Endocrine Homeostasis - DKA, HHS, DI, SIADH (NCLEX 3000)

A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which statement indicates that the client understands her condition and how to control it? 1. "I should avoid becoming dehydrated and pay attention to my need to urinate, drink, or eat more than usual." 2. "If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar." 3. "I will have to monitor my blood glucose level closely for hypoglycemia." 4. "If I begin to feel especially hungry and thirsty, I'll eat a snack high in carbohydrates."

A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which statement indicates that the client understands her condition and how to control it? 1. "I should avoid becoming dehydrated and pay attention to my need to urinate, drink, or eat more than usual." 2. "If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar." 3. "I will have to monitor my blood glucose level closely for hypoglycemia." 4. "If I begin to feel especially hungry and thirsty, I'll eat a snack high in carbohydrates." Correct: 1 RATIONALES: Inadequate fluid intake during hyperglycemic episodes commonly leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. Drinking a glass of nondiet soda would be appropriate for hypoglycemia. The client needs to monitor for hyperglycemia, not hypoglycemia. A high-carbohydrate diet would exacerbate the client's condition, particularly if fluid intake is low. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? 1. Infusing I.V. fluids rapidly as ordered 2. Encouraging increased oral intake 3. Restricting fluids 4. Administering glucose-containing I.V. fluids as ordered

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate? 1. Infusing I.V. fluids rapidly as ordered 2. Encouraging increased oral intake 3. Restricting fluids 4. Administering glucose-containing I.V. fluids as ordered Correct: 3 RATIONALES: To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis

A client is admitted with a serum glucose level of 618 mg/dl. The client is awake and oriented, with hot, dry skin; a temperature of 100.6° F (38.1° C); a heart rate of 116 beats/minute; and a blood pressure of 108/70 mm Hg. Based on these findings, which nursing diagnosis takes highest priority? 1. Deficient fluid volume related to osmotic diuresis 2. Decreased cardiac output related to increased heart rate 3. Imbalanced nutrition: Less than body requirements related to insulin deficiency 4. Ineffective thermoregulation related to dehydration

A client is admitted with a serum glucose level of 618 mg/dl. The client is awake and oriented, with hot, dry skin; a temperature of 100.6° F (38.1° C); a heart rate of 116 beats/minute; and a blood pressure of 108/70 mm Hg. Based on these findings, which nursing diagnosis takes highest priority? 1. Deficient fluid volume related to osmotic diuresis 2. Decreased cardiac output related to increased heart rate 3. Imbalanced nutrition: Less than body requirements related to insulin deficiency 4. Ineffective thermoregulation related to dehydration Correct: 1 RATIONALES: A serum glucose level of 618 mg/dl indicates hyperglycemia, which causes polyuria and deficient fluid volume. In this client, tachycardia is more likely to result from deficient fluid volume than decreased cardiac output because his blood pressure is normal. Although the client's serum glucose level is elevated, food isn't a priority because fluids and insulin should be administered to lower the serum glucose level. Therefore, Imbalanced nutrition: Less than body requirements isn't an appropriate nursing diagnosis. A temperature of 100.6° F (38.1° C) isn't life-threatening, which eliminates Ineffective thermoregulation as the top priority. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will prescribe diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise? 1. Cerebral edema 2. Hypovolemic shock 3. Severe hyperkalemia 4. Tetany

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will prescribe diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise? 1. Cerebral edema 2. Hypovolemic shock 3. Severe hyperkalemia 4. Tetany Correct: 1 RATIONALES: Noncompliance with treatment for SIADH may lead to water intoxication from fluid retention caused by excessive antidiuretic hormone. This, in turn, limits water excretion and increases the risk of cerebral edema. Hypovolemic shock results from severe fluid volume deficit; in contrast, SIADH causes excessive fluid volume. The major electrolyte disturbance in SIADH is dilutional hyponatremia, not hyperkalemia. Because SIADH doesn't alter renal function, potassium excretion remains normal; therefore, severe hyperkalemia doesn't occur. Tetany results from hypocalcemia, an electrolyte disturbance not associated with SIADH. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis

A client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. Preoperatively, the nurse should assess for potential complications by: 1. testing for ketones in the urine. 2. testing urine specific gravity. 3. checking temperature frequently. 4. performing capillary glucose testing frequently.

