Lippincott Q&A: The Client with Endocrine Health Problems

14. Which of the following symptoms might indicate that a client was developing tetany after a subtotal thyroidectomy? ■ 1. Pains in the joints of the hands and feet. ■ 2. Tingling in the fingers. ■ 3. Bleeding on the back of the dressing. ■ 4. Tension on the suture line.

14. 2. Tetany may occur after thyroidectomy if the parathyroid glands are accidentally injured or removed during surgery. This would cause a disturbance in serum calcium levels. An early sign of tetany is numbness and tingling of the fingers or toes and in the circumoral region. Tetany may occur from 1 to 7 days postoperatively. Late signs and symptoms of tetany include seizures, contraction of the glottis, and respiratory obstruction. Pains in the joints of the hands and feet are not early symptoms of tetany. Bleeding on the back of the dressing is related to possible incisional complications. Tension on the suture line may indicate swelling, infection, or internal bleeding, but it is not related to tetany. CN: Physiological adaptation; CL: Analyze

35. Which of the following conditions is the most significant risk factor for the development of type 2 diabetes mellitus? ■ 1. Cigarette smoking. ■ 2. High-cholesterol diet. ■ 3. Obesity. ■ 4. Hypertension.

35. 3. The most important factor predisposing to the development of type 2 diabetes mellitus is obesity. Insulin resistance increases with obesity. Cigarette smoking is not a predisposing factor, but it is a risk factor that increases complications of diabetes mellitus. A high-cholesterol diet does not necessarily predispose to diabetes mellitus, but it may contribute to obesity and hyperlipidemia. Hypertension is not a predisposing factor, but it is a risk factor for developing complications of diabetes mellitus. CN: Health promotion and maintenance; CL: Apply

52. A client is to have a transsphenoidal hypophysectomy to remove a large, invasive pituitary tumor. The nurse should instruct the client that the surgery will be performed through an incision in the: ■ 1. Back of the mouth. ■ 2. Nose. ■ 3. Sinus channel below the right eye. ■ 4. Upper gingival mucosa in the space between the upper gums and lip.

52. 4. With transsphenoidal hypophysectomy, the sella turcica is entered from below, through the sphenoid sinus. There is no external incision; the incision is made between the upper lip and gums. CN: Reduction of risk potential; CL: Apply

58. To provide oral hygiene for a client recovering from transsphenoidal hypophysectomy, the nurse should instruct the client to: ■ 1. Rinse the mouth with saline solution. ■ 2. Perform frequent toothbrushing. ■ 3. Clean the teeth with an electric toothbrush. ■ 4. Floss the teeth thoroughly

58. 1. After transsphenoidal surgery, the client must be careful not to disturb the suture line while healing occurs. Frequent oral care should be provided with rinses of saline, and the teeth may be gently cleaned with Toothettes. Frequent or vigorous toothbrushing or flossing is contraindicated because it may disturb or cause tension on the suture line. CN: Physiological adaptation; CL: Synthesize

73. A nurse is assessing a client with Addison's disease. The nurse should review laboratory reports for which condition? ■ 1. Hypokalemia. ■ 2. Hypernatremia. ■ 3. Hypoglycemia. ■ 4. Decreased blood urea nitrogen (BUN) level.

73. 3. Decreased hepatic gluconeogenesis and increased tissue glucose uptake cause hypoglycemia in clients with Addison's disease. Hyperkalemia and hyponatremia are characteristic of Addison's disease. There is decreased renal perfusion and excretion of waste products, which causes an elevated BUN level. CN: Reduction of risk potential; CL: Analyze

11. The nurse is administering a saturated solution of potassium iodide (SSKI). The nurse should: ■ 1. Pour the solution over ice chips. ■ 2. Mix the solution with an antacid. ■ 3. Dilute the solution with water, milk, or fruit juice and have the client drink it with a straw. ■ 4. Disguise the solution in a pureed fruit or vegetable.

11. 3. SSKI should be diluted well in milk, water, juice, or a carbonated beverage before administration to help disguise the strong, bitter taste. Also, this drug is irritating to mucosa if taken undiluted. The client should sip the diluted preparation through a drinking straw to help prevent staining of the teeth. Pouring the solution over ice chips will not sufficiently dilute the SSKI or cover the taste. Antacids are not used to dilute or cover the taste of SSKI. Mixing in a puree would put the SSKI in contact with the teeth. CN: Pharmacological and parenteral therapies; CL: Apply

12. The nurse asks the client to state her name as soon as she regains consciousness postoperatively after a subtotal thyroidectomy and at each assessment. The nurse does this to monitor for signs of which of the following? ■ 1. Internal hemorrhage. ■ 2. Decreasing level of consciousness. ■ 3. Laryngeal nerve damage. ■ 4. Upper airway obstruction.

12. 3. Laryngeal nerve damage is a potential complication of thyroid surgery because of the proximity of the thyroid gland to the recurrent laryngeal nerve. Asking the client to speak helps assess for signs of laryngeal nerve damage. Persistent or worsening hoarseness and weak voice are signs of laryngeal nerve damage and should be reported to the physician immediately. Internal hemorrhage is detected by changes in vital signs. The client's level of consciousness can be partially assessed by asking her to speak, but that is not the primary reason for doing so in this situation. Upper airway obstruction is detected by color and respiratory rate and pattern. CN: Reduction of risk potential; CL: Analyze

13. A client who has undergone a subtotal thyroidectomy is subject to complications in the first 48 hours after surgery. The nurse should obtain and keep at the bedside equipment to: ■ 1. Begin total parenteral nutrition. ■ 2. Start a cutdown infusion. ■ 3. Administer tube feedings. ■ 4. Perform a tracheotomy.

13. 4. Equipment for an emergency tracheotomy should be kept in the room, in case tracheal edema and airway occlusion occur. Laryngeal nerve damage can result in vocal cord spasm and respiratory obstruction. A tracheostomy set, oxygen and suction equipment, and a suture removal set (for respiratory distress from hemorrhage) make up the emergency equipment that should be readily available. Total parenteral nutrition is not anticipated for the client undergoing thyroidectomy. Intravenous infusion via a cutdown is not an expected possible treatment after thyroidectomy. Tube feedings are not anticipated emergency care. CN: Reduction of risk potential; CL: Synthesize

16. A 60-year-old female is diagnosed with hypothyroidism. The nurse should assess the client for which of the following? ■ 1. Tachycardia. ■ 2. Weight gain. ■ 3. Diarrhea. ■ 4. Nausea.

16. 2. Typical signs and symptoms of hypothyroidism include weight gain, fatigue, decreased energy, apathy, brittle nails, dry skin, cold intolerance, hair loss, constipation, and numbness and tingling in the fingers. Tachycardia is a sign of hyperthyroidism, not hypothyroidism. Diarrhea and nausea are not symptoms of hypothyroidism. CN: Physiological adaptation; CL: Analyze

19. The nurse is teaching a diabetic client using an empowerment approach. The nurse should initiate teaching by asking which of the following? ■ 1. "How much does your family need to be involved in learning about your condition?" ■ 2. "What is required for your family to manage your symptoms?" ■ 3. "What activities are most important for you to be able to maintain control of your diabetes?" ■ 4. "What do you know about your medications and condition?"

19. 3. Empowerment is an approach to clinical practice that emphasizes helping people discover and use their innate abilities to gain mastery over their own condition. Empowerment means that individuals with a health problem have the tools, such as knowledge, control, resources, and experience, to implement and evaluate their self-management practices. Involvement of others, such as asking the client about family involvement, implies that the others will provide the direct care needed rather than the client. Asking the client what the client needs to know implies that the nurse will be the one to provide the information. Telling the client what is required does not provide the client with options or lead to empowerment. CN: Health promotion and maintenance; CL: Synthesize

21. A 57-year-old with diabetes insipidus is hospitalized for care. Which finding should the nurse report to the physician? ■ 1. Urine output of 350 mL in 8 hours. ■ 2. Urine specific gravity of 1.001. ■ 3. Potassium of 4.0 mEq. ■ 4. Weight gain.

