Endocrine Pathopharmacology

The levels of most hormones in the body are monitored and controlled by a (positive/neutral/negative) feedback system.

negative

An overweight patient is distraught after discovering he is at risk for diabetes, i.e. prediabetic. What therapeutic lifestyle change can the nurse teach this patient to reduce the risk of developing full-blown diabetes? A. "Make sure you get aerobic exercise for at least 30 minutes per day, 5 days per week." B. "You must decrease your caloric intake, but your cholesterol intake can stay the same." C. "Medications, such as metformin and simvastatin, can be used to reduce the risk of diabetes." D. "It is desirable to reduce your FPG from 170 mg/dL to below 125 mg/dL."

A (A is correct. Daily aerobic exercise is a TLC that has been shown to help decrease the risk of diabetes among other health problems. B is incorrect, as dietary modifications to decrease cholesterol as well as caloric intake may both help to decrease the risk of diabetes. C is incorrect. Although oral antidiabetics, such as metformin, and cholesterol-controlling drugs, such as simvastatin, can decrease the risk of diabetes, these are pharmacological interventions, not a TLC. D is incorrect. An FPG above 125 implies that the client already has diabetes. For a prediabetic, it is desirable to reduce FPG levels to less than 100 mg/dL.)

Growth hormone deficiency in children results in ___________ while an excess would cause ____________. A. dwarfism; gigantism B. gigantism; acromegaly C. myxedema; Graves' disease D. Addison's disease; Cushing syndrome

A (Dwarfism, or short stature, results from low GH levels during childhood; gigantism results from high GH levels before epiphyseal plates close. Acromegaly results from high GH levels after epiphyseal plates close, i.e. during adulthood. Choices C and D deal with deficiencies and excesses of thyroid hormone and cortisol, respectively.)

A nurse working abroad knows that thyroid disorders diagnosed in third world countries may be attributed to a deficiency in which nutrient? A. iodine B. potassium C. vitamin B12 D. cholesterol

A (Iodine is an essential structural component of T3 and T4, so a lack of iodine in the diet can lead to a thyroid disorder.)

A pediatric nurse assesses a 4-year-old boy whose parents report that he has not been growing as much. You note he has a puffy face with a protruding tongue, and he scores significantly low on the language and speech component of the Denver Developmental Screening Test. IGF-1 levels appear normal on blood draw. What condition is this child likely experiencing? A. Cretinism B. Dwarfism C. Early childhood Addison's disease D. Attention-deficit/hyperactivity disorder

A (Thyroid hormone is critically necessary for both adequate physical and mental development. Congenital hypothyroidism, a disorder in which an infant does not produce enough thyroid hormone on their own, can result in cretinism if not treated within the first 6 months of life. This results in impaired physical and mental development as shown in this patient. Dwarfism can be ruled out due to the normal IGF-1 levels. Addison's disease is due to atrophy of the adrenal cortex, resulting in high ACTH but low cortisol. ADHD is a neurodevelopmental disorder of childhood dealing with limited attention span and impulsiveness, but it is normally not affected by endocrine dysfunction.)

Growth hormone (GH) secretion is stimulated by which factors? Select all that apply. A. Hypoglycemia B. Hyperglycemia C. Fasting D. Free fatty acid release E. Starvation F. Obesity G. Stress H. Cortisol

A, C, E, G (GH release is stimulated by hypoglycemia, fasting, starvation, and stress. It is inhibited by hyperglycemia, free fatty acid circulation, obesity, and cortisol.)

A nurse knows that a client experiencing elevated thyroid hormone levels is likely to experience: A. Decreased metabolism of glucose, fat (lipids and cholesterol), and protein (esp. from muscles) B. Increased blood volume, HR, and RR; vasodilation C. Decreased GI motility and secretions D. Overactivity of the parasympathetic nervous system

B (A client with elevated thyroid hormone levels will experience increased metabolism of glucose, causing an increase in glucose absorption; fat, lowering adiposity and cholesterol levels; and protein, causing muscle wasting and fatigue. Blood volume and respiratory rate will increase due to higher oxygen consumption. BP will remain the same due to the equal forces of increased HR and vasodilation. GI motility and secretions will increase, potentially causing an increase in appetite, diarrhea, and weight loss. The sympathetic nervous system will be put into overdrive, resulting in tachycardia and palpitations, sweating, tremor, restlessness, and anxiety.)

A client with Graves disease is reviewing treatment for his condition with the nurse. The nurse knows that the client has understood the treatment information if he says what? Select all that apply. A. "Graves disease is a special form of hypothyroidism that needs to be treated with a medication like levothyroxine." B. "My doctor may prescribe me B-blockers to help calm my heart down." C. "It is important for me to get my vision checked more frequently than once per year." D. "Surgery to remove all of my thyroid gland will not require me to take thyroid medication for the rest of my life."

B, C (Graves disease is a triad of three conditions: hyperthyroidism, goiter, and exophthalmos, i.e. bulging eyes. It is an autoimmune condition in which abnormal antibodies stimulate normal TSH receptors. The client is correct in saying that B-blockers might be used to lower heart rate and contractile force. Patients with Graves disease or another form of hyperthyroidism tend to suffer from tachycardia and angina, due to an increase in metabolic rate and the heart's increased sensitivity to catecholamines. He is also correct in stating that he must get his eyes checked more frequently as the exophthalmos he experiences may place excessive pressure on his optic discs, negatively affecting his vision. Graves disease is not a form of hypothyroidism and cannot be treated with levothyroxine, which would make it worse. Methimazole or PTU, if intolerant of methimazole, would be indicated in this patient. If treatment requires a total thyroidectomy, the patient will be devoid of natural thyroid hormone production, and he will need to take levothyroxine for the rest of his life.)

A doctor orders an MRI for a client with suspected acromegaly. Based on knowledge of the most common cause of this condition, the nurse knows that the doctor is most likely trying to find: A. a hypothalamic tumor, secreting GnRH B. a lung cancer tumor, secreting GnRH C. a pituitary gland tumor, secreting GH D. none of the above

C (A somatotropic adenoma, or a pituitary gland tumor, accounts for the development of acromegaly in 95% of cases.)

Hypertension, hypokalemia, and metabolic alkalosis are common effects of which endocrine disorder? (Hint: It can be treated with spironolactone.) A. Addison's disease B. Diabetes mellitus C. Primary hyperaldosteronism D. Myxedema

C (Primary hyperaldosteronism occurs when the adrenal cortex produces and secretes excessive amounts of aldosterone into the bloodstream. Because of the sodium-conserving and potassium-wasting effects of aldosterone, hypertension and hypokalemia develop, with metabolic alkalosis developing secondary to the hypokalemia. Spironolactone is the primary drug used to treat this condition if adrenal hyperplasia is the cause; surgical removal is indicated if the cause is an aldosterone-secreting tumor.)

A 56-year-old male client with thin, silky hair with a thin appearance comes into the clinic for a check-up. He complains of restlessness, diarrhea, and the inability to get good sleep over the last month. He states, "I feel like my heart is going to jump out of my chest, and I can't go on outdoor jogs that much anymore because I feel so hot in the sun and can't breathe as easily as before." VS: HR 115, BP 116/80, RR 24, T 100.2F. What endocrine disorder does this client most likely have? A. Hypercortisolism B. Hypocortisolism C. Hyperthyroidism D. Hypothyroidism

C (The combination of these objective and subjective data highly point to hyperthyroidism, a condition in which the body produces too much T3 and T4 hormone, resulting in an excessive boost in metabolism.)

Which hormones must be bound to proteins to circulate in the blood? (Select all that apply.) A. hypothalamic hormones B. posterior pituitary hormones C. thyroid hormones D. steroids

C, D (Steroids and T3 and T4 must be bound to a liver-synthesized protein, such as albumin, to effectively circulate in the blood. A and B represent peptide hormones which can freely circulate in the blood.)

A primary endocrine disorder originates in the _________, a secondary disorder originates in the ___________, and a tertiary in the _________. A. pituitary gland; target gland; hypothalamus B. target gland; hypothalamus; pituitary gland C. pituitary gland; hypothalamus; target gland D. target gland; pituitary gland; hypothalamus

D

(Upregulation/Downregulation) refers to the ability of a cell to reduce the number of receptors in response to high levels of a specific hormone that acts upon that cell.

Downregulation (Upregulation occurs when a cell increases the number of receptors for a specific hormone when there are low levels of that hormone in the blood.)

(Steroid/Peptide) hormones bind to intracellular receptors as opposed to cell-surface receptors.

Steroid (Because steroids are lipophilic, they can easily pass through the fatty plasma membrane of a cell and bind to intracellular receptors. The steroid hormone-receptor complex then migrates into the nucleus to influence gene expression. Peptide hormones are lipophobic, requiring them to bind to cell-surface receptors. The activation of a cell-surface receptor then produces a secondary messenger, e.g. Ca++ or cAMP, that helps influence cell activity.)

Which thyroid hormone is more active: T3 or T4?

T3 (Most thyroid hormone is stored and circulated as T4. The active form, found in lesser quantities, is T3.)

