Endocrine

A 45-year-old female presents with complaints of anxiety, insomnia, weight loss, the inability to concentrate, and eyes feeling "gritty." Thyroid function tests reveal the following: thyroid-stimulating hormone (TSH) of 0.02 mU/L, T3 of 253 ng/dL, T4 of 20 g/dL, and 6-hour radioactive iodine uptake (RAIU) of 85%. Which diagnosis is most likely? A.Graves' disease B.Hashimoto's thyroiditis C.Primary hypothyroidism D.Multinodular goiter

Solution: A Graves' disease, an autoimmune disease that causes hyperthyroidism, is most prevalent in middle-aged females. Symptoms include rapid weight loss, anxiety, and insomnia. The patient may experience cardiac symptoms (e.g., palpitations, hypertension) and ophthalmopathy. Labs show low TSH (<0.5 mU/L) and elevated serum-free T4 and T3. A 6-hour RAIU shows diffuse uptake (goiter). In Hashimoto's thyroiditis, the most common form of hypothyroidism, TSH levels would be high and thyroid hormone levels low. In thyroiditis, RAIU is low (≤2%). A multinodular goiter will show an uptake in the high-normal range (3%-10%).

The nurse practitioner is going to prescribe levothyroxine (Synthroid) to an elderly patient with Hashimoto's thyroiditis and a history of two myocardial infarctions and coronary artery disease. What is the appropriate initial dose for this patient? A.12.5 mcg/day B.50 mcg/day C.25 mcg/day delayed until after thyroid surgery D.100 mcg initiated before thyroid surgery

Solution: A 12.5 mcg/day. Older patients and patients with cardiac disease should begin with an initial dose of 12.5 mcg/day. The dosage is increased at 2- to 4-week intervals until 100 mcg/day is reached. This slow titration prevents further cardiac stress. Younger patients would be started on the usual maintenance dose of 25 to 50 mcg/day. Patients with Hashimoto's thyroiditis do not require surgical intervention.

A patient newly diagnosed with diabetes mellitus has a body mass index (BMI) of 32.5, creatinine of 1.4 mg/dL, blood urea nitrogen (BUN) of 20.0 mg/dL, and fasting blood sugar (FBS) of 186 mg/dL. The patient also has a history of bladder cancer. Which is the most appropriate drug class for this patient? A.Biguanides B.Thiazolidinediones C.Meglitinides D.Sulfonylureas

Solution: A Biguanides. The patient is moderately obese with a BMI of 32.5. BUN and creatinine are within normal limits but should be monitored. Metformin (a biguanide) is preferred for obese patients because it helps with weight loss. Sulfonylureas stimulate the beta cells but have a long half-life, and there is a high risk for severe hypoglycemic events. Thiazolidinediones should not be used with patients who have a history of bladder cancer or heart failure. Meglitinides stimulate pancreatic release of insulin and are indicated for patients with postprandial hyperglycemia.

Which lab results suggest a diagnosis of hypothyroidism? A.Elevated thyroid-stimulating hormone (TSH), low free T4 B.Elevated TSH, normal free T4 C.High free T4 D.Normal free T4

Solution: A Elevated thyroid-stimulating hormone (TSH), low free T4. In hypothyroidism, TSH is >5.0 mU/L, free T4 is low, and T3 is low. In subclinical hypothyroidism, TSH is >5.0 mU/L, free T4 is normal, and T3 is normal. In hyperthyroidism, TSH is <0.5 mU/L, and free T4 and T3 are high. Subclinical hyperthyroidism presents with a TSH <0.5 mU/L and normal free T4 and T3.

Which of the following is recommended on an annual basis for an elderly patient with type 2 diabetes? A.Eye exam with an ophthalmologist B.Follow-up visit with a urologist C.Periodic visits to an optometrist D.Colonoscopy

Solution: A Eye exam with an ophthalmologist. Elderly patients with type 2 diabetes should have a dilated eye exam done annually by an ophthalmologist. They should also see a podiatrist once or twice a year. Preventive care also includes receiving a flu shot annually, receiving a Pneumovax vaccine if older than 60 years of age, and taking an 81-mg baby aspirin each day.

A 30-year-old woman with type 2 diabetes uses regular and intermediate-acting insulin in the morning and evening. She denies changes in her diet or any illness, but she recently started attending aerobic classes in the afternoon. Her fasting blood glucose level before breakfast is now elevated. Which of the following is best described? A.Somogyi phenomenon B.Dawn phenomenon C.Raynaud's phenomenon D.Insulin resistance

Solution: A Somogyi phenomenon Somogyi phenomenon is caused by too much insulin (or missing a meal or snack) in the evening, which results in hypoglycemia in the early morning (2 a.m.-3 a.m.). The body compensates by secreting glucagon (from the liver) and epinephrine, which results in high blood glucose levels in the morning. The Somogyi phenomenon (or Somogyi effect) is also known as the rebound effect.

Which finding will the nurse practitioner expect to see in a 13-year-old male patient with Cushing's syndrome? Excess estrogen Delayed puberty Pseudogynecomastia Accelerated growth in height

Solution: B Delayed puberty. Cushing's syndrome is associated with delayed puberty and growth failure in children and adolescents. Patients with Cushing's syndrome have an excess of androgens, not estrogen. Gynecomastia, not pseudogynecomastia, occurs with Cushing's disease. Pseudogynecomastia is caused by the deposition of fat, whereas gynecomastia is caused by excess cortisol.

A 25-year-old patient with a history of diabetes is positive for serum ketones and has a serum glucose level >300 mg/dL. Which diagnosis is most likely? A.Diabetes insipidus B.Diabetic ketoacidosis C.Hypoglycemia D.Somogyi phenomenon

Solution: B Diabetic ketoacidosis. A patient with serum ketones and serum glucose levels >300 mg/dL is likely experiencing diabetic ketoacidosis. Diabetes insipidus is an overproduction of antidiuretic hormone; it does not create ketones in the blood. Hypoglycemia causes low blood glucose levels. The Somogyi phenomenon is rebound hyperglycemia following an episode of hypoglycemia.

A 10-year-old boy has type 1 diabetes. His late-afternoon blood sugar levels over the past 2 weeks have ranged from 210 mg/dL to 230 mg/dL. He currently injects 10 units of regular insulin and 25 units of neutral protamine Hagedorn (NPH) insulin in the morning and 15 units of regular insulin and 10 units of NPH insulin in the evening. Which of the following is the best treatment plan for this patient? Increase both types of insulin in the morning dose Increase only the NPH insulin in the morning dose Decrease the afternoon dose of NPH insulin Decrease both NPH and regular insulin doses in the morning

Solution: B Increase only the NPH insulin in the morning. Regular insulin is rapid/short-acting insulin. Depending on the type of regular insulin, the onset is 10 to 15 minutes, and the insulin peaks within an average of 1.5 hours, with a duration of 3 to 5 hours. NPH insulin is an intermediate-acting insulin. Depending on the type of NPH insulin, the onset is 1.5 to 3 hours. NPH peaks in 4 to 12 hours, and the duration is from 18 to 24 hours. By increasing the morning NPH, the peak will occur in the afternoon, bringing down the blood glucose.

The nurse practitioner is evaluating a middle-aged woman who has experienced gradual weight gain, lack of energy, dry hair, and an irregular period for the past 8 months. Routine annual laboratory testing showed a thyroid-stimulating hormone (TSH) level of 10 mU/L. The nurse practitioner decides to order a thyroid profile. Results show that TSH is 8.50 mU/L and serum-free T4 is decreased. During the physical exam, the patient's body mass index (BMI) is 28. The heart and lung exams are both normal. Which of the following is the best treatment plan for this patient? A.Advise the patient that the decreased TSH level means her thyroid problem has resolved B.Start patient on levothyroxine (Synthroid) 25 mcg PO daily C.Start patient on Armour thyroid D.Refer the patient to an endocrinologist

Solution: B Start patient on levothyroxine (Synthroid) 25 mcg PO daily. The patient is symptomatic (weight gain, lack of energy, and irregular periods) with low free T4. Even though the TSH level decreased slightly, the free T4 remains low. An elevated TSH and low free T4 are indicative of hypothyroidism. The next step is to start the patient on levothyroxine (Synthroid) 25 mcg daily and recheck the TSH in 6 weeks. The goal is to normalize the TSH (between 1.0 and 3.5) and to ameliorate the patient's symptoms (e.g., increased energy, feels better). Armour thyroid (desiccated thyroid) is a natural supplement composed of dried (desiccated) pork thyroid glands. It is used in alternative medicine as a substitute to synthetic levothyroxine (Synthroid).

The best screening test for both hyperthyroidism and hypothyroidism is: Free T4 (thyroxine) Thyroid-stimulating hormone Thyroid profile Palpation of the thyroid gland

Solution: B Thyroid-stimulating hormone The best screening test for both hypothyroidism and hyperthyroidism is TSH level. A normal TSH rules out primary hypothyroidism in asymptomatic patients. Abnormal TSH should be followed by determination of thyroid hormone levels. Overt hypothyroidism is defined as a clinical syndrome of hypothyroidism associated with elevated TSH and decreased serum levels of T4 or T3. Subclinical hypothyroidism is defined as a condition without typical symptoms of hypothyroidism, elevated TSH (>5 μU/mL), and normal circulating thyroid hormones (free T4). Overt thyrotoxicosis is defined as the syndrome of hyperthyroidism associated with suppressed TSH and elevated serum levels of T4 or T3. Subclinical thyrotoxicosis is devoid of symptoms, but TSH is suppressed, although there are normal circulating levels of thyroid hormone.

The best screening test for both hyperthyroidism and hypothyroidism is: A.Free T4 (thyroxine) B.Thyroid-stimulating hormone (TSH) C.Thyroid profile D.Palpation of the thyroid gland

Solution: B Thyroid-stimulating hormone (TSH). The best screening test for both hypothyroidism and hyperthyroidism is TSH level. A normal TSH rules out primary hypothyroidism in asymptomatic patients. Abnormal TSH should be followed by determination of thyroid hormone levels. Overt hypothyroidism is defined as a clinical syndrome of hypothyroidism associated with elevated TSH and decreased serum levels of T4 or T3. Subclinical hypothyroidism is defined as a condition without typical symptoms of hypothyroidism, elevated TSH (>5 μU/mL), and normal circulating thyroid hormone. Overt thyrotoxicosis is defined as the syndrome of hyperthyroidism associated with suppressed TSH and elevated serum levels of T4 or T3. Subclinical thyrotoxicosis is devoid of symptoms, but TSH is suppressed, although there are normal circulating levels of thyroid hormone.

A patient has been managed for Graves' disease for 2 years. During a recent office visit, the patient is found to also have atrial fibrillation. Which new medication will the nurse practitioner add to the treatment regimen? Furosemide (Lasix) Warfarin (Coumadin) Cholestyramine (Prevalite) Atenolol (Tenormin)

Solution: B Warfarin (Coumadin). Patients with (Graves' disease) hyperthyroidism are at higher risk for osteoporosis and atrial fibrillation. The most appropriate medication to add to the treatment regimen is warfarin (Coumadin), which treats atrial fibrillation. Furosemide (Lasix) is prescribed for heart failure, which is not a risk factor for a patient with hyperthyroidism. Cholestyramine (Prevalite) is used for hyperlipidemia. A beta blocker such as atenolol is normally prescribed when a patient is first diagnosed with Graves' disease, to lessen hyperstimulation.

Which of the following is used to confirm a diagnosis of Hashimoto's thyroiditis? A.Serum thyroid-stimulating hormone (TSH) B.Free T4 test C.Antithyroid peroxidase and antithyroglobulin antibodies D.Thyroid ultrasound

Solution: C Antithyroid peroxidase and antithyroglobulin antibodies. These are the two types of antibodies that are positive in Hashimoto's thyroiditis. Antithyroid peroxidase antibody is also known as antimicrosomal antibody. Hashimoto's thyroiditis is the most common cause of hypothyroidism in the United States. The serum TSH and free T4 are tests for hypothyroidism, but they are not specific for Hashimoto's thyroiditis, an autoimmune disease.

A female patient presents with complaints of fatigue, cold intolerance, and unexplained weight gain. What is the most likely diagnosis? A.Hyperthyroidism B.Diabetes mellitus C.Hypothyroidism D.Heart failure

Solution: C Hypothyroidism. Symptoms of hypothyroidism include fatigue, cold intolerance, weight gain, and constipation. A patient with hyperthyroidism would present with weight loss, anxiety, palpitations, warm skin, and insomnia. Diabetes mellitus symptoms include polyphagia, polydipsia, and polyuria. Heart failure would present with respiratory symptoms, weight gain, tachypnea, fatigue, and edema.

Which statement made by a 24-year-old patient with diabetes mellitus indicates that education about disease management was effective? A.I will check my blood sugars at the same time I do now B.Eating small meals every 2 hours will keep my blood sugars stable C.If I feel really tired or cannot concentrate, I will call you D.I will stop taking my oral medications and just take insulin

Solution: C If I feel really tired or cannot concentrate, I will call you. A patient with diabetes should eat small meals every 3 to 4 hours to keep blood sugars as normal as possible. Patients who have a blood sugar >300 mg/dL, level of consciousness changes, or dehydration should contact the provider for advice. Blood sugars should be checked more frequently when a patient is sick, and they should not stop taking oral medications or insulin unless their fasting blood glucose (FBG) is lower than expected and as per their provider's orders.

A pediatric patient uses a sliding scale in conjunction with a long-acting insulin to manage type 1 diabetes. Which insulin should the patient prepare for an elevated blood sugar between breakfast and lunch? A.Insulin isophane and insulin regular B.Insulin glargine (Lantus) C.Insulin lispro (Humalog) D.Neutral protamine Hagedorn (NPH)

Solution: C Insulin lispro (Humalog). Lispro is a rapid-acting insulin that is used on a sliding scale to work from meal to meal. Insulin isophane and insulin regular is a mixture of intermediate- and shortacting insulins and would not be appropriate for a sliding scale. Insulin glargine is given once a day. NPH is an intermediate-acting insulin that is not appropriate for a sliding scale.

The Somogyi effect is characterized by which of the following? A.It is a complication of high levels of growth hormone B.It is the physiologic spike of serum blood glucose in the early morning that is caused by the secretion of growth hormone C.It is characterized by high fasting blood glucose in the morning that is caused by the secretion of glucagon by the liver. D.It is a rare phenomenon that only occurs in type 1 diabetic patients

Solution: C It is characterized by high fasting blood glucose in the morning that is caused by the secretion of glucagon by the liver. The Somogyi phenomenon or Somogyi effect occurs when nocturnal hypoglycemia (2 a.m.-3 a.m.) stimulates the liver to produce glucagon, which causes the fasting blood glucose to become elevated. It is also known as the "rebound effect."

A patient receiving thyroid replacement therapy contracts the flu and forgets to take her thyroid replacement medicine. The patient is at risk for which life-threatening complication? A.Exophthalmos B.Thyroid storm C.Myxedema coma D.Pretibial myxedema

Solution: C Myxedema coma. Myxedema coma (severe hypothyroidism) is a life-threatening condition that may develop with the abrupt cessation of thyroid replacement therapy. Exophthalmos, protrusion of the eyeballs, is seen with hyperthyroidism. Thyroid storm is life-threatening but is caused by severe hyperthyroidism. Pretibial myxedema, peripheral mucinous edema involving the lower leg, is associated with hypothyroidism but is not life-threatening.

67.9% complete Question The nurse practitioner is conducting a health assessment on a 21-year-old patient with pheochromocytoma. During the assessment, the nurse practitioner is likely to detect all of the following signs and symptoms, except: A.Headaches B.Tachycardia C.Weight gain D.Sweaty palms

Solution: C Weight gain. Pheochromocytoma is a tumor of the adrenal medulla that secretes excessive catecholamine. It causes hypertension, diaphoresis (including sweaty palms), headaches, tachycardia, hyperglycemia, hypermetabolism, and weight loss (not weight gain).

An obese Asian patient with a BMI (body mass index) of 33 complains of fatigue and excessive thirst and hunger. You suspect type 2 diabetes mellitus. Initial testing to confirm diagnosis can include: A.Fasting plasma glucose level B.Glycated hemoglobin level (A1C) C.Oral glucose tolerance testing D.All of the above

Solution: D All of the above Type 2 diabetes mellitus screening tests include fasting plasma glucose level (>126 mg/dL), random plasma glucose level (>200 mg/dL), and oral glucose tolerance testing (2-hour blood glucose level >200 mg/dL) with a 75-g glucose load. Normal A1C (glycosylated hemoglobin) levels are <6%.

A middle-aged female presents with complaints of weight gain, constipation, and alopecia of the eyebrows. Serum cholesterol is 247 mg/dL and thyroid peroxidase (TPO) is 161 IU/mL. Which diagnosis is most likely? Thyroid cancer Hyperprolactinemia Pheochromocytoma Hashimoto's thyroiditis

Solution: D Hashimoto's thyroiditis. Hashimoto's thyroiditis is an autoimmune disorder of the thyroid gland that is more common in women than men (8:1). Thyroid peroxidase (TPO) levels are the gold standard for diagnosis. Elevated levels confi rm diagnosis (normal TPO is <35 IU/mL). Patients present with weight gain, cold intolerance, goiter (in most cases), and an elevated cholesterol level. Thyroid cancer presents as hoarseness and problems with swallowing (dysphagia, dyspnea, or cough) . There is a higher prevalence in women (3:1) and in women age 20 to 55 years with a family history. Pheochromocytoma causes episodes of headaches, diaphoresis, tachycardia, and hypertension. After an attack, vitals return to normal. Hyperprolactinemia can be a sign of pituitary adenoma (benign) and has a slow onset. Serum prolactin is elevated, and women can present with amenorrhea. As the tumor grows, it will affect vision and cause headaches.

Which mineral lab finding is deficient in a patient presenting with lethargy, weight gain, bradycardia, and a goiter? A.Fluoride B.Calcium C.Sodium D.Iodine

Solution: D Iodine. Iodine is a central component of thyroid hormones, which regulate growth, development, and metabolic rate. Low iodine levels result in hypothyroidism. A patient deficient in iodine will present with weight gain, lethargy, and goiter. If deficient in calcium, a patient will present with impaired growth and osteoporosis. When deficient in fluoride, a patient will present with dental decay and is subject to osteoporosis. A sodium deficiency presents as restlessness, irritability, muscle weakness, cramps, and possibly nausea and vomiting.

Which one of the following findings is associated with diabetic retinopathy? AV nicking Copper wire arterioles Flame-shaped hemorrhages Microaneurysms

Solution: D Microaneurysms Microaneurysms are seen with diabetic retinopathy. Arteriovenous (AV) nicking, copper wire arterioles, and flame hemorrhages are seen with uncontrolled hypertension.

Which of the following findings is associated with thyroid hypofunction? Graves' disease Eye disorder Thyroid storm Myxedema

Solution: D Myxedema. Myxedema (or myxedema coma) is seen in patients with severe hypothyroidism. It refers to the skin changes (thickened skin) seen in chronic severe hypothyroidism. It is a medical emergency with mortality rates exceeding 20%. It is treated with very high doses of thyroid hormone. A thyroid storm occurs when there is extreme elevation of thyroid hormones. Thyroid storm is life-threatening; if left untreated, the mortality rate is about 90%. Call 911 if suspected. Graves' disease is associated with thyroid hyperfunction.

A female patient with a body mass index (BMI) of 29 has a 20-year history of primary hypertension. She has been taking hydrochlorothiazide 25 mg PO daily with excellent results. On this visit, she complains of feeling thirsty all the time, even though she drinks more than 10 glasses of water per day. She reports to the nurse practitioner that she has been having this problem for about 6 months. Upon reading the chart, the nurse practitioner notes that the last two fasting blood glucose levels have been 140 mg/dL and 168 mg/dL. The result of a random blood glucose test is 210 mg/dL. The nurse practitioner will: A.Order another random blood glucose test in 2 weeks B.Initiate a prescription of metformin (Glucophage) 500 mg PO BID C.Order a 3-hour glucose tolerance test D.Order an A1C level

Solution: D Order an A1C level. The next step is to check the A1C level. The treatment goal is an A1C less than 7%. But if the patient is frail or has frequent hypoglycemic episodes, the American Diabetes Association allows a goal of up to 8%. If the A1C level is 6.5 or higher, the patient has type 2 diabetes. With a history of primary hypertension and the use of hydrochlorothiazide, which can have some diuretic-induced renal impairment, this patient is also at moderately increased risk for a rare, but serious and potentially life-threatening, condition—lactic acidosis—when using metformin. Thiazide diuretics have been associated with hyperglycemia, so checking the A1C would help to better understand the role that these medications may be playing in the glucose levels seen in recent lab testing.

A male patient has type 2 diabetes mellitus and a "sensitive stomach." Which medication is least likely to cause him gastrointestinal distress? Naproxen sodium (Anaprox) Aspirin (Bayer's aspirin) Erythromycin (E-mycin) Sucralfate (Carafate)

Solution: D Sucralfate (Carafate) Naproxen sodium, aspirin, and erythromycin all have gastrointestinal side effects. Sucralfate is used to protect the stomach lining by building a protective layer over the stomach lining; it allows healing to occur.