21. 2. Diabetes insipidus is caused by a deficiency of antidiuretic hormone, which results in excretion of a large volume of dilute urine. Therefore, a urine specific gravity of less than 1.005 should be reported. Urine output should be 30 to 50 mL/hour; thus, 350 mL is a normal urinary output over 8 hours. The potassium level is normal. Weight loss, not weight gain, should be monitored as a sign of dehydration. CN: Reduction of risk potential; CL: Synthesize

24. A client is to receive glargine (Lantus) insulin in addition to a dose of aspart (NovoLog). When the nurse checks the blood glucose level at the bedside, it is greater than 200 mg/dL. How should the nurse administer the insulins? ■ 1. Put air into the glargine insulin vial, and then air into the aspart insulin vial, and draw up the correct dose of aspart insulin first. ■ 2. Roll the glargine insulin vial, then roll the aspart insulin vial. Draw up the longer-acting glargine insulin first. ■ 3. Shake both vials of insulin before drawing up each dose in separate insulin syringes. ■ 4. Put air into the glargine insulin vial, and draw up the correct dose in an insulin syringe; then, with a different insulin syringe, put air into the aspart vial and draw up the correct dose.

24. 4. Glargine (Lantus) is a long-acting recombinant human insulin analog. Glargine should not be mixed with any other insulin product. Insulins should not be shaken; instead, if the insulin is cloudy, roll the vial or insulin pen between the palms of the hands. CN: Pharmacological and parenteral therapies; CL: Synthesize

25. An adult client with type 2 diabetes is taking metformin (Glucophage) 1,000 mg two times every day. After the nurse provides instructions regarding the interaction of alcohol and metformin, the nurse evaluates that the client understands the instructions when the client says: ■ 1. "If I know I'll be having alcohol, I must not take metformin; I could develop lactic acidosis." ■ 2. "If my physician approves, I may drink alcohol with my metformin." ■ 3. "Adverse effects I should watch for are feeling excessively energetic, unusual muscle stiffness, low back pain, and a rapid heartbeat." ■ 4. "If I feel bloated, I should call my physician."

25. 1. A rare but serious adverse effect of metformin (Glucophage) is lactic acidosis; half the cases are fatal. Ideally, one should stop metformin for 2 days before and 2 days after drinking alcohol. Signs and symptoms of lactic acidosis are weakness, fatigue, unusual muscle pain, dyspnea, unusual stomach discomfort, dizziness or light-headedness, and bradycardia or cardiac arrhythmias. Bloating is not an adverse effect of metformin. CN: Pharmacological and parenteral therapies; CL: Evaluate

27. Which information should the nurse include when developing a teaching plan for a client newly diagnosed with type 2 diabetes mellitus. Select all that apply. ■ 1. A major risk factor for complications is obesity and central abdominal obesity. ■ 2. Supplemental insulin is mandatory for controlling the disease. ■ 3. Exercise increases insulin resistance. ■ 4. The primary nutritional source requiring monitoring in the diet is carbohydrates. ■ 5. Annual eye and foot examinations are recommended by the American Diabetes Association (ADA).

27. 1, 5. Being overweight and having a large waist-hip ratio (central abdominal obesity) increase insulin resistance, making control of diabetes more difficult. The ADA recommends a yearly referral to an ophthalmologist and podiatrist. Exercise and weight management decrease insulin resistance. Insulin is not always needed for type 2 diabetes; diet, exercise, and oral medications are the first-line treatment. The client must monitor all nutritional sources for a balanced diet-fats, carbohydrates, and protein. CN: Reduction of risk potential; CL: Create

29. A client with diabetes mellitus asks the nurse to recommend something to remove corns from his toes. The nurse should advise the client to: ■ 1. Apply a high-quality corn plaster to the area. ■ 2. Consult a physician or podiatrist about removing the corns. ■ 3. Apply iodine to the corns before peeling them off. ■ 4. Soak the feet in borax solution to peel off the corns.

29. 2. A client with diabetes should be advised to consult a physician or podiatrist for corn removal because of the danger of traumatizing the foot tissue and potential development of ulcers. The diabetic client should never self-treat foot problems but should consult a physician or podiatrist. CN: Reduction of risk potential; CL: Synthesize

30. A client with diabetes mellitus comes to the clinic for a regular 3-month follow-up appointment. The nurse notes several small bandages covering cuts on the client's hands. The client says, "I'm so clumsy. I'm always cutting my finger cooking or burning myself on the iron." Which of the following responses by the nurse would be most appropriate? ■ 1. "Wash all wounds in isopropyl alcohol." ■ 2. "Keep all cuts clean and covered." ■ 3. "Why don't you have your children do the cooking and ironing?" ■ 4. "You really should be fine as long as you take your daily medication."

30. 2. Proper and careful first-aid treatment is important when a client with diabetes has a skin cut or laceration. The skin should be kept supple and as free of organisms as possible. Washing and bandaging the cut will accomplish this. Washing wounds with alcohol is too caustic and drying to the skin. Having the children help is an unrealistic suggestion and does not educate the client about proper care of wounds. Tight control of blood glucose levels through adherence to the medication regimen is vitally important; however, it does not mean that careful attention to cuts can be ignored. CN: Reduction of risk potential; CL: Synthesize

33. Which of the following findings should the nurse report to the client's physcian for a client with unstable type 1 diabetes mellitus? Select all that apply. ■ 1. Systolic blood pressure, 145 mm Hg. ■ 2. Diastolic blood pressure, 87 mm Hg. ■ 3. High-density lipoprotein (HDL), 30 mg/dL. ■ 4. Glycosylated hemoglobin (HbA1c), 10.2%. ■ 5. Triglycerides, 425 mg/dL. ■ 6. Urine ketones, negative.

33. 1, 2, 3, 4, 5. The client with unstable diabetes mellitus is at risk for many microvascular and macrovascular complications. Heart disease is the leading cause of mortality in clients with diabetes. The goal blood pressure for diabetics is less than 130/80 mm Hg. Therefore, the nurse would need to report any findings greater than 130/80 mm Hg. The goal of HbA 1c is less than 7%; thus, a level of 10.2% must be reported. HDL less than 40 mg/dL and triglycerides greater than 150 mg/dL are risk factors for heart disease. The nurse would need to report the client's HDL and triglyceride levels. The urine ketones are negative, but this is a late sign of complications when there is a profound insulin deficiency. CN: Reduction of risk potential; CL: Analyze

34. The nurse should caution the client with diabetes mellitus who is taking a sulfonylurea that alcoholic beverages should be avoided while taking these drugs because they can cause which of the following? ■ 1. Hypokalemia. ■ 2. Hyperkalemia. ■ 3. Hypocalcemia. ■ 4. Disulfiram (Antabuse)-like symptoms

34. 4. A client with diabetes who takes any first- or second-generation sulfonylurea should be advised to avoid alcohol intake. Sulfonylureas in combination with alcohol can cause serious disulfiram (Antabuse)-like reactions, including flushing, angina, palpitations, and vertigo. Serious reactions, such as seizures and possibly death, may also occur. Hypokalemia, hyperkalemia, and hypocalcemia do not result from taking sulfonylureas in combination with alcohol. CN: Physiological adaptation; CL: Apply

36. Which of the following indicates a potential complication of diabetes mellitus? ■ 1. Inflamed, painful joints. ■ 2. Blood pressure of 160/100 mm Hg. ■ 3. Stooped appearance. ■ 4. Hemoglobin of 9 g/dL

36. 2. The client with diabetes mellitus is especially prone to hypertension due to atherosclerotic changes, which leads to problems of the microvascular and macrovascular systems. This can result in complications in the heart, brain, and kidneys. Heart disease and stroke are twice as common among people with diabetes mellitus than among people without the disease. Painful, inflamed joints accompany rheumatoid arthritis. A stooped appearance accompanies osteoporosis with narrowing of the vertebral column. A low hemoglobin concentration accompanies anemia, especially iron deficiency anemia and anemia of chronic disease. CN: Reduction of risk potential; CL: Analyze

37. The nurse is teaching the client about home blood glucose monitoring. Which of the following blood glucose measurements indicates hypoglycemia? ■ 1. 59 mg/dL. ■ 2. 75 mg/dL. ■ 3. 108 mg/dL. ■ 4. 119 mg/dL

37. 1. Although some individual variation exists, when the blood glucose level decreases to less than 70 mg/dL, the client experiences or is at risk for hypoglycemia. Hypoglycemia can occur in both type 1 and type 2 diabetes mellitus, although it is more common when the client is taking insulin. The nurse should instruct the client on the prevention, detection, and treatment of hypoglycemia. CN: Physiological adaptation; CL: Analyze

38. Assessment of the diabetic client for common complications should include examination of the: ■ 1. Abdomen. ■ 2. Lymph glands. ■ 3. Pharynx. ■ 4. Eyes

38. 4. Diabetic retinopathy, cataracts, and glaucoma are common complications in diabetics, necessitating eye assessment and examination. The feet should also be examined at each client encounter, monitoring for thickening, fissures, or breaks in the skin; ulcers; and thickened nails. Although assessments of the abdomen, pharynx, and lymph glands are included in a thorough examination, they are not pertinent to common diabetic complications. CN: Reduction of risk potential; CL: Analyze

39. The client with type 1 diabetes mellitus is taught to take isophane insulin suspension NPH (Humulin N) at 5 p.m. each day. The client should be instructed that the greatest risk of hypoglycemia will occur at about what time? ■ 1. 11 a.m., shortly before lunch. ■ 2. 1 p.m., shortly after lunch. ■ 3. 6 p.m., shortly after dinner. ■ 4. 1 a.m., while sleeping.