A client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. Preoperatively, the nurse should assess for potential complications by: 1. testing for ketones in the urine. 2. testing urine specific gravity. 3. checking temperature frequently. 4. performing capillary glucose testing frequently. Correct: 4 RATIONALES: The nurse should perform capillary glucose testing frequently because excess cortisol may cause insulin resistance, placing the client at risk for hyperglycemia. Urine ketone testing isn't indicated because the client does secrete insulin and, therefore, isn't at risk for ketosis. Urine specific gravity isn't indicated because although fluid balance can be compromised, it usually isn't dangerously imbalanced. Temperature regulation may be affected by excess cortisol and isn't an accurate indicator of infection. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level? 1. Cool, moist skin 2. Rapid, thready pulse 3. Trembling arms and legs 4. Slow, shallow respirations

A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level? 1. Cool, moist skin 2. Rapid, thready pulse 3. Trembling arms and legs 4. Slow, shallow respirations Correct: 2 RATIONALES: This client's abnormally high blood glucose level indicates hyperglycemia, which typically causes polyuria, polyphagia, and polydipsia. Because polyuria leads to fluid loss, the nurse should expect to assess signs of a fluid volume deficit, such as a rapid, thready pulse, decreased blood pressure, and rapid respirations. Cool, moist skin trembling arms and legs are associated with hypoglycemia. Rapid respirations — not slow, shallow ones — are associated with hyperglycemia. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis

A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize? 1. "You must lie flat for 24 hours after surgery." 2. "You must avoid coughing, sneezing, and blowing your nose." 3. "You must restrict your fluid intake." 4. "You must report ringing in your ears immediately."

A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize? 1. "You must lie flat for 24 hours after surgery." 2. "You must avoid coughing, sneezing, and blowing your nose." 3. "You must restrict your fluid intake." 4. "You must report ringing in your ears immediately." Correct: 2 RATIONALES: After a transsphenoidal hypophysectomy, the client must refrain from coughing, sneezing, and blowing the nose for several days to avoid disturbing the surgical graft used to close the wound. The head of the bed must be elevated, not kept flat, to prevent tension or pressure on the suture line. Within 24 hours after a hypophysectomy, transient diabetes insipidus commonly occurs; this calls for increased, not restricted, fluid intake. Visual, not auditory, changes are a potential complication of hypophysectomy. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

A client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) has a history of type 2 diabetes, which is controlled by tolazamide (Tolinase). What is the most important laboratory test for confirming HHNS? 1. Serum potassium level 2. Serum sodium level 3. Arterial blood gas (ABG) values 4. Serum osmolarity

A client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) has a history of type 2 diabetes, which is controlled by tolazamide (Tolinase). What is the most important laboratory test for confirming HHNS? 1. Serum potassium level 2. Serum sodium level 3. Arterial blood gas (ABG) values 4. Serum osmolarity Correct: 4 RATIONALES: Serum osmolarity is the most important test for confirming HHNS; it's also used to guide treatment strategies and determine evaluation criteria. A client with HHNS typically has a serum osmolarity of more than 350 mOsm/L. Serum potassium, serum sodium, and ABG values are also measured, but they aren't as important as serum osmolarity for confirming a diagnosis of HHNS. A client with HHNS typically has hypernatremia and osmotic diuresis. ABG values reveal acidosis, and the potassium level is variable. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Comprehension

A client with primary diabetes insipidus is prescribed desmopressin (DDAVP). Which instruction should the nurse provide before the client is discharged? 1. "Administer desmopressin while the suspension is cold." 2. "Your condition isn't chronic, so you won't need to wear a medical identification bracelet." 3. "You may not be able to use desmopressin nasally if you have nasal discharge or blockage." 4. "You won't need to monitor your fluid intake and output after you start taking desmopressin."