What synthetic analog of ACTH is used to diagnose adrenal insufficiency?

cosyntropin (Plasma cortisol is measured just before injection and then 30-60 minutes later. If cortisol rises adequately, then adrenal response is considered normal. If it does not rise, primary adrenal insufficiency may be diagnosed.)

Name 3 other glucocorticoid medications that may be substituted for hydrocortisone: ______________, ______________, and ______________.

dexamethasone, prednisone, cortisone (Dexamethasone, in addition to the same indications of hydrocortisone may be used to help diagnose Cushing's syndrome. Along with prednisone, they are preferred drugs for treatment of chronic adrenal insufficiency. Cortisone is a prodrug that is converted to hydrocortisone in the body.)

T/F: Out of all proteins circulating in the blood, T3 and T4 tend to bind to albumin the most.

false (70% of circulating T3 and T4 bind to a protein called TBG, or thyroid hormone-binding globulin. 15% bind to albumin, and another 10% to TBPA, or thyroxine-binding prealbumin.)

T/F: Vasopressin antagonists, such as conivaptan and tolvaptan, are only used to treat hypernatremia.

false (Conivaptan [IV] and tolvaptan [PO] work by binding to vasopressin receptors in the kidney tubules, blocking its action. This leads to more free water excretion, which would worsen hypernatremia. It is thus used for hyponatremia in euvolemic or hypervolemic hospitalized patients. Adverse effects include hypernatremia, hypokalemia, orthostatic hypotension, headache, fever, and GI problems, i.e. diarrhea. Thus, it is important to monitor fluid and electrolytes when administering these drugs.)

T/F: Growth hormone directly influences the growth of muscle, bone tissue, and organs.

false (Growth hormone stimulates the liver to produce insulin-like growth factor 1, or IGF-1 to carry out these growth-promoting processes.)

T/F: Insulin detemir [Levemir] is the only insulin that can be given by the inhaled route.

false (Regular insulin is the only insulin with inhaled formulations. Inhaled human insulin [Afrezza] works more quickly and has a shorter duration than subQ regular insulin; it is administered with a DPI.)

T/F: It is never advisable to abruptly withdraw glucocorticoid medications.

true (Abrupt withdrawal of long-term glucocorticoid therapy can result in an acute adrenal crisis since the body's adrenal cortices are not used to producing the needed cortisol in times of stress.)

A nursing professor discusses calcium physiology with a group of first-semester nursing students. Which statement by the nursing students requires further teaching by the professor? A. Parathyroid hormone and vitamin D have identical effects in regulating calcium and phosphate levels in the blood. B. Calcitonin reduces plasma levels of calcium in response to high calcium levels. C. Osteoclasts break down bone and osteoblasts make new bone. D. Certain foods and drugs affect the metabolism of calcium.

A (A is correct. PTH, a hormone released by the parathyroid glands in response to low calcium, and vitamin D, a fat-soluble vitamin activated by the kidneys, regulate calcium and phosphate levels. They increase calcium levels by increasing calcium absorption in the small intestine, decreasing renal excretion, and increasing calcium resorption from the bone. However, whereas PTH decreases phosphate levels, vitamin D increases them. B is incorrect. Calcitonin counteracts high calcium levels by increasing renal calcium excretion as well as decreasing calcium resorption from bone. It has no effect on calcium absorption. C is incorrect. Osteoclasts are responsible for resorbing bone while osteoblasts are responsible for depositing new bone in a process known as bone remodeling. D is incorrect. A variety of food and drugs impact calcium metabolism. - Increase absorption: PTH and vitamin D - Decrease absorption: glucocorticoids; insoluble fiber and oxalate-containing foods - Increase excretion: loop diuretics, calcitonin, sodium - Decrease excretion: PTH, vitamin D, thiazide diuretics)

The counterhormone for GnRH, inhibiting GH release from the anterior pituitary gland, released by the hypothalamus is known as: A. somatostatin B. growth-inhibiting hormone C. adrenocorticotropic hormone D. antidiuretic hormone

A (The hypothalamus secretes two hormones, GnRH and somatostatin, to influence release of GH from the anterior pituitary gland. Growth-inhibiting hormone is not real. Adrenocorticotropic hormone (ACTH) is released from the anterior pituitary gland to stimulate corticosteroid release from the adrenal cortex. Antidiuretic hormone is released by the posterior pituitary in response to decreased fluid volume.)

T/F: Sulfonylureas are oral antidiabetic agents that are used for both type 1 and type 2 diabetes.

false (Sulfonylureas, like glipizide and glyburide, are only effective in type 2 diabetes. This type of drug stimulates insulin release from the pancreas, so this would not work in a type 1 diabetic, as that client's beta cells are nonfunctional.)

What drugs can intensify hypoglycemia secondary to sulfonylurea use? Select all that apply. A. NSAIDs B. Sulfonamide antibiotics C. Alcohol, especially binge-drinking D. Cimetidine

A, B, C, D (All these drugs are known to increase hypoglycemia associated with sulfonylurea use.)

The nurse recognizes which lab values correspond to tight glycemic control: (Select all that apply.) A. HbA1c <7.0% B. Premeal plasma glucose 80-130 mg/dL C. Hypoglycemia D. Peak postmeal plasma glucose <180 mg/dL

A, B, D (A, B, and D are all lab values that indicate tight glycemic control. C is incorrect b/c it is not a lab value. Rather hypoglycemia is the primary drawback of tight glycemic control, since a modest overdose in insulin therapy can lead to this condition. Weight gain is also another common long-term effect of insulin therapy.)

A nursing student studying diabetes correctly identifies which differences between type 1 and type 2 diabetes? Select all that apply. A. Type 1 diabetes is an autoimmune disorder while type 2 diabetes is usually a problem of insulin resistance. B. Insulin replacement is an option in type 1 diabetes but is mandatory in type 2 diabetes. C. Tight glycemic control decreases the risk of both microvascular and macrovascular complications of type 1 diabetes; it only reduces microvascular complications in type 2 diabetes. D. HHS is common in type 1 diabetes while DKA is more common in type 2 diabetes.

A, C (A is correct. Type 1 diabetes occurs when the body attacks its own pancreatic beta cells that produce insulin, characteristic of an autoimmune disorder. Type 2 diabetes is often the result of the body's inability to utilize insulin to reduce blood glucose levels. B is incorrect, as insulin replacement in type 1 diabetes is mandatory. Depending on the severity of type 2 diabetes, insulin may or may not be used. C is correct. Microvascular complications, such as retinopathy, neuropathy, nephropathy, gastroparesis, and impotence, are reduced in both type 1 and type 2 diabetes with tight glycemic control. Macrovascular complications, such as heart disease, HTN, atherosclerosis, and stroke, are reduced in type 1 but not type 2 diabetes with this treatment. D is incorrect. DKA is more common in type 1 diabetics; HHS is more common in type 2 diabetics.)

The nurse knows that the actions of oxytocin include... Select all that apply. A. Promotion of uterine contractions during labor B. Stimulation of breast milk production during pregnancy C. Promotion of breast tissue development during pregnancy D. Stimulation of milk ejection during lactation

A, D (The actions of oxytocin are to promote uterine contractions during childbirth and stimulate milk ejection during breastfeeding [letdown reflex]. B and C are incorrect because they describe the actions of prolactin, not oxytocin.)

Which of the following statements is true concerning gestational diabetes? A. Gestational diabetes usually progresses to type 2 diabetes following birth. B. Expectant mothers must treat their gestational diabetes like DM with diet and insulin/antidiabetic drugs. C. The cause of gestational diabetes is not due to hormonal imbalances. D. Gestational diabetes has severe negative effects for the mother, but little to none for the developing fetus.

B (B is correct. Gestational diabetes is treated like DM with diet, exercise, and insulin or antidiabetic drugs. It usually develops in the 2nd or 3rd trimester, so quality prenatal care is important. A is incorrect, as gestational diabetes usually fades away right after childbirth. If it remains, it is no longer considered gestational and should be rediagnosed and treated appropriately. C is incorrect. Gestational diabetes usually occurs due to (1) the placenta releasing hormones that work against insulin and (2) cortisol levels increasing threefold during pregnancy. These two hormonal factors contribute to the development of gestational diabetes. D is incorrect. Gestational diabetes increases the risk of pregnancy complications and mortality in the mother. It also increases the risk of fetal abnormalities, such as macrosomia, hypoglycemia, hypocalcemia, polycythemia, and hyperbilirubinemia.)

Which of the following statements regarding cortisol is false? A. Cortisol decreases the use of glucose and promotes gluconeogenesis; increases breakdown of protein for energy use; and increases mobilization of fatty acids. B. Cortisol does not contribute to emotional instability. C. Cortisol has anti-inflammatory and immunosuppressive actions. D. Cortisol is known as the "stress" hormone.

B (Cortisol, the stress hormone, does contribute to emotional instability. It has several metabolic effects, including the making of more glucose yet with decreased glucose use as well as increased breakdown of proteins and fats. Cortisol is also known to suppress inflammation and the immune response. Cortisol can also potentiate the effects of catecholamines, such as epinephrine.)

Out of all the pituitary hormones, which two are secreted by the posterior pituitary gland? A. GnRH and CRH B. ADH and oxytocin C. growth hormone and TSH D. cortisol and aldosterone

B (GnRH and CRH are released by the hypothalamus, GH and TSH by the anterior pituitary, and cortisol and aldosterone by the adrenal cortex.)

T/F: Drugs can influence the binding of protein-bound hormones in the blood.

true (Some drugs that have a high affinity for plasma proteins, displacing hormones that normally bind to those proteins. An example would be aspirin competing with thyroid hormone for protein-binding, which could elevate thyroid hormones to a point of thyrotoxic crisis.)

The adrenal cortex produces which three main hormones? A. CRH, ACTH, and cortisol B. TSH, T3, and T4 C. Aldosterone, cortisol, and androgens D. GHRH, GH, and IGF-1

C (Aldosterone [mineralocorticoid], cortisol [glucocorticoid], and androgens are the three primary hormones produced by the adrenal cortex. CRH, ACTH, and cortisol are hormones involved in the HPA axis. Only cortisol is made in the adrenal cortex out of these three. TSH is made in the anterior pituitary gland while T3 and T4 are made in the thyroid gland. GHRH is produced in the hypothalamus, GH in the anterior pituitary, and IGF-1 in the liver.)

An example of __________ signaling is illustrated by the release of insulin by pancreatic beta cell, which in turn inhibits further release of insulin from that same cell. A. autocrine B. paracrine C. gap junction D. endocrine

A (Autocrine signaling occurs when a cell releases a signaling molecule that acts upon itself, as in the insulin released by a beta cell influencing that same beta cell's action. Paracrine signaling occurs when a cells releases mediators that influence the actions of nearby cells, such as ovarian granulosa cells releasing estrogen to influence the maturation of nearby ovarian follicles. Gap junction signaling occurs when a cell releases mediators, often ions, into an adjacent cell connected to it by gap junctions, an example being myocardial cells with sodium and calcium channels. Endocrine signaling occurs when a cell releases hormones that must travel through the bloodstream in order to reach its effector cell/gland. An example would be the release of ACTH by the anterior pituitary, which then stimulates the adrenal cortex to release cortisol.)

A diabetes nurse educator is reviewing insulin dosing schedules with a patient recently diagnosed with type 2 diabetes. Which statement made by the patient indicates she has understood the information? A. "An advantage of the twice-daily premixed regimen is that I would only have to stick myself with the needle two times a day. However, I don't have lunch time control with this schedule." B. "With the intensive basal/bolus strategy, I only need one dose of long-acting insulin per day, usually before bedtime, and one does of short-acting insulin, taken in the morning." C. "Continuous subcutaneous insulin infusion [CSII] requires the most injections per day out of all three dosing schedules." D. "For all three schedules, treatment requires the use of both a short-acting insulin and a long-acting insulin."

A (A is correct. The twice-daily premixed regimen involves the client administering a pre-made mixture of a short- and a long-acting insulin only two times a day, once before breakfast and once before dinner. This schedule provides good basal control and postprandial control before breakfast and dinner, but not for lunch. B is incorrect. The client is correct in stating that with the intensive basal/bolus strategy, a long-acting insulin is taken HS to provide basal control. However, the short-acting insulin prescribed has to be taken multiple times per day before mealtimes. Thus, this schedule requires the most injections per day. C is incorrect. CSII does not require any injections since it involves the use of a portable insulin infusion pump connected to an indwelling subQ catheter. A dose of short-acting insulin is automatically released when blood glucose levels are high and is manually released before mealtimes. D is incorrect. The twice-daily premixed regimen and intensive basal/bolus strategy use combination treatment involving both a short-acting and long-acting insulin. CSII only uses short-acting insulins.)

Norepinephrine (NE) and epinephrine belong to which class of hormones? A. amines B. peptide hormones C. steroids D. eicosanoids

A (Amines, which are derived from single amino acids; other examples include dopamine, T3, and T4. Peptide hormones, derived from polypeptide chains, include the majority of hormones: those released by the hypothalamus, pituitary gland, and the pancreas. Steroid hormones, derived from cholesterol, include those released by gonads and the adrenal cortex. Eicosanoids, which are fatty acid derivatives, are hormones involved in the inflammatory response, e.g. prostaglandins, thromboxanes, leukotrienes.)

An RN is observing a nursing student explain the drug hydrocortisone for Addison's disease to a client. Which statement by the nursing student requires correction by the RN? A. "Hydrocortisone acts as a glucocorticoid, to raise glucose levels, with no mineralocorticoid effects, such as raising sodium levels." B. "Your physician may increase the amount of hydrocortisone you receive or have it given IV in times of stress. Otherwise, you can take a pill version of the medication for long-term use." C. "Cushing's syndrome may occur as a result of hydrocortisone use, and you should notify the doctor if you develop a 'buffalo hump' or 'potbelly.'" D. You have the option of taking the entirety of the daily dose of hydrocortisone in the morning, or you can divide the dose: 2/3 in the morning and 1/3 in the afternoon.

A (Hydrocortisone, even though it is known for its glucocorticoid effects, also possesses mineralocorticoid effects. The drug may also be used for nonendocrine disorders, such as allergic reactions and inflammation r/t cancer, in higher doses. In times of stress, such as infection, surgery, or trauma, the HCP may require the client to increase their dosage or may even give hydrocortisone IV. PO forms of the drug are desirable for long-term therapy. Due to the risk of excessive dosing with hydrocortisone, Cushing's syndrome may develop. The client should notify the HCP if S&S of this condition do occur. Because cortisol is naturally secreted in the morning, it would be best for a client to take hydrocortisone in the morning. However, if the client experiences afternoon or evening fatigue, they may split the drug into morning and afternoon doses.)

In treating hyperthyroidism, the nurse knows that methimazole and PTU are the two most commonly used drugs for this condition. Which statement made by the nurse needs to be corrected in regards to the differences between the drugs? A. Methimazole causes liver injury while PTU does not. B. Methimazole can cross membranes readily, making it contraindicated in the 1st trimester of pregnancy and breastfeeding; PTU crosses less readily. C. Although both can inhibit thyroid hormone synthesis, PTU can also prevent conversion of T4 to T3 in peripheral circulation. D. The half-life of PTU is much shorter than that of methimazole.

A (Methimazole is safe for the liver while PTU can be hepatotoxic. The nurse should look for signs of liver injury in the patient, such as jaundice and fatigue. PTU is preferred for the 1st trimester of pregnancy to reduce the risk of cretinism associated with methimazole. It is also preferred for lactation. Due to its ability to prevent conversion of T4 to T3, PTU is generally preferred over methimazole in a thyrotoxic crisis. PTU must be taken 2-3 times daily instead of once like methimazole due to the PTU's shorter half-life.)

A nurse is assessing a 35-year-old man who is experiencing galactorrhea. He says, "I can't get an erection that easily anymore for sex, and I generally don't feel like having sex anymore." What test and drug would the physician most likely order for this client? A. Prolactin levels; cabergoline B. ACTH levels; hydrocortisone C. IGF-1 levels; somatropin D. T4 levels; levothyroxine

A (This client is most likely experiencing prolactin excess, as evidenced by galactorrhea and a decrease in libido and potency. Thus, the physician would probably order a prolactin level test to see if the prolactin levels are high. If they are high, they would prescribe cabergoline (preferred) or bromocriptine. ACTH levels and hydrocortisone would be ordered for a client with suspected Addison's disease. IGF-1 levels and somatropin would be ordered for a client with suspected GH deficiency. T4 levels and levothyroxine would be ordered for a client with suspected hypothyroidism.)

When reviewing conditions of growth hormone excess, the nurse knows that acromegaly is different from gigantism in which ways? Select all that apply. A. Acromegaly occurs in adults while gigantism occurs in children. B. Acromegaly is treated via surgery, radiation, or drug therapy. To treat gigantism, the pituitary gland is removed. C. Acromegaly occurs when there is an excess of GH before the epiphyseal plates in the long bones close. Gigantism occurs when there is an excess after closure. D. Acromegaly patients tend to have high IGF-1 levels while gigantism patients tend to have normal or low IGF-1 levels.

A, B (Acromegaly occurs in adults when there is an excess of GH after closure of the epiphyseal plates. In contrast, gigantism occurs in children when there is an excess before closure, causing a large height of 7-9 ft. While gigantism is treated by removing a child's pituitary gland, acromegaly can be treated with surgery [to remove the GH-secreting adenoma], radiation, or drug therapy. Drug therapy is used when surgery and radiation therapy are insufficient. In both conditions, IGF-1 levels remain high.)

Other than its use in treating type 1 and type 2 diabetes, for what other conditions and procedures is insulin indicated? Select all that apply. A. Diabetic ketoacidosis, given IV B. Diagnosis of GH deficiency by inducing hypoglycemia C. Hyperkalemia D. Angioplasty

A, B, C (A is correct. Diabetic ketoacidosis is commonly an exacerbation of untreated type 1 DM and is considered a medical emergency, characterized by hyperglycemia and metabolic acidosis due to the buildup of ketones in the blood. IV insulin will primarily promote glucose uptake by body tissues, lower blood sugar, but can also help with the acidosis. B is correct. Insulin can be administered to clients with suspected GH deficiency. The insulin causes hypoglycemia, which naturally stimulates GH secretion. If GH do not rise significantly during an insulin-induced hypoglycemic test, a client may be diagnosed with GH deficiency. C is correct. Insulin can be given with glucose intravenously to treat hyperkalemia by stimulating the return of potassium ions in the blood into the cells. D is incorrect. Insulin has not been found useful in cases of angioplasty.)

The nurse is discussing NPH insulin with a client with diabetes. What patient education should the nurse provide? Select all that apply. A. "NPH insulin, like regular insulin, can be bought over-the-counter." B. "NPH is primarily used to help control blood glucose levels between meals and overnight." C. "NPH insulin can only be injected in areas of fatty tissue, like the back of your upper arm, abdomen, or the front of the thighs." D. "NPH insulin can be mixed with your insulin lispro in the same syringe."

A, B, C, D (A is correct. NPH insulin can be bought OTC in all states, except Indiana. B is correct. Unlike short-acting insulins which provide postprandial control and long-acting insulins which provide basal control over an entire day, NPH insulin helps control blood glucose levels between meals and overnight. C is correct. NPH is only given subcutaneously, and this answer response lists appropriate subQ sites of injection. D is correct. NPH can be mixed with short-acting insulins, like insulin lispro, in the same syringe.)

A nurse teaching a client about fludrocortisone for her primary hypoaldosteronism should include what patient teaching points? Select all that apply. A. Fludrocortisone is primarily a mineralocorticoid, helping to increase the salt levels in your blood. B. Notify your primary care provider if you experience any unusual weight gain or swelling in the feet or legs. C. This medication poses no threat to your heart health. D. Your prescriber will likely combine this medication with hydrocortisone, a glucocorticoid medication helping to increase blood sugar.

A, B, D (A is correct. Fludrocortisone is a mineralocorticoid medication with some glucocorticoid effects. B is correct. This drug may cause excessive sodium and water retention, resulting in weight gain and dependent edema. C is incorrect. Fludrocortisone may increase potassium excretion to the point of hypokalemia, causing dysrhythmias and a weak heart muscle. Excessive sodium and water retention may also cause hypertension, which is also detrimental to the heart. D is correct. Fludrocortisone is often combined with hydrocortisone for most conditions it is used to treat.)

A nurse working in an adult health clinic knows that it is important to monitor a client with acromegaly for which complications. Select all that apply. A. hypertension B. diabetes C. thinned skin D. osteoarthritis E. shrinking of hands and feet

A, B, D (An adult with acromegaly has an excess of GH will have thicker skin as a result of hypertrophy of sweat and oil glands. They will also have larger hands and feet due to growth of short bones. GH also increases the size of organs. An enlarged heart, or cardiomegaly, can cause hypertension in the long run, which could lead to heart failure. GH can also cause goiter, an enlarged thyroid gland. Because GH decreases carbohydrate usage, it increases blood sugar and promotes insulin resistance, potentially resulting in diabetes and DM-related peripheral neuropathy. An adult with acromegaly is at risk of osteoarthritis, especially in the knee joints, as a result of increased cartilage growth and rubbing. Other clinical S&S include acromegalic facies, kyphosis, deepened voice, hirsutism, male sexual dysfunction, and menstrual disorders.)

In explaining levothyroxine [Synthroid] to a patient with myxedema, the nurse should teach... Select all that apply. A. This drug is safe during pregnancy. B. It must be taken 30-60 minutes before breakfast time on an empty stomach. C. It is safe to use with catecholamine medications and warfarin. D. In addition to thyrotoxicosis, long-term overtreatment with levothyroxine may cause atrial fibrillation and bone loss in older adults. E. The half-life of this medication is short, about 1 day. F. Although levothyroxine has a host of drugs that affect its absorption and metabolism, it has little pharmacokinetic effects on other drugs.

A, B, D (Levothyroxine, used to treat hypothyroid disorders, is safe to use during pregnancy. Its counterpart to treat hyperthyroid disorders, methimazole, is toxic to the fetus. Levothyroxine should be taken on an empty stomach to prevent erratic absorption of the medication. Levothyroxine should be used with caution in patients taking catecholamines and warfarin. It increases the sensitivity of the heart to catecholamines, potentially resulting in dysrhythmias. It potentiates the actions of warfarin, increasing the risk of bleeding. Atrial fibrillation and bone loss, which increase the risk of stroke and fractures, respectively, are legitimate concerns in older adults persistently taking levothyroxine. Thus, thyroid hormone levels should be taken annually to therapeutic levels. Levothyroxine has a long half-life of 7 days, which helps with long-term maintenance dosing but hurts the initial onset of effects, which takes 1 month. Digoxin and insulin levels are reduced by levothyroxine and thus should be increased in dosage in patients taking this drug.)

Select all the possible causes for hormone hypofunction: A. Atrophy due to drug therapy or unknown cause B. Congenital defects C. Hormone-producing tumor, esp. cancerous D. Ischemia, infection, inflammation, and autoimmune responses E. Decline in function with aging F. Excessive stimulation and hyperplasia of endocrine gland G. Receptor defects

A, B, D, E, G (Hormone-producing tumors, especially if cancerous, and excessive stimulation or hyperplasia of an endocrine gland are possible causes of hormone hyperfunction, not hypofunction.)

Which of the following statements are true regarding the treatment of Cushing's syndrome? Select all that apply. A. Ketoconazole, an antifungal drug, can be used as adjunct therapy to surgery and radiation. B. Bilateral adrenalectomy does not require lifetime glucocorticoid and mineralocorticoid therapy post-surgery. C. Surgical or radiation therapy depends on the location of the ACTH-producing tumor. D. Obesity related to Cushing's syndrome is irreversible.

A, C (A is correct. Ketoconazole, b/c it helps block synthesis of glucocorticoids, is used alongside surgical and radiation therapy to control Cushing's syndrome. B is incorrect. Once the adrenal cortices are surgically removed, the client must take corticosteroid medications for life since they no longer can naturally produce their own corticosteroids. C is correct. If the tumor is in the pituitary gland, partial/total surgical removal or irradiation of the gland is indicated. If it is on one of the adrenal glands, therapy will be directed to that location. D is incorrect. Symptoms of Cushing's disease, unless complicated by another condition, are reversible in most cases.)

An unconscious 38-year-old female client is wheeled into the ED, and after an assessment made by the physician, he determines that the client is experiencing a myxedematous coma. What nursing interventions are appropriate in order to assist in stabilizing this patient? Select all that apply. A. Monitoring HR and BP B. Using warming blankets to rapidly reheat the client C. Administering IV levothyroxine, as ordered D. Monitoring sodium and glucose levels

A, C, D (The manifestations of a myxdematous coma include coma, hypothermia, cardiovascular collapse, and metabolic imbalances, such as hypoglycemia, hyponatremia, hypoglycemia, and lactic acidosis.) For a patient under a myxedematous coma, the nurse must watch the HR and BP to ensure cardiovascular collapse does not worsen and that treatment to regain hemodynamic stability are working. The nurse must use warming measures, such as blankets, to slowly reheat the client from a hypothermic state. Since a myxedematous coma is the result of critically low thyroid hormone levels, it is appropriate for the nurse to administer IV levothyroxine to raise thyroid hormone levels back to normal. Monitoring sodium and glucose levels will be helpful in evaluating treatments used to treat metabolic imbalances secondary to myxedematous coma.)

Addison's disease is often caused by autoimmune destruction of the adrenal cortex, resulting in the lack of glucocorticoid, mineralocorticoid, and androgen production. A client with this disease will present with: (Select all that apply.) A. Orthostatic hypotension secondary to hyponatremia B. Hypokalemia C. Fatigue and weakness D. Anorexia and weight gain E. Myalgia, arthralgia, and abdominal pain F. Bronze pigmentation of the skin

A, C, E, F (A is correct. Hyponatremia is the result of the lack of aldosterone, the primary mineralocorticoid, responsible for sodium and water retention. A lack of aldosterone means lower concentrations of sodium in the blood, leading to lower blood pressure. B is incorrect b/c the lack of aldosterone actually helps potassium become conserved by the body, leading to hyperkalemia. C is correct b/c fatigue and weakness are common symptoms of Addison's disease, due to the lack of cortisol affecting skeletal muscle function. D is incorrect b/c Addison's disease leads to GI upset, causing weight loss secondary to anorexia [loss of appetite] and vomiting. E is correct b/c aches and pains in the muscles, joints, and abdomen are common. F is correct b/c the buildup of ACTH results in the skin appearing with a bronze color.)

A 12-year-old girl comes into the ED with her mother who states, "My daughter has become less energetic over the last month. I've noticed she's been hungrier and thirstier often, and she's been using the bathroom more." Her urine contains moderate amounts of glucose, normal electrolyte levels, and no ketones. The girl's body weight is also lower than the norm for her age. Upon blood sample analysis, the girl's insulin levels were extremely low. VS: HR 92, BP 106/72, RR 18, T 98.6F. What endocrine disorder should the nurse suspect? A. Diabetes insipidus B. Type 1 diabetes mellitus C. Type 2 diabetes mellitus D. Diabetic ketoacidosis

B (B is correct because patients with untreated type 1 diabetes tend to have polyphagia, polydipsia, and polyuria in addition to glycosuria, fatigue, and weight loss. Children are also at a higher risk for developing this disorder. A is incorrect because even though DI involves polydipsia and polyuria, it does not account for the glucose in the urine. In DI, the urine would also be dilute and contain very little electrolytes, but in this case, electrolyte levels are normal. C is incorrect because even with hallmark S&S of diabetes (polyphagia, polydipsia, and polyuria), the girl also had extremely low insulin levels, indicative of type 1 DM. In type 2 DM, insulin levels tend to be normal or high. Moreover, childhood age and low body weight is more predictive of type 1 DM than type 2 DM, which is predicted by adult age and obesity. D is incorrect because DKA is an exacerbation of type 1 DM that involves ketonuria, Kussmaul breathing, and hypokalemia, all of which are absent upon assessment. However, if the girl's type 1 DM is not treated with insulin, she could progress into DKA.)

Metformin is the most commonly prescribed oral drug after a client is diagnosed with type 2 diabetes. Which following statement about this drug is false? A. The risk for hypoglycemia with metformin is low when used alone, since it does not alter insulin levels. Thus, it is safer than insulin when a meal is skipped. B. Metformin is safe for use with patients with renal insufficiency and fatty liver disease. C. Because the drug works by increasing insulin sensitivity, it works well for polycystic ovary syndrome. D. Metformin has adverse effects of GI upset, potential vitamin B12 and folic acid deficiencies, and rarely, lactic acidosis. E. Weight gain is not an issue with metformin, unlike other antidiabetic drugs.

B (B is correct, since metformin is not safe for patients with heart failure, renal insufficiency, alcohol and liver problems, and severe infection due to the increased risk of lactic acidosis. A is incorrect. Metformin works by increasing the sensitivity of insulin receptors, promoting glucose uptake into cells, and by reducing glucose production and absorption. Because it does not influence insulin levels in the blood, it has low risk of hypoglycemia, and skipping a meal would be safe. C is incorrect. PCOS can result in insulin resistance, meaning that metformin can be used to help since it increases insulin sensitivity. D is incorrect. GI symptoms, such as anorexia, nausea, and diarrhea, are the most common side effects, generally fading over time; they can, however, lead to nonadherence. The absorption of vitamin B12 is impaired, leading to peripheral neuropathy and anemia, so vitamin B12 levels should be monitored periodically. Folic acid absorption is also impaired, but this does not preclude the use of metformin in gestational diabetes. Lactic acidosis is a rare adverse effect of metformin, involving hyperventilation, myalgia, malaise, and drowsiness. E is incorrect. Insulin and sulfonylureas tend to increase the risk for weight gain while metformin cannot.)

A client with type 2 diabetes has a hemoglobin A1C level of 8.8 after 6 months of oral therapy with metformin (Glucophage®). The client tells the nurse that she often forgets to take her medication and doesn't really follow her diet. Which of the following is the nurse's best first response? A. "If you don't get control of your blood sugar, you'll need to take insulin." B. "It can be hard to get used to having a disease like diabetes. What are some of the things you find challenging about it?" C. "Uncontrolled diabetes can lead to eye problems and kidneys problems." D. "Many people have diabetes."

B (B is the correct response because it provides an open line of communication between the patient and nurse regarding the patient's nonadherence to the treatment regimen without asking, "Why?" A is incorrect. Even though it is true that the client may need to take insulin eventually if metformin doses are missed, this response sounds threatening. C is incorrect. Although it is true that uncontrolled diabetes can cause eye and kidney problems, this response does not directly address the patient's nonadherence to the treatment regimen. D is incorrect, as it is dismissive and misses the point of the patient's concerns.)

A nurse explaining the function of growth hormone to a child's parents would need to be corrected if he says: A. GH is necessary for linear bone growth in children. B. GH increases use of carbohydrates, but decreases use of fatty acids by cells. C. GH is produced in and secreted by the anterior pituitary gland. D. GH stimulates cells to divide more quickly and grow in size, and it enhances amino acid transport across cell membranes.

B (GH actually increases the use of free fatty acids, or FFAs, by cells; it decreases carbohydrate metabolism. As a result, it increases blood sugar against high insulin levels and decreases adiposity. All other answer choices are true regarding GH and do not need to be corrected.)

A nurse practitioner is rehearsing a presentation regarding diabetes mellitus (DM) for an older adult population in a nursing home. Which information in the presentation should be revised and corrected? A. DM is a common non-traumatic cause of lower extremity amputations. B. Type 1 DM is less common than type 2 DM. The former happens more in adults. C. DM is the leading cause of blindness and chronic kidney disease. D. Diabetes mellitus occurs more commonly in American Indians and Alaska Natives, non-Hispanic African Americans, and Hispanic Americans.

B (The information in option B is wrong. Although type 1 DM only represents 5% of cases, as opposed to 95% of cases with type 2 DM, it develops in childhood more than in adulthood. Because of peripheral neuropathy, patients with DM may lose sensation and adequate blood flow to peripheral parts of the body, increasing the risk of damage to the feet, leading to amputation. Because of DM's complications of retinopathy and nephropathy, it is the leading cause of blindness and CKD. DM is more common in American Indians and Alaska Natives, non-Hispanic African Americans, and Hispanic Americans. Alone it can increase the risk of coronary heart disease and stroke in these populations; risk is increased with other symptoms of metabolic syndrome: HTN, dyslipidemia, and obesity.)

Which of the following patients is most at risk for developing hypothyroidism? A. A 24-year-old male client, who has a family history of thyroid disease, being treated for a pneumothorax B. A 65-year-old female client, who recently had a partial thyroidectomy C. A 32-year-old female client 3 months postpartum and experiences clinical depression D. A 48-year-old male client with type 1 diabetes being treated for diabetic ketoacidosis

B (The most prominent risk factor for hypothyroidism is having any treatment for hyperthyroidism, e.g. surgery or radiation. Other risk factors include female sex, advanced age over 60 years, family history of thyroid problems, presence of another autoimmune disease, or having had a baby in the last 6 months. Although the other options include risk factors, option B has the most prominent and numerous risk factors involved in hypothyroidism.)

A nurse is checking the MAR before preparing morning medications for a client with type 2 diabetes. He notices that the client is taking both metformin and glipizide. What comparisons between these drugs should the nurse know? Select all that apply. A. Metformin carries a higher risk of hypoglycemia than glipizide. B. Metformin does not affect weight while glipizide can cause weight gain. C. Both metformin and glipizide are contraindicated in clients with kidney and liver dysfunction. D. A pregnant patient cannot take metformin but can take glipizide. E. Alcohol should be avoided while on metformin or glipizide.

B, C, E (B is correct, because metformin is the only antidiabetic agent that does not affect weight. Insulin and sulfonylureas, like sulfonylureas, can cause weight gain in long-term therapy. C is correct. Both metformin and glipizide are dangerous for patients with renal impairment and/or liver disease. A patient with kidney or liver dysfunction taking metformin has an increased risk of deadly lactic acidosis. On the other hand, the same patient taking glipizide is at increased risk of severe hypoglycemia secondary to impaired hepatic metabolism and renal excretion of the drug. E is correct. Drinking alcohol while on metformin therapy increases the risk of lactic acidosis. Drinking alcohol while on glipizide can produce a disulfiram-like reaction and intensify hypoglycemia. A is incorrect, since glipizide and other sulfonylureas carry a greater risk of hypoglycemia than metformin, since sulfonylureas directly stimulate insulin release while metformin just increases insulin sensitivity. D is incorrect. Metformin has shown to be useful for gestational diabetes despite the risk of folic acid deficiency, but glipizide is contraindicated in pregnancy and lactation.)

A nursing student is frantically preparing for a nursing exam on endocrine disorders and is asking her friend for help. Which statements given by the friend regarding hormonal control of glucose levels are true? Select all that apply. A. "Somatostatin increases secretion of insulin and glucagon." B. "Counter-regulatory hormones of insulin include catecholamines, growth hormone, and cortisol." C. "Insulin is secreted by pancreatic alpha cells in response to high blood glucose levels." D. "Glucagon, by promoting the breakdown of glycogen in the liver, helps to maintain glucose levels in times of fasting and strenuous exercise."

B, D (A is incorrect, since somatostatin decreases insulin and glucagon levels. B is correct, since epinephrine and NE [catecholamines] increase blood glucose levels by promoting glycogen breakdown in muscle cells. Growth hormone increases blood glucose levels by inhibiting the use of glucose in favor of free fatty acids; it also promotes glycogenolysis and gluconeogenesis. Finally, cortisol increases blood glucose levels primarily by gluconeogenesis, telling the body to break down fat and protein to make glucose. C is incorrect, because it is produced and secreted by beta cells in the pancreas. Glucagon production and secretion falls to the alpha cells. D is correct, as it is secreted when blood glucose levels fall to promote glycogenolysis by the liver.)

Which of the following thyroid medications are used to suppress thyroid function before a subtotal thyroidectomy? Select all that apply. A. Levothyroxine B. Methimazole C. Radioactive iodine (iodine-131) D. Nonradioactive iodine (Lugol's solution)

B, D (Although its primary use is for treatment of Graves disease, methimazole can also be used to suppress thyroid function before thyroidectomy. Nonradioactive iodine's is also used pre-thyroidectomy to suppress thyroid function. Some common adverse effects include brassy taste, irritation of the mouth and throat, and coryza; it should be given with fruit juice. Severe abdominal distress can be treated with gastric lavage and sodium thiosulfate. A is incorrect because levothyroxine is used for hypothyroid disorders. A subtotal thyroidectomy is used for hyperthyroidism. C is incorrect because radioactive iodine is often used as a replacement for thyroidectomy.)

Which of the following statements regarding thyroid testing are correct? Select all that apply. A. TSH levels are used to distinguish between secondary and tertiary thyroid disorders. B. In hypothyroidism, T3 and T4 are found in low levels while TSH is found in high levels. C. Radioactive iodine testing helps distinguish between benign and malignant thyroid gland tumors. D. Fine-needle aspiration biopsy tests the ability of the thyroid gland to concentrate and retain iodine from the blood. E. Scans, such as MRI and CT, can help identify thyroid hypertrophy or atrophy and possible impingement of other nearby structures, e.g. trachea.

B, E (A is incorrect b/c TSH levels are used to differentiate primary thyroid disorders originating in the thyroid gland from secondary thyroid disorders originating in the pituitary gland. C is incorrect b/c radioactive iodine testing helps measure the ability of the thyroid to concentrate and retain iodine from the blood. D is incorrect b/c fine-needle aspiration biopsy is used to distinguish b/w benign and malignant tumors of the thyroid gland.)

What following term describes a life-threatening situation in which there is a lack of cortisol to keep up with the demands of stress? A. Primary adrenal cortical insufficiency B. Secondary adrenal cortical insufficiency C. Acute adrenal crisis D. Stress-cortisol syndrome

C (An acute adrenal crisis occurs when there is a lack of cortisol in the bloodstream to keep up with the demands of stress, resulting in S&S of hypoglycemia, N/V, muscle weakness, hypotension, dehydration, hemorrhage, and cardiovascular collapse. Primary adrenal cortical insufficiency, or Addison's disease, occurs when there is lack of cortical hormones and high ACTH as a result of lack of feedback inhibition. Secondary adrenal cortical insufficiency occurs as a result of hypopituitarism or surgical removal of the pituitary gland. Stress-cortisol syndrome does not exist.)

Which adrenal function test is considered the gold standard in assessing the integrity of the hypothalamic-pituitary-adrenal (HPA) axis? A. ACTH blood level test B. CRH test C. Insulin-induced hypoglycemic test D. 24-hour urine specimen test

C (An insulin-induced hypoglycemic test involves causing a CNS stress response due to low blood sugar. If the HPA axis is intact, the body will release cortisol in response to help raise blood sugar; both cortisol and glucose levels will be measured together. An ACTH blood level test is used simply to measure how much ACTH is in the blood and whether it is above, within, or below normal limits. The CRH test is primarily used to diagnose a pituitary ACTH-secreting tumor, as in Cushing's disease. Increased CRH will cause greater amounts of ACTH and cortisol to be released, both of which can be measured. Ectopic ACTH-secreting tumors will not respond as strongly to this test. The 24-hour urine specimen test measures the various metabolic end products of adrenal hormones, providing information about any possible alteration in biosynthesis of those hormones.)

The ED nurse should question which order from the nurse practitioner regarding treatment for a client's thyroid storm? A. Propylthiouracil 250 mg PO q 6 hrs B. Metoprolol 100 mg PO q 6 hrs C. Aspirin 500 mg PO q 6 hrs D. Hydrocortisone IV 100 mg q 6 hrs

C (Aspirin should never be used for individuals experiencing a thyrotoxic crisis, as it is a drug that further displaces thyroid hormones from their binding proteins in the bloodstream, increasing their blood levels. In order to reduce hyperthermia, acetaminophen should be given along with cooling therapy. Thyroid hormones may be removed from the blood using plasmapheresis or dialysis. Propylthiouracil (PTU) is the antithyroid drug of choice for inhibiting thyroid hormone synthesis during a thyroid storm. Metoprolol or other B-blockers may be used to reduce cardiac workload during a thyroid storm, decreasing the risk of severe CV effects. Nonselective B-blockers shouldn't be used for patients with asthma, COPD, or diabetes. Hydrocortisone or another glucocorticoid may be used to prevent conversion of T4 to T3 in the bloodstream and correct adrenal insufficiency during the stress response.)

The nurse practitioner and pharmacist are working together to determine the correct dosage of insulin for a client recently diagnosed with type 2 diabetes. After determining the dosage, the nurse practitioner walks into the client's room to teach about insulin administration. However, before she can start talking about the medication, the client says, "I should have told you this earlier, but I have a really bad drinking problem." The nurse practitioner's best course of action, other than address the client's potential alcohol abuse, is to: A. Proceed to teach the client about administration of the insulin. B. Tell the client he cannot take insulin with alcohol due to the risk of disulfiram-like reaction. C. Consult with the pharmacist again in order to discuss decreasing the dose of insulin. D. Inform the client that insulin must be taken 2 hours before alcohol consumption.

C (C is correct, as alcohol is one type of drug that can intensify hypoglycemia induced by insulin. Thus, it is appropriate for the nurse practitioner to call the pharmacist about reducing the dosage. Other antidiabetic drugs like sulfonylureas and glinides can also intensify insulin-induced hypoglycemia. When used in combination with drugs that raise glucose levels, such as glucocorticoids and sympathomimetic drugs, insulin doses should be increased. A is incorrect, as it does not address the potential for the risk of hypoglycemia when insulin is combined with alcohol. B is incorrect, since it is not true that insulin and alcohol combined together contribute to a disulfiram-like reaction. D is incorrect, since alcohol does not have a significant impact on the absorption of insulin.)

The nurse is reviewing the treatment regimen for a client recently diagnosed with type 1 diabetes. Which statement by the client indicates that he has understood the nurse's instructions? A. "Diet modifications and adequate exercise are the key solutions to type 1 diabetes. Insulin is just side therapy." B. "I only need to check my blood sugar before and after meals." C. "My doctor may prescribe me lisinopril to reduce my risk of kidney disease related to diabetes." D. "I should inject myself with the insulin pen in my deltoid muscle."

C (C is correct, as other medications may be used to decrease long-term complications associated with diabetes. ACE-Is, like lisinopril, and ARBs are antihypertensive drugs that help reduce the risk of diabetic nephropathy and adverse CV events. Statins may be prescribed to reduce the progression of atherosclerosis secondary to diabetes. A is incorrect, since the principal treatment for type 1 diabetes is insulin replacement, since patients with this condition cannot make their own insulin. Diet and exercise changes are adjunct therapies. B is incorrect, since clients also need to check blood sugar at least before and after exercise and before bedtime, not just before and after meals. They may need to check it more often depending on the severity of their disorder. D is incorrect, since insulin should be injected subQ, not IM, into the posterior aspect of an upper arm, into the fat of the abdomen, or anterior aspect of a thigh. Patients should be instructed to inject in the same region to maintain predictable action of their insulin, but to rotate sites around that region to prevent excessive bruising and to reduce the risk of lipohypertrophy.)

A diabetic client who takes Lantus once a day before bed wakes up with a blood sugar of 175 mg/dL. This paradoxical effect is known as: A. Insulin-induced hyperglycemia B. Dawn phenomenon C. Somogyi effect D. Insulin resistance

C (C is correct, since hypoglycemic events, such as administered insulin lowering blood glucose, can precipitate rebound hyperglycemia, which is called the Somogyi effect. It is caused by a compensatory increase of insulin's counter-regulatory hormones (e.g. epinephrine, glucagon, cortisol, and GH) in response to the hypoglycemia. A is incorrect, since insulin only causes hypoglycemia. B is incorrect, since the Dawn phenomenon occurs without the need of a hypoglycemic event. It is often caused by variations in circadian rhythms, causing unexpected releases of glucagon which increase blood glucose levels. D is incorrect, since insulin resistance describes the body's inability to use its own insulin to lower blood glucose, not its inability to use synthetic versions of insulin.)

A client with postmenopausal osteoporosis is asking the nurse at the nursing home what meal on today's lunch menu may best help with her condition. A. A steak filet with beans and pasta on the side, served with an apricot sauce. B. Roasted sweet potatoes with mushroom and shallots, served with an orange. C. A tofu noodle soup served with cooked spinach, served with a cup of yogurt. D. Pan-fried salmon and deviled eggs, served with fortified almond milk.