39. 4. The client with diabetes mellitus who is taking NPH insulin (Humulin N) in the evening is most likely to become hypoglycemic shortly after midnight because this insulin peaks in 6 to 8 hours. The client should eat a bedtime snack to help prevent hypoglycemia while sleeping. CN: Pharmacological and parenteral therapies; CL: Apply

41. A client with diabetes is taking insulin lispro (Humalog) injections. The nurse should advise the client to eat: ■ 1. Within 10 to 15 minutes after the injection. ■ 2. 1 hour after the injection. ■ 3. At any time, because timing of meals with lispro injections is unnecessary. ■ 4. 2 hours before the injection.

41. 1. Insulin lispro (Humalog) begins to act within 10 to 15 minutes and lasts approximately 4 hours. A major advantage of Humalog is that the client can eat almost immediately after the insulin is administered. The client needs to be instructed regarding the onset, peak, and duration of all insulin, as meals need to be timed with these parameters. Waiting 1 hour to eat may precipitate hypoglycemia. Eating 2 hours before the insulin lispro could cause hyperglycemia if the client does not have circulating insulin to metabolize the carbohydrate. CN: Pharmacological and parenteral therapies; CL: Synthesize

42. The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can: ■ 1. Perform the procedure safely and correctly. ■ 2. Critique the nurse's performance of the procedure. ■ 3. Explain all steps of the procedure correctly. ■ 4. Correctly answer a posttest about the procedure

42. 1. The nurse should judge that learning has occurred from evidence of a change in the client's behavior. A client who performs a procedure safely and correctly demonstrates that he has acquired a skill. Evaluation of this skill acquisition requires performance of that skill by the client with observation by the nurse. The client must also demonstrate cognitive understanding, as shown by the ability to critique the nurse's performance. Explaining the steps demonstrates acquisition of knowledge at the cognitive level only. A posttest does not indicate the degree to which the client has learned a psychomotor skill. CN: Pharmacological and parenteral therapies; CL: Evaluate

45. The nurse should teach the diabetic client that which of the following is the most common symptom of hypoglycemia? ■ 1. Nervousness. ■ 2. Anorexia. ■ 3. Kussmaul's respirations. ■ 4. Bradycardia.

45. 1. The four most commonly reported signs and symptoms of hypoglycemia are nervousness, weakness, perspiration, and confusion. Other signs and symptoms include hunger, incoherent speech, tachycardia, and blurred vision. Anorexia and Kussmaul's respirations are clinical manifestations of hyperglycemia or ketoacidosis. Bradycardia is not associated with hypoglycemia; tachycardia is. CN: Reduction of risk potential; CL: Apply

48. Which of the following is a priority nursing diagnosis for the diabetic client who is taking insulin and has nausea and vomiting from a viral illness or influenza? ■ 1. Imbalanced nutrition: Less than body requirements. ■ 2. Ineffective health maintenance related to ineffective coping skills. ■ 3. Acute pain. ■ 4. Activity intolerance.

48. 1. Imbalanced nutrition: Less than body requirements is a priority nursing diagnosis for the client with diabetes mellitus who is experiencing vomiting with influenza. The diabetic client should eat small, frequent meals of 50 g of carbohydrate or food equal to 200 calories every 3 to 4 hours. If the client cannot eat the carbohydrates or take fluids, the health care provider should be called or the client should go to the emergency department. The diabetic client is in danger of complications with dehydration, electrolyte imbalance, and ketoacidosis. Increasing the client's coping skills is important to lifestyle behaviors, but it is not a priority during this acute illness of influenza. Pain relief may be a need for this client, but it is not the priority at this time; neither is intolerance for activity. CN: Basic care and comfort; CL: Analyze

49. During a home visit, a diabetic client begins to cry and says, "I just cannot stand the thought of having to give myself a shot every day." Which of the following would be the best response by the nurse? ■ 1. "If you do not give yourself your insulin shots, you will die." ■ 2. "We can teach your daughter to give the shots so you will not have to do it." ■ 3. "I can arrange to have a home care nurse give you the shots every day." ■ 4. "What is it about giving yourself the insulin shots that bothers you?"

49. 4. The best response is to allow the client to verbalize her fears about giving herself a shot each day. Tactics that increase fear are not effective in changing behavior. If possible, the client needs to be responsible for her own care, including giving selfinjections. It is unlikely that the client's insurance company will pay for home-care visits if the client is capable of self-administration. CN: Psychosocial adaptation; CL: Synthesize

51. Which of the following signs and symptoms are common in male clients with prolactin-secreting tumors? ■ 1. Severe lethargy and fatigue. ■ 2. Decreased libido and impotence. ■ 3. Bony proliferation of the hands, jaw, and feet. ■ 4. Deepening or coarsening of the voice.

51. 2. Excessive prolactin secretion in men results in decreased libido and impotence; these are often the only significant signs and symptoms until the tumor becomes large. Signs and symptoms of pituitary tumors result from both the presence of a space-occupying mass in the cranium and the excess secretion of hormones. Lethargy and fatigue are associated with hypothyroidism or Addisonian crisis. Bony proliferation and voice changes are associated with excessive growth hormone. CN: Physiological adaptation; CL: Analyze

53. To help minimize the risk of postoperative respiratory complications after a hypophysectomy, during preoperative teaching, the nurse should instruct the client how to: ■ 1. Use blow bottles. ■ 2. Turn in bed. ■ 3. Take deep breaths. ■ 4. Cough.

53. 3. Deep breathing is the best choice for helping prevent atelectasis. The client should be placed in the semi-Fowler's position (or as ordered) and taught deep breathing, sighing, mouth breathing, and how to avoid coughing. Blow bottles are not effective in preventing atelectasis because they do not promote sustained alveolar inflation to maximal lung capacity. Frequent position changes help loosen lung secretions, but deep breathing is most important in preventing atelectasis. Coughing is contraindicated because it increases intracranial pressure and can cause cerebrospinal fluid to leak from the point at which the sella turcica was entered. CN: Reduction of risk potential; CL: Synthesize

54. Follwing a transsphenoidal hypophysectomy, the nurse should assess the client for: ■ 1. Cerebrospinal fluid (CSF) leak. ■ 2. Fluctuating blood glucose levels. ■ 3. Cushing's syndrome. ■ 4. Cardiac arrthymias.

54. 1. A major focus of nursing care after transsphenoidal hypophysectomy is prevention of and monitoring for a CSF leak. CSF leakage can occur if the patch or incision is disrupted. The nurse should monitor for signs of infection, including elevated temperature, increased white blood cell count, rhinorrhea, nuchal rigidity, and persistent headache. Hypoglycemia and adrenocortical insufficiency may occur. Monitoring for fluctuating blood glucose levels is not related specifically to transsphenoidal hypophysectomy. The client will be given I.V. fluids postoperatively to supply carbohydrates. Cushing's disease results from adrenocortical excess, not insufficiency. Monitoring for cardiac arrtyhmias is important, but arrtythimias are not anticipated following a transsphenoidal hypophysectomy. CN: Reduction of risk potential; CL: Analyze

55. A client expresses concern about how a hypophysectomy will affect his sexual function. Which of the following statements provides the most accurate information about the physiologic effects of hypophysectomy? ■ 1. Removing the source of excess hormone should restore the client's libido, erectile function, and fertility. ■ 2. Potency will be restored, but the client will remain infertile. ■ 3. Fertility will be restored, but impotence and decreased libido will persist. ■ 4. Exogenous hormones will be needed to restore erectile function after the adenoma is removed.