A client with primary diabetes insipidus is prescribed desmopressin (DDAVP). Which instruction should the nurse provide before the client is discharged? 1. "Administer desmopressin while the suspension is cold." 2. "Your condition isn't chronic, so you won't need to wear a medical identification bracelet." 3. "You may not be able to use desmopressin nasally if you have nasal discharge or blockage." 4. "You won't need to monitor your fluid intake and output after you start taking desmopressin." Correct: 3 RATIONALES: Desmopressin may not be absorbed if the intranasal route is compromised. Although diabetes insipidus is treatable, the client should wear medical identification and carry medication at all times to alert medical personnel in an emergency and ensure proper treatment. The client must continue to monitor fluid intake and output and receive adequate fluid replacement. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Application

A client with type 1 diabetes is admitted to an acute care facility with diabetic ketoacidosis. To correct this acute diabetic emergency, which measure should the health care team take first? 1. Initiate fluid replacement therapy. 2. Administer insulin. 3. Correct diabetic ketoacidosis. 4. Determine the cause of diabetic ketoacidosis.

A client with type 1 diabetes is admitted to an acute care facility with diabetic ketoacidosis. To correct this acute diabetic emergency, which measure should the health care team take first? 1. Initiate fluid replacement therapy. 2. Administer insulin. 3. Correct diabetic ketoacidosis. 4. Determine the cause of diabetic ketoacidosis. Correct: 1 RATIONALES: The health care team first initiates fluid replacement therapy to prevent or treat circulatory collapse caused by severe dehydration. Although diabetic ketoacidosis results from insulin deficiency, the client must have an adequate fluid volume before insulin can be administered; otherwise, the drug won't circulate throughout the body effectively. Therefore, insulin administration follows fluid replacement therapy. Determining and correcting the cause of diabetic ketoacidosis are important steps, but the client's condition must be stabilized first to prevent life-threatening complications. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Application

Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)? 1. Administer 2 to 3 L of I.V. fluid over 2 to 3 hours. 2. Administer 6 L of I.V. fluid over the first 24 hours. 3. Administer a dextrose solution containing normal saline solution. 4. Administer I.V. fluid slowly to prevent circulatory overload and collapse.

Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)? 1. Administer 2 to 3 L of I.V. fluid over 2 to 3 hours. 2. Administer 6 L of I.V. fluid over the first 24 hours. 3. Administer a dextrose solution containing normal saline solution. 4. Administer I.V. fluid slowly to prevent circulatory overload and collapse. Correct: 1 RATIONALES: Regardless of the client's medical history, rapid fluid resuscitation is critical for maintaining cardiovascular integrity. Therefore, 2 to 3 L of I.V. fluid should be given over 2 to 3 hours. Profound intravascular depletion requires aggressive fluid replacement. A typical fluid resuscitation protocol is 6 L of fluid over the first 12 hours, with more fluid to follow over the next 24 hours. Various fluids can be used, depending on the degree of hypovolemia. Commonly prescribed fluids include dextran (in cases of hypovolemic shock), isotonic normal saline solution and, when the client is stabilized, hypotonic half-normal saline solution. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Application

For a client with hyperglycemia, which data collection finding best supports a nursing diagnosis of Deficient fluid volume? 1. Cool, clammy skin 2. Distended neck veins 3. Increased urine osmolarity 4. Decreased serum sodium level

For a client with hyperglycemia, which data collection finding best supports a nursing diagnosis of Deficient fluid volume? 1. Cool, clammy skin 2. Distended neck veins 3. Increased urine osmolarity 4. Decreased serum sodium level Correct: 3 RATIONALES: In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the urine) increases as glucose particles move into the urine. The client experiences glucosuria and polyuria, losing body fluids and experiencing fluid volume deficit. Cool, clammy skin; distended neck veins; and a decreased serum sodium level are signs of fluid volume excess. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

The nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate? 1. Elevated serum acetone level 2. Serum ketone bodies 3. Serum alkalosis 4. Below-normal serum potassium level

The nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate? 1. Elevated serum acetone level 2. Serum ketone bodies 3. Serum alkalosis 4. Below-normal serum potassium level Correct: 4 RATIONALES: A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency. An elevated serum acetone level and serum ketone bodies are characteristic of diabetic ketoacidosis. Metabolic acidosis, not serum alkalosis, may occur in HHNS. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis

Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications? 1. Tetanic contractions 2. Neck vein distention 3. Weight loss 4. Polyuria

Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications? 1. Tetanic contractions 2. Neck vein distention 3. Weight loss 4. Polyuria Correct: 2 RATIONALES: SIADH secretion causes antidiuretic hormone overproduction, which leads to fluid retention. Severe SIADH can cause such complications as vascular fluid overload, signaled by neck vein distention. This syndrome isn't associated with tetanic contractions. It may cause weight gain and fluid retention (secondary to oliguria). NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension

After falling off a ladder and suffering a brain injury, a client develops syndrome of inappropriate antidiuretic hormone (SIADH). Which findings indicate that the treatment he's receiving is effective? Select all that apply: 1. Decrease in body weight 2. Rise in blood pressure and drop in heart rate 3. Absence of wheezes in his lungs 4. Increased urine output 5. Decreased urine osmolarity

After falling off a ladder and suffering a brain injury, a client develops syndrome of inappropriate antidiuretic hormone (SIADH). Which findings indicate that the treatment he's receiving is effective? Select all that apply: 1. Decrease in body weight 2. Rise in blood pressure and drop in heart rate 3. Absence of wheezes in his lungs 4. Increased urine output 5. Decreased urine osmolarity Correct: 1, 4, 5 RATIONALES: SIADH is an abnormality in which there is an abundance of the antidiuretic hormone. The predominant features are hyponatremia, oliguria, edema, and weight gain. Evidence of successful treatment includes a reduction in weight, an increase in urine output, and a decrease in the urine's concentration (urine osmolarity). NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis

The nurse is developing a teaching plan for a client diagnosed with diabetes insipidus. The nurse should include information about which hormone lacking in clients with diabetes insipidus? 1. Antidiuretic hormone (ADH) 2. Thyroid-stimulating hormone (TSH) 3. Follicle-stimulating hormone (FSH) 4. Luteinizing hormone (LH)

The nurse is developing a teaching plan for a client diagnosed with diabetes insipidus. The nurse should include information about which hormone lacking in clients with diabetes insipidus? 1. Antidiuretic hormone (ADH) 2. Thyroid-stimulating hormone (TSH) 3. Follicle-stimulating hormone (FSH) 4. Luteinizing hormone (LH) Correct: 1 RATIONALES: Clients with diabetes insipidus lack the hormone ADH. The client's TSH, FSH, and LH levels aren't affected. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis

When caring for a client with diabetes insipidus, the nurse expects to administer: 1. vasopressin (Pitressin Synthetic). 2. furosemide (Lasix). 3. regular insulin. 4. 10% dextrose.

When caring for a client with diabetes insipidus, the nurse expects to administer: 1. vasopressin (Pitressin Synthetic). 2. furosemide (Lasix). 3. regular insulin. 4. 10% dextrose. Correct: 1 RATIONALES: Because diabetes insipidus results from decreased antidiuretic hormone (vasopressin) production, the nurse should expect to administer synthetic vasopressin for hormone replacement therapy. Furosemide, a diuretic, is contraindicated because a client with diabetes insipidus experiences polyuria. Insulin and dextrose are used to treat diabetes mellitus and its complications, not diabetes insipidus. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological therapies COGNITIVE LEVEL: Comprehension

Which of the following would indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? 1. Confusion and seizures 2. Sunken eyeballs and spasticity 3. Flaccidity and thirst 4. Tetany and increased blood urea nitrogen (BUN) levels.

Which of the following would indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? 1. Confusion and seizures 2. Sunken eyeballs and spasticity 3. Flaccidity and thirst 4. Tetany and increased blood urea nitrogen (BUN) levels. Correct: 1 RATIONALES: Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication. NURSING PROCESS STEP: Data collection CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis

Which outcome indicates that treatment of a client with diabetes insipidus has been effective? 1. Fluid intake is less than 2,500 ml/day. 2. Urine output measures more than 200 ml/hour. 3. Blood pressure is 90/50 mm Hg. 4. The heart rate is 126 beats/minute.

Which outcome indicates that treatment of a client with diabetes insipidus has been effective? 1. Fluid intake is less than 2,500 ml/day. 2. Urine output measures more than 200 ml/hour. 3. Blood pressure is 90/50 mm Hg. 4. The heart rate is 126 beats/minute. Correct: 1 RATIONALES: Diabetes insipidus is characterized by polyuria (up to 8 L/day), constant thirst, and an unusually high oral intake of fluids. Treatment with the appropriate drug should decrease both oral fluid intake and urine output. A urine output of 200 ml/hour indicates continuing polyuria. A blood pressure of 90/50 mm Hg and a heart rate of 126 beats/minute indicate compensation for the continued fluid deficit, suggesting that treatment hasn't been effective. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis