to assist in achieving a reasonable weight and beneficial exercise. Critical Thinking Questions 1. Ms. Thompson received Humalog 75/25, 25 units subQ at 7:30 AM. She ate her American Diabetes Association diet at breakfast and lunch. At 3:00 PM she complains of being hungry, nervous, and tremulous. What are the immediate nursing interventions? 2. Ms. Thompson states, "I need to lose about 40 pounds, and I'm considering joining a weight-reduction club." What would be some helpful suggestions by the nurse? 3. In discharge planning, the nurse notes that Ms. Thompson has poorly fitting shoes. What would be some important discharge patient teaching for foot care?

Life Span Considerations

Older Adults Endocrine Disorder • Diabetes mellitus is more prevalent in older adults. A major reason for this is that the process of aging involves insulin resistance and glucose intolerance, which are believed to be precursors to type 2 diabetes. • The classic signs and symptoms of diabetes may not be obvious in older adults. • Dietary management may be complicated by a variety of functional, social, economic, and financial factors. • Hormone supplements must be administered with caution. • Older adult diabetic patients are at increased risk for infection and should be counseled to receive proper immunizations and seek regular medical attention for even minor symptoms. The older adult often has considerable difficulty in managing diabetes. • Some symptoms of hypothyroidism in the older adult are similar to those in a younger person but are more likely to be overlooked because the symptoms—fatigue, mental impairment, sluggishness, and constipation—are often attributed solely to aging. The older person with hypothyroidism has symptoms unique to the age set, including more disturbances of the central nervous system, such as syncope, convulsions, dementia, and coma. There is often pitting edema and deafness. • The older patient with hyperthyroidism frequently has manifestations related only to the cardiovascular system, such as palpitations, angina, atrial fibrillation, and breathlessness. Signs and symptoms often attributed to "aging" may actually indicate an endocrine problem.

Turgor

The normal resiliency of the skin caused by the outward pressure of the cells and interstitial fluid; may be assessed as increased or decreased skin turgor.

Safety Alert! Emergency Care for Hyperglycemic Reaction (Diabetic Ketoacidosis)

USUAL TREATMENT DURING ACUTE STAGE • Start an IV, using an 18-gauge needle, and begin fluid replacement, usually with 0.9% normal saline 1L/hr, until blood pressure is stabilized and urinary output is 30 to 60 mL/hr. When blood glucose levels approach 250 mg/dL, add 5% dextrose to the fluid regimen to prevent hypoglycemia. • Give regular insulin (the only kind that can be given intravenously) as a piggyback infusion, using 100 units regular insulin in 500 mL normal saline. Administer the infusion with a pump controller. Adjust the infusion rate to obtain and maintain desired blood glucose levels. • Determine blood glucose level hourly (SMBG method or venous sample). • Provide IV replacement of potassium to help move insulin into cells; monitor serum potassium. • Administer oxygen via nasal cannula or nonrebreather mask. • Monitor cardiac status, with central venous pressure and Swan-Ganz monitoring if available. • Insert Foley catheter and monitor I&O hourly. • Assess vital signs and neurologic status. NURSING INTERVENTIONS DURING AND AFTER DIABETIC KETOACIDOSIS • Keep airway patent. • Maintain patent IV infusion at prescribed rate. • Keep accurate I&O record. • Do accurate blood testing for glucose and urine testing for acetone. • Monitor vital signs frequently, and assess cardiac status on monitor. • Assess breath sounds for fluid overload. • Assess level of consciousness frequently, and perform neurologic checks as ordered. • Assess the cause of DKA.

Hyperglycemia

abnormally high blood sugar usually associated with diabetes

Hypocalcemia

abnormally low level of calcium in the blood

hypocalcemia

abnormally low level of calcium in the blood

Ketoacidosis

acidosis with an accumulation of ketone bodies Acidosis accompanied by an accumulation of ketone in the blood resulting from faulty carbohydrate metabolism.

Hypoglycemia

a. abnormally low blood sugar usually resulting from excessive insulin or a poor diet b. A lower than normal amount of glucose in the blood; usually caused by administration of too much insulin, excessive secretion of insulin by the islet cells of the pancreas, or dietary deficiency.

Neuropathy

any pathology of the peripheral nerves Any abnormal condition characterized by inflammation and degeneration of the peripheral nerves.