55. 1. The client's sexual problems are directly related to the excessive prolactin level. Removing the source of excessive hormone secretion should allow the client to return gradually to a normal physiologic pattern. Fertility will return, and erectile function and sexual desire will return to baseline as hormone levels return to normal. CN: Physiological adaptation; CL: Apply

56. Before undergoing a transsphenoidal hypophysectomy for pituitary adenoma, the client asks the nurse how the surgeon will close the incision made in the dura. The nurse should respond based on the knowledge that: ■ 1. Dissolvable sutures are used to close the dura. ■ 2. Nasal packing provides pressure until normal wound healing occurs. ■ 3. A patch is made with a piece of fascia. ■ 4. A synthetic mesh is placed to facilitate healing

56. 3. The dural opening is typically repaired with a patch of muscle or fascia taken from the abdomen or thigh. The client should be prepared preoperatively for the presence of this additional incision in the abdomen or thigh. The client will need the patch of muscle or fascia to replace the dura. Disposable sutures alone will not provide an intact suture line. Nasal packing will not provide closure for the dural opening. A synthetic mesh is not the tissue of choice for surgical repair of the dura. CN: Reduction of risk potential; CL: Apply

57. Initial treatment for a cerebrospinal fluid (CSF) leak after transsphenoidal hypophysectomy would most likely involve: ■ 1. Repacking the nose. ■ 2. Returning the client to surgery. ■ 3. Enforcing bed rest with the head of the bed elevated. ■ 4. Administering high-dose corticosteroid therapy

57. 3. If CSF leakage is suspected or confirmed, the client is treated initially with bed rest with the head of the bed elevated to decrease pressure on the graft site. Most leaks heal spontaneously, but occasionally surgical repair of the site in the sella turcica is needed. Repacking the nose will not heal the leak at the graft site in the dura. The client will not be returned to surgery immediately because most leaks heal spontaneously. High-dose corticosteroid therapy is not effective in healing a CSF leak. CN: Physiological adaptation; CL: Apply

6. Serum concentrations of thyroid hormones and thyroid-stimulating hormone (TSH) are tests ordered for the client with thyrotoxicosis. Which of the following laboratory values are indicative of thyrotoxicosis? ■ 1. Elevated thyroid hormone concentrations and normal TSH. ■ 2. Elevated TSH and normal thyroid hormone concentrations. ■ 3. Decreased thyroid hormone concentrations and elevated TSH. ■ 4. Elevated thyroid hormone concentrations and decreased TSH.

6. 4. Elevated serum concentrations of thyroid hormones and suppressed serum TSH are the features of thyrotoxicosis. Decreased or absent serum TSH is a very accurate indicator of thyrotoxicosis. Increased levels of circulating thyroid hormones cause the feedback mechanism to the brain to suppress TSH secretion. CN: Physiological adaptation; CL: Analyze

61. Vasopressin (Pitressin) is administered to the client with diabetes insipidus because it: ■ 1. Decreases blood pressure. ■ 2. Increases tubular reabsorption of water. ■ 3. Increases release of insulin from the pancreas. ■ 4. Decreases glucose production within the liver

61. 2. The major characteristic of diabetes insipidus is decreased tubular reabsorption of water due to insufficient amounts of antidiuretic hormone (ADH). Vasopressin (Pitressin) is administered to the client with diabetes insipidus because it has pressor and ADH activities. Vasopressin works to increase the concentration of the urine by increasing tubular reabsorption, thus preserving up to 90% water. Vasopressin is administered to the client with diabetes insipidus because it is a synthetic ADH. The administration of vasopressin results in increased tubular reabsorption of water, and it is effective for emergency treatment or daily maintenance of mild diabetes insipidus. Vasopressin does not decrease blood pressure or affect insulin production or glucose metabolism, nor is insulin production a factor in diabetes insipidus. CN: Pharmacological and parenteral therapies; CL: Apply

63. The nurse is instructing a young adult with Addison's disease how to adjust the dose of glucocorticoids. The nurse should explain that the client may need an increased dosage of glucocorticoids in which of the following situations? ■ 1. Completing the spring semester of school. ■ 2. Gaining 4 pounds. ■ 3. Becoming engaged. ■ 4. Undergoing a root canal

63. 4. Adrenal crisis can occur with physical stress, such as surgery, dental work, infection, flu, trauma, and pregnancy. In these situations, glucocorticoid and mineralocorticoid dosages are increased. Weight loss, not gain, occurs with adrenal insufficiency. Psychological stress has less effect on corticosteroid need than physical stress. CN: Reduction of risk potential; CL: Synthesize

64. Which of the following is the priority for a client in addisonian crisis? ■ 1. Controlling hypertension. ■ 2. Preventing irreversible shock. ■ 3. Preventing infection. ■ 4. Relieving anxiety

64. 2. Addison's disease is caused by a deficiency of adrenal corticosteroids and can result in severe hypotension and shock because of uncontrolled loss of sodium in the urine and impaired mineralocorticoid function. This results in loss of extracellular fluid and dangerously low blood volume. Glucocorticoids must be administered to reverse hypotension. Preventing infection is not an appropriate goal of care in this life-threatening situation. Relieving anxiety is appropriate when the client's condition is stabilized, but the calm, competent demeanor of the emergency department staff will be initially reassuring. CN: Physiological adaptation; CL: Synthesize

66. The client is receiving an I.V. infusion of 5% dextrose in normal saline running at 125 mL/ hour. When hanging a new bag of fluid, the nurse notes swelling and hardness at the infusion site. The nurse should first: ■ 1. Discontinue the infusion. ■ 2. Apply a warm soak to the site. ■ 3. Stop the flow of solution temporarily. ■ 4. Irrigate the needle with normal saline.

66. 1. Signs of infiltration include slowing of the infusion and swelling, pain, hardness, pallor, and coolness of the skin at the site. If these signs occur, the I.V. line should be discontinued and restarted at another infusion site. The new anatomic site, time, and type of cannula used should be documented. The nurse may apply a warm soak to the site, but only after the I.V. line is discontinued. Parenteral administration of fluids should not be stopped intermittently. Stopping the flow does not treat the problem, nor does it address the client's needs for fluid replacement. Infiltrated I.V. sites should not be irrigated; doing so will only cause more swelling and pain. CN: Pharmacological and parenteral therapies; CL: Synthesize

68. A client with Addison's disease is admitted to the medical unit. The nurse diagnoses the client with Deficient fluid volume related to inadequate fluid intake and to fluid loss secondary to inadequate adrenal hormone secretion. As the client's oral intake increases, which of the following fluids would be most appropriate? ■ 1. Milk and diet soda. ■ 2. Water and eggnog. ■ 3. Bouillon and juice. ■ 4. Coffee and milkshakes

68. 3. Electrolyte imbalances associated with Addison's disease include hypoglycemia, hyponatremia, and hyperkalemia. Salted bouillon and fruit juices provide glucose and sodium to replenish these deficits. Diet soda does not contain sugar. Water could cause further sodium dilution. Coffee's diuretic effect would aggravate the fluid deficit. Milk contains potassium and sodium. CN: Basic care and comfort; CL: Apply

7. The nurse should teach the client to prevent corneal irritation from mild exophthalmos by: ■ 1. Massaging the eyes at regular intervals. ■ 2. Instilling an ophthalmic anesthetic as ordered. ■ 3. Wearing dark-colored glasses. ■ 4. Covering both eyes with moistened gauze pads.

7. 3. Treatment of mild ophthalmopathy that may accompany thyrotoxicosis includes measures such as wearing sunglasses to protect the eyes from corneal irritation. Treatment of ophthalmopathy should be performed in consultation with an ophthalmologist. Massaging the eyes will not help to protect the cornea. An ophthalmic anesthetic is used to examine and possibly treat a painful eye, not protect the cornea. Covering the eyes with moist gauze pads is not a satisfactory nursing measure to protect the eyes of a client with exophthalmos because treatment is not focused on moisture to the eye but rather on protecting the cornea and optic nerve. In exophthalmos, the retrobulbar connective tissues and extraocular muscle volume are expanded because of fluid retention. The pressure is also increased. CN: Reduction of risk potential; CL: Synthesize

71. The nurse is conducting discharge education with a client newly diagnosed with Addison's disease. Which information should be included in the client and family teaching plan? Select all that apply. ■ 1. Addison's disease will resolve over a few weeks, requiring no further treatment. ■ 2. Avoiding stress and maintaining a balanced lifestyle will minimize risk for exacerbations. ■ 3. Fatigue, weakness, dizziness, and mood changes need to be reported to the physician. ■ 4. A medical identification bracelet should be worn. ■ 5. Family members need to be informed about the warning signals of adrenal crisis. ■ 6. Dental work or surgery will require adjustment of daily medication.

71. 2, 3, 4, 5, 6. Addison's disease occurs when the client does not produce enough steroids from the adrenal cortex. Lifetime steroid replacement is needed. The client should be taught lifestyle management techniques to avoid stress and maintain rest periods. A medical identification bracelet should be worn and the family should be taught signs and symptoms that indicate an impending adrenal crisis, such as fatigue, weakness, dizziness, or mood changes. Dental work, infections, and surgery commonly require an adjusted dosage of steroids. CN: Physiological adaptation; CL: Create

72. The nurse should assess a client with Addison's disease for which of the following? ■ 1. Weight gain. ■ 2. Hunger. ■ 3. Lethargy. ■ 4. Muscle spasms

72. 3. Although many of the disease signs and symptoms are vague and nonspecific, most clients experience lethargy and depression as early symptoms. Other early signs and symptoms include mood changes, emotional lability, irritability, weight loss, muscle weakness, fatigue, nausea, and vomiting. Most clients experience a loss of appetite. Muscles become weak, not spastic, because of adrenocortical insufficiency. CN: Physiological adaptation; CL: Analyze

74. The client with Addison's disease is taking glucocorticoids at home. Which of the following statements indicate that the client understands how to take the medication? ■ 1. "Various circumstances increase the need for glucocorticoids, so I will need to adjust the dosage." ■ 2. "My need for glucocorticoids will stabilize and I will be able to take a predetermined dose once a day." ■ 3. "Glucocorticoids are cumulative, so I will take a dose every third day." ■ 4. "I must take a dose every 6 hours to ensure consistent blood levels of glucocorticoids."

74. 1. The need for glucocorticoids changes with circumstances. The basal dose is established when the client is discharged, but this dose covers only normal daily needs and does not provide for additional stressors. As the manager of the medication schedule, the client needs to know signs and symptoms of excessive and insufficient dosages. Glucocorticoid needs fluctuate. Glucocorticoids are not cumulative and must be taken daily. They must never be discontinued suddenly; in the absence of endogenous production, addisonian crisis could result. Two-thirds of the daily dose should be taken at about 8 a.m. and the remainder at about 4 p.m. This schedule approximates the diurnal pattern of normal secretion, with highest levels between 4 a.m. and 6 a.m. and lowest levels in the evening. CN: Pharmacological and parenteral therapies; CL: Evaluate

75. Cortisone acetate (Cortone) and fludrocortisone acetate (Florinef Acetate) are prescribed as replacement therapy for a client with Addison's disease. What administration schedule should be followed for this therapy? ■ 1. Take both drugs three times a day. ■ 2. Take the entire dose of both drugs first thing in the morning. ■ 3. Take all the fludrocortisone acetate and twothirds of the cortisone acetate in the morning, and take the remaining cortisone acetate in the afternoon. ■ 4. Take half of each drug in the morning and the remaining half of each drug at bedtime.

75. 3. Fludrocortisone acetate (Florinef Acetate) can be administered once a day, but cortisone acetate (Cortone) administration should follow the body's natural diurnal pattern of secretion. Greater amounts of cortisol are secreted during the day to meet increased demand of the body. Typically, baseline administration of cortisone acetate is 25 mg in the morning and 12.5 mg in the afternoon. Taking it three times a day would result in an excessive dose. Taking the drug only in the morning would not meet the needs of the body later in the day and evening. CN: Pharmacological and parenteral therapies; CL: Apply

77. Which of the following is the best indicator for determining whether a client with Addison's disease is receiving the correct amount of glucocorticoid replacement? ■ 1. Skin turgor. ■ 2. Temperature. ■ 3. Thirst. ■ 4. Daily weight.

77. 4. Measuring daily weight is a reliable, objective way to monitor fluid balance. Rapid variations in weight reflect changes in fluid volume, which suggests insufficient control of the disease and the need for more glucocorticoids in the client with Addison's disease. Nurses should instruct clients taking oral steroids to weigh themselves daily and to report any unusual weight loss or gain. Skin turgor testing does supply information about fluid status, but daily weight monitoring is more reliable. Temperature is not a direct measurement of fluid balance. Thirst is a nonspecific and very late sign of weight loss. CN: Pharmacological and parenteral therapies; CL: Evaluate

78. Which of the following signs and symptoms would probably indicate that the client with Addison's disease is receiving too much glucocorticoid replacement? ■ 1. Anorexia. ■ 2. Dizziness. ■ 3. Rapid weight gain. ■ 4. Poor skin turgor.

78. 3. Rapid weight gain, because it reflects excess fluids, is a warning sign that the client is receiving too much hormone replacement. It may be difficult to individualize the correct dosage for a client taking glucocorticoids, and the therapeutic range between underdosage and overdosage is narrow. Maintaining the client on the lowest dose that provides satisfactory clinical response is always the goal of pharmacotherapeutics. Fluid balance is an important indicator of the adequacy of hormone replacement. Anorexia is not present with glucocorticoid therapy because these drugs increase the appetite. Dizziness is not specific to the effects of glucocorticoid therapy. Poor skin turgor is a late sign of fluid volume deficit. CN: Pharmacological and parenteral therapies; CL: Evaluate

79. Which of the following is a priority outcome for the client with Addison's disease? ■ 1. Maintenance of medication compliance. ■ 2. Avoidance of normal activities with stress. ■ 3. Adherence to a 2-g sodium diet. ■ 4. Prevention of hypertensive episodes.

79. 1. Medication compliance is an essential part of the self-care required to manage Addison's disease. The client must learn to adjust the glucocorticoid dose in response to the normal and unexpected stresses of daily living. The nurse should instruct the client never to stop taking the drug without consulting the health care provider to avoid an addisonian crisis. Regularity in daily habits makes adjustment easier, but the client should not be encouraged to withdraw from normal activities to avoid stress. The client does not need to restrict sodium. The client is at risk for hyponatremia. Hypotension, not hypertension, is more common with Addison's disease. CN: Reduction of risk potential; CL: Evaluate

80. The client with Addison's disease should anticipate the need for increased glucocorticoid supplementation in which of the following situations? ■ 1. Returning to work after a weekend. ■ 2. Going on vacation. ■ 3. Having oral surgery. ■ 4. Having a routine medical checkup.

80. 3. Illness or surgery places tremendous stress on the body, necessitating increased glucocorticoid dosage. Extreme emotional or psychological stress also necessitates dosage adjustment. Increased dosages are needed in times of stress to prevent druginduced adrenal insufficiency. Returning to work after the weekend, going on a vacation, or having a routine checkup usually will not alter glucocorticoid dosage needs. CN: Reduction of risk potential; CL: Synthesize

81. The nurse should teach the client with Addison's disease that the adverse effect of bronzecolored skin is thought to be caused by which of the following? ■ 1. Hypersensitivity to sun exposure. ■ 2. Increased serum bilirubin level. ■ 3. Adverse effects of the glucocorticoid therapy. ■ 4. Increased secretion of adrenocorticotropic hormone (ACTH).

81. 4. Bronzing, or general deepening of skin pigmentation, is a classic sign of Addison's disease and is caused by melanocyte-stimulating hormone produced in response to increased ACTH secretion. The hyperpigmentation is typically found in the distal portion of extremities and in areas exposed to sun. Additionally, areas that may not be exposed to sun, such as the nipples, genitalia, tongue, and knuckles, become bronze-colored. Treatment of Addison's disease usually reverses the hyperpigmentation. Bilirubin level is not related to the pathophysiology of Addison's disease. Hyperpigmentation is not related to the effects of the glucocorticoid therapy. CN: Physiological adaptation; CL: Apply

82. A client reports that she has gained weight and that her face and body are "rounder," while her legs and arms have become thinner. A tentative diagnosis of Cushing's disease is made. When examining this client, the nurse would expect to find: ■ 1. Orthostatic hypotension. ■ 2. Muscle hypertrophy in the extremities. ■ 3. Bruised areas on the skin. ■ 4. Decreased body hair.