C (C is correct. Calcium-rich foods include tofu, cooked spinach, broccoli, and dairy products, e.g. milk, cheese, and yogurt. A is incorrect. This meal is primarily high in iron due to the red meat, beans, pasta (if fortified), and apricots. B is incorrect. This meal is primarily high in potassium due to the sweet potatoes, mushrooms, and orange. D is incorrect. This meal is primarily high in vitamin B12 due to the salmon, eggs, and fortified almond milk.)

A nurse preceptor is working with a newly licensed nurse who is providing care to multiple patients with diabetes on a medical-surgical floor. Which action by the new nurse requires intervention by the preceptor? A. The nurse rolls a vial containing NPH insulin between his palms before drawing up the prescribed dose. B. The nurse explains to a diabetic patient who is about to be discharged that he should discard a vial with normally clear insulin if it becomes cloudy. C. The nurse places unused insulin vials in the freezer for storage. D. The nurse draws up regular insulin before drawing up NPH insulin into the same syringe.

C (C is correct. Insulin should never be stored in the freezer, rather in the refrigerator until their expiration date. Used vials can be stored at room temperature away from sunlight and extreme heat for 1 month. Pre-filled syringes with insulin mixtures can be stored in the fridge upright, needle pointing up, for 1-2 weeks. A is incorrect; no intervention is needed since NPH insulin is supposed be gently agitated by rolling the vial between the nurse's palms before usage. It should not be shaken. B is incorrect; no intervention is needed since all insulin vials, except those containing NPH insulin, should appear clear and colorless. Discard if cloudy. D is incorrect; no intervention is needed since shorter-acting insulins should be drawn up before NPH insulin into the same syringe to prevent contamination of the stock vial with the shorter-acting insulin. Remember NPH insulin is the only other insulin that can be mixed with short-acting insulins.)

Which of the following statements comparing short-acting and long-acting insulins is incorrect? A. Short-acting insulins can be administered IV in emergencies, such as DKA, while long-acting insulins are only administered subQ. B. Short-acting insulins are taken shortly before meals to provide postprandial control of blood glucose levels. Long-acting insulins are taken 1-2 times a day, being able to provide basal control. C. Both short-acting and long-acting insulins are clear, meaning that they cannot be mixed with one another but each of them can be mixed with NPH insulin. D. Short-acting insulins include regular insulin, insulin lispro, insulin aspart, and insulin glulisine. Longer-acting insulins include insulin glargine, insulin detemir, and insulin degludec.

C (C is correct. Only short-acting insulins can be mixed with NPH insulin. It would be inappropriate to mix long-acting insulins with NPH insulin. A is incorrect. It is true that short-acting insulins can be given IV; long-acting insulins are only given subQ. B is incorrect. Short-acting insulins are taken AC to control blood glucose levels after a meal. Long-acting insulins are taken only once or twice to provide basal control of blood glucose levels. D is incorrect. This answer choice provides an accurate description of the available short-acting and long-acting insulins.)

One disadvantage of radioactive iodine (iodine-131) is: A. It is more expensive than other thyroid medications and requires a subtotal thyroidectomy as adjunct therapy. B. There is a high risk of damage to tissue other than the thyroid gland, and death may even occur. C. Because it takes months to see effects, if dosage is not monitored, delayed hypothyroidism may occur. D. This medication is primarily useful in children and is not effective in adults.

C (Iodine-131 gradually destroys thyroid tissue to treat hyperthyroidism over a course of 2-3 months. This means there is a high risk of excessive dosage if not monitored, leading to hypothyroidism. Other uses of radioactive iodine include in specific types of thyroid cancer and to diagnose thyroid disease. A is incorrect because it is less expensive than other thyroid meds; it does not require thyroid surgery to work and is often used as a replacement for thyroid surgery. B is incorrect because iodine-131 acts selectively upon the thyroid gland. D is incorrect since the use of this drug in children can increase the risk of cancer and delayed hypothyroidism, leading to cretinism. It cannot be used in pregnancy and lactation. It is primarily used in adults who have not responded to other antithyroid medications or surgery.)

In response to an increase in the levels of thyroid-stimulating hormone (TSH) in the bloodstream, the hypothalamus will ______________ and the thyroid gland will ________________. A. increase secretion of TRH; increase secretion of T3/T4 B. increase secretion of TRH; decrease secretion of T3/T4 C. decrease secretion of TRH; increase secretion of T3/T4 D. decrease secretion of TRH; decrease secretion of T3/T4

C (More TSH in the bloodstream will stimulate the thyroid gland to produce more thyroid hormones like T3 and T4. The increased levels of thyroid hormones as well as TSH in the blood will signal the hypothalamus to decrease TRH secretion through the negative feedback system.)

A nurse notices a client ravenously drinking from a gallon of water as he enters the adult health clinic. Upon interview, he says, "Ever since I accidentally got smacked by a baseball bat in the back of my head, I've been feeling so thirsty. I also have to pee about every 30 minutes." Urine specific gravity testing shows a value of 1.000 [Normal is 1.005-1.030] and urine is negative for glucose. What condition is the client likely experiencing and what would be appropriate treatment be? A. Diabetes mellitus; insulin B. Acromegaly; growth hormone C. Diabetes insipidus; desmopressin D. SIADH; fluid restriction

C (This client is most likely experiencing hypothalamic diabetes insipidus [DI], a disorder in which the hypothalamus does not produce enough antidiuretic hormone, or ADH. This can be caused by head trauma, as shown in this example, neurosurgery, cancer, or even genetic heredity. Hallmark S&S of DI include polydipsia and polyuria with low urine specific gravity, or dilute urine. Treatment usually involves ADH replacement, usually with desmopressin [DDAVP]. Diabetes mellitus is a condition of insulin resistance, causing hyperglycemia and glycosuria, if left untreated. It is treated with insulin and other antidiabetic medications. Acromegaly is caused by excessive GH at adult age. It should not be treated with growth hormone, rather with surgery, radiation, or somatostatin drugs, such as octreotide or lanreotide. SIADH, or syndrome of inappropriate diuretic hormone, is caused by an excess of ADH secretion by the hypothalamus, causing too much sodium and water retention. It should be treated with fluid restriction.)

A client with Graves disease tells the nurse, "I have been taking PTU for a couple weeks now, but I haven't seen an improvement in my symptoms." What should the nurse tell the patient? A. "We can notify your primary care provider about increasing the dosage." B. "You might need to be transferred to another medication like methimazole." C. "It usually takes 6 to 12 months to see positive effects with PTU." D. "This medication only works if you cut down on your iodine intake."

C (Thyroid medications tend to take a longer time to see substantial effects: - levothyroxine - 6 weeks - methimazole - 3-12 weeks - PTU - 6-12 months - Radioactive iodine - 2-3 months Thus, option C is the most appropriate answer. Increasing the dosage will not change the fact it will take 6-12 months for PTU to work and may increase the risk of accidental hypothyroidism. A patient taking PTU, if initially prescribed by the HCP, should switch to methimazole if signs of liver injury are present. There is no need to switch now. PTU works to reduce iodine uptake by the thyroid, reducing thyroid hormone levels. Iodine intake has no bearing on the mechanism of action.)

A client visiting the clinic complains of general feeling of "grogginess" and constipation. She says, "I've gained 20 lbs in the last 2 months, and I don't eat as much as I used to. I also can't stand being in the cold for long." Upon assessment, you notice a puffy face and tongue and nonpitting edema in the hands and feet. VS: HR 49, BP 124/78, RR 8, T 96.8F. What condition is she most likely experiencing? A. Opioid overdose B. Cushing syndrome C. Hypothyroidism D. A bad day

C (While opioids can cause cardio-respiratory depression and constipation, these data in combination with the other symptoms like grogginess, puffiness in the face, cold intolerance, nonpitting edema, and below average body temp better point the diagnosis to hypothyroidism. Other symptoms of hypothyroidism include coarse dry hair and skin, impaired memory, muscle weakness, and menstrual cycle disturbances.)

List the following insulin types in order, starting with the one with the shortest onset of action: A. NPH insulin [Humulin N] B. Insulin glargine [Lantus] C. Insulin aspart [Novolog] D. Regular insulin [Humulin R]

C, D, A, B (The short-acting insulins—lispro, aspart, and glulisine—have a quick onset of action, ranging from 10-30 minutes from time of injection. Their effects last about 3-6 hours. Regular insulin has an onset of action that is between 30-60 minutes from time of injection. Its effects peak between 1-5 hours, overall lasting for 10 hours. NPH insulin has an onset of action that is between 1-2 hours. Its effects peak between 4-6 hours and can last over 12 hours. Long-acting insulins—glargine, detemir, and degludec—have the slowest onset of action, as they have the longest duration, around 24 hours.)

A thyroid storm is an extreme form of a hyperthyroid state, if left untreated, resulting in very high fever, extreme CV effects, and a high mortality rate. A nurse knows that all of the following are common causes of a thyroid storm except: A. Infection B. Acute emotional distress C. Manipulation of the thyroid gland during a thyroidectomy D. Prolonged immobility

D (Any form of stress, such as infection, physical or emotional distress, or the manipulation of the thyroid gland during surgery can precipitate a thyroid storm. Prolonged immobility is not likely to cause a thyroid storm.)