Lipodystrophy

atrophy of subcutaneous tissue and may occur if hte same injection site is used too frequently; prevented by rotation of injection sites Abnormality in the metabolism or deposition of fats. Insulin lipodystrophy is the loss of local fat deposits in diabetic patients as a complication of repeated insulin injections.

type 2 diabetes mellitus

diabetes in which the body produces insulin, but not enough, or there is insulin resistance (a defective use of the insulin that is produced)--the patient usually is not dependent on insulin for survival

Type 1 diabetes mellitus

diabetes in which there is no beta cell production of insulin--the patient is dependent on insulin for survival

polyphagia

excessive hunger

Polydipsia

excessive thirst (as in cases of diabetes or kidney dysfunction)

polyuria

excessive urination

Endocrinologist

physician who specializes in the diagnosis and treatment of conditions affecting the endocrine system

Glycosuria

the presence of abnormally high levels of sugar in the urine

Get Ready for the NCLEX® Examination! Key Points

• Endocrine glands are ductless glands that release chemicals (hormones) into the bloodstream to regulate body activities. • The pituitary gland, located in the brain, is the master gland of the endocrine system. • Hormones have a generalized effect on metabolism, growth and development, and reproduction. • The endocrine glands regulate themselves by a series of negative feedback messages. • The hormones secreted by the endocrine glands affect tissues of the entire body, and an imbalance in their levels may contribute to pathologic changes in many different systems. • Acromegaly and gigantism, disorders of the pituitary gland, result in growth changes that may have a negative effect on the patient's self-image and self-esteem. • Diabetes insipidus is a disorder of the posterior pituitary and must not be confused with DM, a disorder of the pancreas. • Clinically, SIADH is characterized by hyponatremia and water retention that progresses to water intoxication. When caring for the patient with hyperthyroidism, provide for adequate rest periods and be sure that fluid and food intake meets the patient's nutritional needs. • The emotions of the patient with hyperthyroidism are labile, so try to eliminate sources of stress from the environment, to help prevent emotional trauma. • 131I should not be administered to a pregnant patient because of the risk to the fetus; nurses who are pregnant should not care for these patients. • The thyroidectomy patient faces three life-threatening postoperative complications: hemorrhage, tetany, and thyroid crisis. • The patient with hypothyroidism may experience sluggish mental and physical functioning, so be patient and allow adequate time for nursing routines. • The prognosis for papillary adenocarcinoma of the thyroid is excellent because few of these tumors metastasize. • When administering IV calcium chloride to any patient, be careful that none of the drug extravasates because tissue sloughing may result. • The extreme hypertension often seen in patients with pheochromocytoma may result in cerebrovascular accident. • Depression is common in patients who suffer from Cushing's syndrome; be alert for suicidal thoughts and suicide attempts. • The four main facets of medical treatment for the patient with DM are diet, SMBG, exercise, and medication. • Type 1 DM is usually first diagnosed in people younger than 30 years of age; type 2 DM is more commonly found after age 35, and the incidence increases with age. • As insulin resistance progresses, the pancreas secretes greater amounts of insulin to compensate. This in turn leads to progressive beta-cell failure and a lessening of insulin production. Both beta-cell dysfunction and insulin resistance are required for the development of hyperglycemia, the central metabolic characteristic of type 2 DM. • The older person with diabetes may have a high blood glucose level before excreting any into the urine because of an increased renal threshold for glucose. • The diabetic diet must be individualized, taking into consideration many factors, such as age, lifestyle, food preferences, and the ability to cook and store food. • The person with type 1 DM must have access to a source of quick glucose at all times, in the event of a hypoglycemic reaction. • Become familiar with the clinical manifestations of DKA, HHNC, and hypoglycemic reaction to properly assess diabetic patients, respond therapeutically, and educate them in self-care. • Observe patients on insulin therapy and oral hypoglycemic medications during the time of peak action of the medication, and initiate treatment promptly if hypoglycemia develops. • The nurse must be knowledgeable about the various insulin types and characteristics. • Two new insulin-enhancing drugs given subcutaneously are pramlintide and exenatide. • There are five classes of oral hypoglycemic drugs: sulfonylureas, meglitinides, biguanide, alpha-glucosidase inhibitors, and thiazolidinediones. • DKA can result in seizures, brain damage, or death for the patient with type 1 DM.

Health Promotion Foot Care for the Patient with Diabetes Mellitus

• Wash feet daily with a mild soap and warm water. Test water temperature with hands first. • Pat feet dry gently, especially between toes. • Examine feet daily for cuts, blisters, edema, erythema, and tender areas. If patient's eyesight is poor, have others inspect feet. • Use lanolin on feet to prevent skin from drying and cracking. Do not apply between toes. • Use mild foot powder on feet if perspiring. • Do not use commercial remedies to remove calluses or corns. • Cleanse cuts with warm water and mild soap, covering with clean dressing. Do not use iodine, rubbing alcohol, or strong adhesives. • Report skin infections or nonhealing lesions to health care provider immediately. • Cut toenails even with rounded contour of toes. Do not cut down corners. The best time to trim nails is after a shower or bath. • Separate overlapping toes with cotton or lamb's wool. • Avoid open-toe, open-heel, and high-heel shoes. Leather shoes are preferred to plastic ones. Wear slippers with soles. Do not go barefoot. Shake out shoes before putting on. • Wear clean, absorbent (cotton or wool) socks or stockings that have not been mended. Colored socks must be colorfast. • Do not wear clothing that leaves impressions or constricts circulation. • Do not use hot water bottles or heating pads to warm feet. Wear socks for warmth. • Guard against frostbite. • Exercise feet daily either by walking or by flexing and extending feet in suspended position. Avoid prolonged sitting, standing, and crossing of legs.