82. 3. Skin bruising from increased skin and blood vessel fragility is a classic sign of Cushing's disease. Hyperpigmentation and bruising are caused by the hypersecretion of glucocorticoids. Fluid retention causes hypertension, not hypotension. Muscle wasting occurs in the extremities. Hair on the head thins, while body hair increases. CN: Physiological adaptation; CL: Analyze

84. Cushing's disease is manifested by the excessive secretion of corticosteroids. The hormones involved are: ■ 1. Glucocorticoids and aldosterone. ■ 2. Adrenocorticotropic hormone (ACTH). ■ 3. Glucocorticoids, aldosterone, and androgens. ■ 4. Catecholamines

84. 3. Excessive levels of glucocorticoids, aldosterone, and androgens secreted from the adrenal cortex result in the constellation of symptoms known as Cushing's disease. Cushing's disease can be caused by a tumor, overstimulation from the pituitary, or the use of prescription steroid drugs. Androgens are also secreted in excess. ACTH is only one hormone that is abnormal in Cushing's disease. Excessive secretion of catecholamines accompanies pheochromocytoma, a disease of the adrenal medulla. CN: Physiological adaptation; CL: Apply

86. A client with Cushing's disease tells the nurse that the physician said the morning serum cortisol level was within normal limits. The client asks, "How can that be? I'm not imagining all these symptoms!" The nurse's response will be based on which of the following concepts? ■ 1. Some clients are very sensitive to the effects of cortisol and develop symptoms even with normal levels. ■ 2. A single random blood test cannot provide reliable information about endocrine levels. ■ 3. The excessive cortisol levels seen in Cushing's disease commonly result from loss of the normal diurnal secretion pattern. ■ 4. Tumors tend to secrete hormones irregularly, and the hormones are generally not present in the blood.

86. 3. Cushing's disease is commonly caused by loss of the diurnal cortisol secretion pattern. The client's random morning cortisol level may be within normal limits, but secretion continues at that level throughout the entire day. Cortisol levels should normally decrease after the morning peak. Analysis of a 24-hour urine specimen is often useful in identifying the cumulative excess. Clients will not have symptoms with normal cortisol levels. Hormones are present in the blood. CN: Reduction of risk potential; CL: Apply

87. The client with Cushing's disease needs to modify dietary intake to control symptoms. In addition to increasing protein, which strategy would be most appropriate? ■ 1. Increase calories. ■ 2. Restrict sodium. ■ 3. Restrict potassium. ■ 4. Reduce fat to 10%.

87. 2. A primary dietary intervention is to restrict sodium, thereby reducing fluid retention. Increased protein catabolism results in loss of muscle mass and necessitates supplemental protein intake. The client may be asked to restrict total calories to reduce weight. The client should be encouraged to eat potassium-rich foods because serum levels are typically depleted. Although reducing fat intake as part of an overall plan to restrict calories is appropriate, fat intake of less than 20% of total calories is not recommended. CN: Basic care and comfort; CL: Synthesize

88. Bone resorption is a possible complication of Cushing's disease. Which of the following interventions should the nurse recommend to help the client prevent this complication? ■ 1. Increase the amount of potassium in the diet. ■ 2. Maintain a regular program of weight-bearing exercise. ■ 3. Limit dietary vitamin D intake. ■ 4. Perform isometric exercises.

88. 2. Osteoporosis is a serious outcome of prolonged cortisol excess because calcium is resorbed out of the bone. Regular daily weight-bearing exercise (e.g., brisk walking) is an effective way to drive calcium back into the bones. The client should also be instructed to have a dietary or supplemental intake of calcium of 1,500 mg daily. Potassium levels are not relevant to prevention of bone resorption. Vitamin D is needed to aid in the absorption of calcium. Isometric exercises condition muscle tone but do not build bones. CN: Reduction of risk potential; CL: Synthesize

89. A client has an adrenal tumor and is scheduled for a bilateral adrenalectomy. During prepoperative teaching, the nurse teaches the client how to do deep breathing exercises after surgery by telling the client to: ■ 1. "Sit in an upright position and take a deep breath." ■ 2. "Hold your abdomen firmly with a pillow and take several deep breaths." ■ 3. "Tighten your stomach muscles as you inhale and breathe normally." ■ 4. "Raise your shoulders to expand your chest."

89. 2. Effective splinting for a high incision reduces stress on the incision line, decreases pain, and increases the client's ability to deep-breathe effectively. Deep breathing should be done hourly by the client after surgery. Sitting upright ignores the need to splint the incision to prevent pain. Tightening the stomach muscles is not an effective strategy for promoting deep breathing. Raising the shoulders is not a feature of deep-breathing exercises. CN: Physiological adaptation; CL: Apply

9. After treatment with radioactive iodine (RAI) in the form of sodium iodide 131I, the nurse teaches the client to: ■ 1. Monitor for signs and symptoms of hyperthyroidism. ■ 2. Rest for 1 week to prevent complications of the medication. ■ 3. Take thyroxine replacement for the remainder of the client's life. ■ 4. Assess for hypertension and tachycardia resulting from altered thyroid activity

9. 3. The client needs to be educated about the need for lifelong thyroid hormone replacement. Permanent hypothyroidism is the major complication of RAI 131I treatment. Lifelong medical follow-up and thyroid replacement are warranted. The client needs to monitor for signs and symptoms of hypothyroidism, not hyperthyroidism. Resting for 1 week is not necessary. Hypertension and tachycardia are signs of hyperthyroidism, not hypothyroidism. CN: Pharmacological and parenteral therapies; CL: Synthesize

91. A client undergoing a bilateral adrenalectomy has postoperative orders for hydromorphone hydrochloride (Dilaudid) 2 mg to be given subcutaneously every 4 hours p.r.n. for pain. This drug is administered in relatively small doses primarily because it is: ■ 1. Less likely to cause dependency in small doses. ■ 2. Less irritating to subcutaneous tissues in small doses. ■ 3. As potent as most other analgesics in larger doses. ■ 4. Excreted before accumulating in toxic amounts in the body

91. 3. Hydromorphone hydrochloride (Dilaudid) is about five times more potent than morphine sulfate, from which it is prepared. Therefore, it is administered only in small doses. Hydromorphone hydrochloride can cause dependency in any dose; however, fear of dependency developing in the postoperative period is unwarranted. The dose is determined by the client's need for pain relief. Hydromorphone hydrochloride is not irritating to subcutaneous tissues. As with opioid analgesics, excretion depends on normal liver function. CN: Pharmacological and parenteral therapies; CL: Apply

95. After surgery for bilateral adrenalectomy, the client is kept on bed rest for several days to stabilize the body's need for steroids postoperatively. Which of the following exercises will be most effective for preparing a client for ambulation after a period of bed rest? ■ 1. Alternately flexing and extending the knees. ■ 2. Alternately abducting and adducting the legs. ■ 3. Alternately stretching the Achilles tendons. ■ 4. Alternately flexing and relaxing the quadriceps femoris muscles.

95. 4. Alternately flexing and relaxing the quadriceps femoris muscles helps prepare the client for ambulation. This exercise helps maintain the strength in the quadriceps, which is the major muscle group used when walking. The other exercises listed do not increase a client's readiness for walking. CN: Basic care and comfort; CL: Synthesize

96. As the nurse assists the postoperative client out of bed, the client reports having gas pains in the abdomen. Which of the following is the most effective nursing intervention to relieve this discomfort? ■ 1. Encourage the client to ambulate. ■ 2. Insert a rectal tube. ■ 3. Insert a nasogastric (NG) tube. ■ 4. Encourage the client to drink carbonated liquids

96. 1. Decreased mobility is one of the most common causes of abdominal distention related to retained gas in the intestines. Peristalsis has been inhibited by the general anesthesia, analgesics, and inactivity during the immediate postoperative period. Ambulation increases peristaltic activity and helps move gas. Walking can prevent the need for a rectal tube, which is a more invasive procedure. An NG tube is also a more invasive procedure and requires a physician's order. It is not a preferred treatment for gas postoperatively. Walking should prevent the need for further interventions. Carbonated liquids can increase gas formation. CN: Reduction of risk potential; CL: Synthesize

114. A young adult client has been diagnosed with type 1 diabetes. He has an insulin drip to aid in lowering the serum blood glucose level of 600 mg/dL. He is also receiving ciprofloxacin (Cipro) I.V. The physician orders discontinuation of the insulin drip. The nurse should next? ■ 1. Discontinue the insulin drip, as ordered. ■ 2. Hang the next I.V. dose of antibiotic before discontinuing the insulin drip. ■ 3. Inform the physician that the client has not received any subcutaneous insulin yet. ■ 4. Add glargine (Lantus) to the insulin drip before discontinuing it.