A 44-year-old female client is admitted to med-surg unit with a diagnosis of Cushing's syndrome. Which of the following is not a clinical manifestation of this disorder? A. Muscle weakness and muscle wasting B. Altered fat metabolism C. Increased gastric acid secretions D. Hyperkalemia E. Hyperglycemia

D (Critical signs of Cushing's disease include hyperglycemia, hypokalemia, and increased gastric acid secretions. Important nursing interventions include: - Taking AC & HS blood glucose levels - Monitoring potassium levels and cardiac condition - Checking client's vomit and feces for blood, for possible evidence of GI bleeding. Other S&S of Cushing's syndrome that take time to develop include muscle weakness and wasting, altered fat metabolism [e.g. buffalo hump, moon face, and potbelly], purple striae on the abdomen, and osteoporosis. Incidental S&S include ecchymosis and purpura, emotional disturbance, amenorrhea, hirsutism, and acne.)

A client experiencing type 2 diabetes complains that her blood glucose levels have remained high despite being on metformin for 6 months. Her husband has told you that she has been diligent with her medication regimen, but does not consistently eat a diabetic diet and exercise. What should you as the RN tell the client about her treatment? A. "Speak with your primary care provider about potentially adding another drug to the medication regimen, such as a sulfonylurea or insulin." B. "You will need to double the dosage of your metformin starting today." C. "Metformin should be taken with food to reduce GI upset." D. "Drug treatment with metformin works best with lifestyle changes, such as daily exercise and a low-fat and low-calorie diet."

D (D is correct, because it accurately and positively reinforces the importance of TLCs in conjunction with metformin monotherapy for diabetes treatment. A is incorrect, because the nurse should first consider reinforcing diet and exercise as an alternative to getting the HCP to add another drug to her treatment regimen. B is incorrect, because it is not within the RN's scope of practice to prescribe changes in dosage for medications. C is incorrect, because although taking food with metformin may decrease GI upset, this response does not address the patient's nonadherence to TLCs with metformin therapy.)

Hypoglycemia is the most common adverse effect of insulin therapy for diabetes. Which of the following statements is true regarding this condition? A. It is difficult to differentiate between a hypoglycemic coma and a coma precipitated by DKA. B. For all conscious patients experiencing hypoglycemia, principal treatment involves parenteral treatment with glucose or glucagon. C. Common manifestations of hypoglycemia that a diabetic patient should know only include CNS symptoms, like headache and confusion. D. Beta-blockers may mask the signs and symptoms of hypoglycemia and even worsen the condition.

D (D is correct. Because beta blockers inhibit stimulation of the SNS, S&S of hypoglycemia like tachycardia, palpitations, sweating, and nervousness will not be present in diabetic patients taking this type of drug. Hypoglycemia may be worsened with beta blockers since they also inhibit glycogen breakdown into usable glucose for energy. A is incorrect. The easiest and most definitive method of differentiating between a hypoglycemic coma and a coma due to DKA is measuring blood glucose levels. If levels are high, DKA is present; if low, hypoglycemia is present. B is incorrect. For conscious patients, glucose levels should be restored with a fast-acting oral sugar, e.g. glucose tablet, regular soda, or sugar cubes. IV glucose or parenteral glucagon is only used when the swallowing reflex is impaired or if the patient is unconscious. C is incorrect. In addition to CNS symptoms, like headache, confusion, drowsiness, and fatigue that indicate the brain is not receiving enough glucose, SNS symptoms as mentioned in the rationale for choice D also indicate hypoglycemia.)

A hospitalized client taking DDAVP for diabetes insipidus tells the nurse that she has a headache and feels sleepier than usual and fatigued. What is the priority intervention by the nurse? A. Check the client's urine output and electrolyte panel for any abnormalities. B. Tell the patient that these symptoms are normal side effects of the medication. Check on the patient again in one hour. C. Give the patient a sugary snack to help alleviate the headache and boost her energy levels. D. Contact the HCP and be ready to administer furosemide.

D (Headache, drowsiness, and fatigue are signs of water intoxication secondary to DDAVP usage for DI. This could have been prevented with fluid restriction at the start of treatment. Because water intoxication can lead to seizures, coma, and death, it is necessary to contact the HCP and be ready to administer the client a diuretic, like furosemide [Lasix]. A is incorrect. Checking urine output and the electrolyte panel may show low urine volume and electrolyte imbalances because of water intoxication, but this is an assessment and not an intervention. B is incorrect because symptoms of water intoxication are serious and should not be ignored. It is inappropriate to leave and check on the patient later. C is incorrect. Although giving a sugary snack may help with the headache and lack of energy, this intervention does not directly address the client's water intoxication. In this situation, safety would trump comfort.)

A client experiencing DI in addition to coronary insufficiency and stable angina asks the nurse, "Don't they usually use vasopressin to treat diabetes insipidus? The doctor told me I will be taking desmopressin instead." What is the most appropriate response by the nurse? A. Both drugs work the same, so there isn't a thing to worry about. B. We've begun reserving vasopressin for use in cardiac arrest. That's why we're using desmopressin for you instead. C. Just be quiet and take your medicine. D. Desmopressin is much safer to use than vasopressin in DI patients with pre-existing heart problems.

D (Option D is the most therapeutic response and contains accurate information regarding the differences between desmopressin, or DDAVP, and vasopressin. Because vasopressin is a potent vasoconstrictor, it may constrict the client's coronary vessels, exacerbating the client's angina. Desmopressin is a weak vasoconstrictor and primarily acts to conserve water with fewer CV effects. It also works for a longer period of time and is more convenient to administer, i.e. intranasal; vasopressin has a shorter half-life and must be given IM or subQ. A is wrong because even though they work the same, the side effects are different, so there is something to worry about. B is wrong because vasopressin is no longer used as the primary drug for cardiac arrest. C is wrong because it does not demonstrate therapeutic communication and is dismissive of the client's concerns.)

A nurse educator is giving a lecture on medication for growth hormone deficiency. Which statement by one of the students indicates the need for further teaching? A. "Human growth hormone, or somatropin, is given subQ or IM to treat GH deficiency." B. "Mecasermin is an alternative, if a client develops antibodies against somatropin over the course of treatment." C. "Somatropin cannot be used after a client's epiphyseal plates have closed." D. "Somatropin can be used in children with DM."

D (Somatropin should be used with caution in children with diabetes because GH naturally elevates glucose levels; insulin dosages need to be adjusted accordingly. It is also be carefully used in children with hypothyroidism, as GH can suppress thyroid function; levothyroxine may be indicated. Somatropin is given subQ preferred. It can also be given IM. If a client does develop antibodies to somatropin, a child can take mecasermin, or IGF-1, instead. Hypoglycemia is a common adverse effect. Somatropin should only be used before epiphyseal plates have closed, satisfactory adult height has been achieved, or until the ages of 20-24 when treatment is not effective anymore. Going past these limits increases the risk of acromegaly.)

Which diagnostic test for DM involves the measurement of glycated hemoglobin, reflecting average blood glucose levels over the last 2-3 months? A. FPG test B. OGTT C. Random glucose test D. HbA1c test

D (The HbA1c test measures the percentage of hemoglobin in the blood to which glucose has binded, reflecting the average blood glucose levels in the previous 2-3 months. - Normal: <6% - Diabetes: ≥6.5% The fasting plasma glucose (FPG) test measures blood glucose levels at least 8 hours after a client's last meal. - Normal: <100 mg/dL - At risk: 100-125 mg/dL - Diabetes: ≥126 mg/dL The oral glucose tolerance test (OGTT) measures blood glucose levels 2 hours after the client consumes a 75 g glucose load. - Normal: <140 mg/dL - At risk: 140-199 mg/dL - Diabetes: ≥200 mg/dL The random, or casual, plasma glucose test measures blood glucose levels at a random time, often with a finger-stick blood sample. - A diagnosis of diabetes is only made if the blood glucose level is ≥200 mg/dL in addition to classic S&S of diabetes: polyuria, polydipsia, rapid weight loss [type 1], and ketonuria [type 1].)

T/F: A stimulation test would be appropriate to help diagnose a hormone disorder of hyperfunction.

false (Stimulation tests are used to help diagnose disorders of hormone hypofunction, e.g. giving TSH to diagnose a thyroid hormone deficiency. Suppression tests are used to help diagnose disorders of hormone hyperfunction.)

T/F: The bones of the body hold most of its calcium stores, and the amount of calcium in the blood is ~10 mg/dL.

true (98% of calcium is stored in the bones while only about 10 mg/dL circulates in the bloodstream. However, only 50% of this amount is free, ionized calcium that is able to participate in physiologic processes.)

T/F: When caring for a client on methimazole, the nurse should monitor a client's CBC with differential periodically.

true (Methimazole and PTU can cause a rare condition called agranulocytosis, where there is a dramatic reduction in granulocytes, e.g. neutrophils, in the blood. Because this predisposes them to infection, the nurse should monitor the CBC with differential and the patient for signs of infection.)