114. 3. Because subcutaneous administration of insulin has a slower rate of absorption than I.V. insulin, there must be an adequate level of insulin in the bloodstream before discontinuing the insulin drip; otherwise, the glucose level will rise. Adding an I.V. antibiotic has no influence on the insulin drip; it should not be piggy-backed into the insulin drip. Glargine (Lantus) cannot be administered I.V., and should not be mixed with other insulins or solutions. CN: Management of care; CL: Synthesize

23. A client with type 1 diabetes mellitus has diabetic ketoacidosis. Which of the following findings has the greatest effect on fluid loss? ■ 1. Hypotension. ■ 2. Decreased serum potassium level. ■ 3. Rapid, deep respirations. ■ 4. Warm, dry skin.

23. 3. Due to the rapid, deep respirations, the client is losing fluid from vaporization from the lungs and skin (insensible fluid loss). Normally, about 900 mL of fluid is lost per day through vaporization. Decreased serum potassium level has no effect on insensible fluid loss. Hypotension occurs due to polyurea and inadequate fluid intake. It may decrease the flow of blood to the skin, causing skin to be warm and dry. CN: Reduction of risk potential; CL: Analyze

28. When teaching the diabetic client about foot care, the nurse should instruct the client to do which of the following? ■ 1. Avoid going barefoot. ■ 2. Buy shoes a half size larger. ■ 3. Cut toenails at angles. ■ 4. Use heating pads for sore feet.

28. 1. The client with diabetes is prone to serious foot injuries secondary to peripheral neuropathy and decreased circulation. The client should be taught to avoid going barefoot to prevent injury. Shoes that do not fit properly should not be worn because they will cause blisters that can become nonhealing, serious wounds for the diabetic client. Toenails should be cut straight across. A heating pad should not be used because of the risk of burns due to insensitivity to temperature. CN: Reduction of risk potential; CL: Synthesize

46. The nurse is assessing the client's use of medications. Which of the following medications may cause a complication with the treatment plan of a client with diabetes? ■ 1. Aspirin. ■ 2. Steroids. ■ 3. Sulfonylureas. ■ 4. Angiotensin-converting enzyme (ACE) inhibitors.

46. 2. Steroids can cause hyperglycemia because of their effects on carbohydrate metabolism, making diabetic control more difficult. Aspirin is not known to affect glucose metabolism. Sulfonylureas are oral hypoglycemic agents used in the treatment of diabetes mellitus. ACE inhibitors are not known to affect glucose metabolism. CN: Pharmacological and parenteral therapies; CL: Apply

47. A client with type 1 diabetes mellitus has influenza. The nurse should instruct the client to: ■ 1. Increase the frequency of self-monitoring (blood glucose testing). ■ 2. Reduce food intake to diminish nausea. ■ 3. Discontinue that dose of insulin if unable to eat. ■ 4. Take half of the normal dose of insulin.

47. 1. Colds and influenza present special challenges to the client with diabetes mellitus because the body's need for insulin increases during illness. Therefore, the client must take the prescribed insulin dose, increase the frequency of blood glucose testing, and maintain an adequate fluid intake to counteract the dehydrating effect of hyperglycemia. Clear fluids, juices, and Gatorade are encouraged. Not taking insulin when sick, or taking half the normal dose, may cause the client to develop ketoacidosis. CN: Reduction of risk potential; CL: Synthesize

60. After pituitary surgery, the nurse should assess the client for which of the following? ■ 1. Urine specific gravity less than 1.010. ■ 2. Urine output between 1 and 2 L/day. ■ 3. Blood glucose level higher than 300 mg/dL. ■ 4. Urine negative for glucose and ketones.

60. 1. Pituitary diabetes insipidus is a potential complication after pituitary surgery because of possible interference with the production of antidiuretic hormone (ADH). One major manifestation of diabetes insipidus is polyuria because lack of ADH results in insufficient water reabsorption by the kidneys. The polyuria leads to a decreased urine specific gravity (between 1.001 and 1.010). The client may drink and excrete 5 to 40 L of fluid daily. Diabetes insipidus does not affect metabolism. A blood glucose level higher than 300 mg/dL is associated with impaired glucose metabolism or diabetes mellitus. Urine negative for sugar and ketones is normal. CN: Reduction of risk potential; CL: Analyze

65. Which of the following would be an expected finding in a client with adrenal crisis (addisonian crisis)? ■ 1. Fluid retention. ■ 2. Pain. ■ 3. Peripheral edema. ■ 4. Hunger.

65. 2. Adrenal hormone deficiency can cause profound physiologic changes. The client may experience severe pain (headache, abdominal pain, back pain, or pain in the extremities). Inhibited gluconeogenesis commonly produces hypoglycemia, and impaired sodium retention causes decreased, not increased, fluid volume. Edema would not be expected. Gastrointestinal disturbances, including nausea and vomiting, are expected findings in Addison's disease, not hunger. CN: Physiological adaptation; CL: Analyze

67. The client's wife asks the nurse whether the I.V. infusion is meeting her husband's nutritional needs because he has vomited several times. The nurse's response should be based on the knowledge that 1 L of 5% dextrose in normal saline solution delivers: ■ 1. 170 calories. ■ 2. 250 calories. ■ 3. 340 calories. ■ 4. 500 calories

67. 1. Each liter of 5% dextrose in normal saline solution contains 170 calories. The nurse should consult with the physician and dietitian when a client is on I.V. therapy or is on nothing-by-mouth status for an extended period because further electrolyte supplementation or alimentation therapy may be needed. CN: Pharmacological and parenteral therapies; CL: Apply

69. After stabilization of Addison's disease, the nurse teaches the client about stress management. The nurse should instruct the client to: ■ 1. Remove all sources of stress from daily life. ■ 2. Use relaxation techniques such as music. ■ 3. Take antianxiety drugs daily. ■ 4. Avoid discussing stressful experiences.

69. 2. Finding alternative methods of dealing with stress, such as relaxation techniques, is a cornerstone of stress management. Removing all sources of stress from one's life is not possible. Antianxiety drugs are prescribed for temporary management during periods of major stress, and they are not an intervention in stress management classes. Avoiding discussion of stressful situations will not necessarily reduce stress. CN: Psychosocial adaptation; CL: Synthesize

8. A client with Graves' disease is treated with radioactive iodine (RAI) in the form of sodium iodide 131I. Which of the following statements by the nurse will explain to the client how the drug works? ■ 1. "The radioactive iodine stabilizes the thyroid hormone levels before a thyroidectomy." ■ 2. "The radioactive iodine reduces uptake of thyroxine and thereby improves your condition." ■ 3. "The radioactive iodine lowers the levels of thyroid hormones by slowing your body's production of them." ■ 4. "The radioactive iodine destroys thyroid tissue so that thyroid hormones are no longer produced."

8. 4. Sodium iodide 131I destroys the thyroid follicular cells, and thyroid hormones are no longer produced. RAI is commonly recommended for clients with Graves' disease, especially the elderly. The treatment results in a "medical thyroidectomy." RAI is given in lieu of surgery, not before surgery. RAI does not reduce uptake of thyroxine. The outcome of giving RAI is the destruction of the thyroid follicular cells. It is possible to slow the production of thyroid hormones with RAI. CN: Pharmacological and parenteral therapies; CL: Synthesize

90. A priority in the first 24 hours after a bilateral adrenalectomy is: ■ 1. Beginning oral nutrition. ■ 2. Promoting self-care activities. ■ 3. Preventing adrenal crisis. ■ 4. Ambulating in the hallway.

90. 3. The priority in the first 24 hours after adrenalectomy is to identify and prevent adrenal crisis. Monitoring of vital signs is the most important evaluation measure. Hypotension, tachycardia, orthostatic hypotension, and arrhythmias can be indicators of pending vascular collapse and hypovolemic shock that can occur with adrenal crisis. Beginning oral nutrition is important, but not necessarily in the first 24 hours after surgery, and it is not more important than preventing adrenal crisis. Promoting self-care activities is not as important as preventing adrenal crisis. Ambulating in the hallway is not a priority in the first 24 hours after adrenalectomy. CN: Physiological adaptation; CL: Synthesize

93. In the early postoperative period after a bilateral adrenalectomy, the client has an increased temperature. The nurse should assess the client further for signs of: ■ 1. Dehydration. ■ 2. Poor lung expansion. ■ 3. Wound infection. ■ 4. Urinary tract infection.

93. 2. Poor lung expansion from bed rest, pain, and retained anesthesia is a common cause of slight postoperative temperature elevation. Nursing care includes turning the client and having the client cough and deep-breathe every 1 to 2 hours, or more frequently as ordered. The client will have postoperative I.V. fluid replacement ordered to prevent dehydration. Wound infections typically appear 4 to 7 days after surgery. Urinary tract infections would not be typical with this surgery. CN: Physiological adaptation; CL: Analyze

94. A client who is recovering from a bilateral adrenalectomy has a patient-controlled analgesia (PCA) system with morphine sulfate. Which of the following actions is a priority nursing intervention for the client? ■ 1. Observing the client at regular intervals for opioid addiction. ■ 2. Encouraging the client to reduce analgesic use and tolerate the pain. ■ 3. Evaluating pain control at least every 2 hours. ■ 4. Increasing the amount of morphine if the client does not administer the medication.

94. 3. Pain control should be evaluated at least every 2 hours for the client with a PCA system. Addiction is not a common problem for the postoperative client. A client should not be encouraged to tolerate pain; in fact, other nursing actions besides PCA should be implemented to enhance the action of opioids. One of the purposes of PCA is for the client to determine frequency of administering the medication; the nurse should not interfere unless the client is not obtaining pain relief. The nurse should ensure that the client is instructed on the use of the PCA control button and that the button is always within reach. CN: Pharmacological and parenteral therapies; CL: Synthesize

97. Because of steroid excess after a bilateral adrenalectomy, the nurse should assess the client for: ■ 1. Postoperative confusion. ■ 2. Delayed wound healing. ■ 3. Emboli. ■ 4. Malnutrition

97. 2. Persistent cortisol excess undermines the collagen matrix of the skin, impairing wound healing. It also carries an increased risk of infection and of bleeding. The wound should be observed and documentation performed regarding the status of healing. Confusion and emboli are not expected complications after adrenalectomy. Malnutrition also is not an expected complication after adrenalectomy. Nutritional status should be regained postoperatively. CN: Reduction of risk potential; CL: Analyze

99. After a bilateral adrenalectomy for Cushing's disease, the client will receive periodic testosterone injections. The expected outcome of these injections is: ■ 1. Balanced reproductive cycle. ■ 2. Restored sodium and potassium balance. ■ 3. Stimulated protein metabolism. ■ 4. Stabilized mood swings.

99. 3. Testosterone is an androgen hormone that is responsible for protein metabolism as well as maintenance of secondary sexual characteristics; therefore, it is needed by both males and females. Removal of both adrenal glands necessitates replacement of glucocorticoids and androgens. Testosterone does not balance the reproductive cycle, stabilize mood swings, or restore sodium and potassium balance. CN: Physiological adaptation; CL: Apply

10. A client with a large goiter is scheduled for a subtotal thyroidectomy to treat thyrotoxicosis. Saturated solution of potassium iodide (SSKI) is prescribed preoperatively for the client. The primary reason for using this drug is that it helps: ■ 1. Slow progression of exophthalmos. ■ 2. Reduce the vascularity of the thyroid gland. ■ 3. Decrease the body's ability to store thyroxine. ■ 4. Increase the body's ability to excrete thyroxine.

10. 2. SSKI is frequently administered before a thyroidectomy because it helps decrease the vascularity of the thyroid gland. A highly vascular thyroid gland is very friable, a condition that presents a hazard during surgery. Preparation of the client for surgery includes depleting the gland of thyroid hormone and decreasing vascularity. SSKI does not decrease the progression of exophthalmos, and it does not decrease the body's ability to store thyroxine or increase the body's ability to excrete thyroxine. CN: Pharmacological and parenteral therapies; CL: Apply

111. The nurse is reviewing the postoperative orders (see chart) just written by a physician for a client with insulin-dependent diabetes who has returned to the surgery floor from the recovery room following surgery for a left hip replacement. The client has pain of 5 on a scale of 1 to 10. The hand-off report from the nurse in the recovery room indicated that the vital signs have been stable for the last 30 minutes. After obtaining the client's glucose level, the nurse should do which of the following first? Physician Order Vital signs every 15 minutes for 4 hours, then every hour for 8 hours. Oxygen 2 L/minute per nasal canula. 1000 mL NS every 8 hours. 10 mg morphine intramuscularly every 4 hours as needed. 10 u regular insulin stat. ■ 1. Administer the morphine. ■ 2. Contact the physician to report the glucose level and rewrite the insulin order. ■ 3. Administer oxygen per nasal canula at 2 L/ minute. ■ 4. Take the vital signs.

111. 2. Insulin is on the list of error-prone medications and the nurse should ask the physician to rewrite the order to spell out the word "units" and to indicate the route the drug is to be administered. The nurse should contact the physician immediately as the nurse is to administer the insulin now. The nurse can then also report the most current glucose level. While waiting for the insulin order to be rewritten, the nurse can administer the pain medication if needed, start the oxygen, and check the client's vital signs. CN: Safety and infection control; CL: Synthesize

17. Appropriate nursing diagnoses for a client with hypothyroidism would include which of the following? ■ 1. Risk for injury (corneal abrasion) related to incomplete closure of the eyelid. ■ 2. Imbalanced nutrition: Less than body requirements related to hypermetabolism. ■ 3. Deficient fluid volume related to diarrhea. ■ 4. Activity intolerance related to fatigue associated with the disorder.

17. 4. A major problem for the person with hypothyroidism is fatigue. Other signs and symptoms include lethargy, personality changes, generalized edema, impaired memory, slowed speech, cold intolerance, dry skin, muscle weakness, constipation, weight gain, and hair loss. Incomplete closure of the eyelids, hypermetabolism, and diarrhea are associated with hyperthyroidism. CN: Basic care and comfort; CL: Analyze

20. A nurse is participating in a diabetes screening program. Who of the following is (are) at risk for developing type 2 diabetes? Select all that apply. ■ 1. A 32-year-old female who delivered a 9½-lb infant. ■ 2. A 44-year-old Native American Indian who has a body mass index (BMI) of 32. ■ 3. An 18-year-old Hispanic who jogs four times a week. ■ 4. A 55-year-old Asian American who has hypertension and two siblings with type 2 diabetes. ■ 5. A 12-year-old who is overweight.

20. 1, 2, 4, 5. The risk factors for developing type 2 diabetes include giving birth to an infant weighing more than 9 lb; obesity (BMI over 30); ethnicity of Asian, African American, or Native American Indian; age greater than 45 years; hypertension; and family history in parents or siblings. Childhood obesity is also a risk factor for type 2 diabetes. Maintaining an ideal weight, eating a low-fat diet, and exercising regularly decrease the risk of type 2 diabetes. CN: Reduction of risk potential; CL: Analyze

22. The nurse is checking the laboratory results on a 52-year-old client with type 1 diabetes (see chart). What laboratory result indicates a problem that should be managed? (LDL) cholesterol. Laboratory Results Test Result Blood glucose 192 mg/dL Total cholesterol 250 mg/dL Hemoglobin 12.3 mg/dL Low-density lipoprotein cholesterol 125 mg/dL ■ 1. Blood glucose. ■ 2. Total cholesterol. ■ 3. Hemoglobin. ■ 4. Low-density lipoprotein

22. 1. The elevated blood glucose level indicates hyperglycemia. The hemoglobin is normal. The client's cholesterol and LDL levels are both normal. The nurse should determine if there are standing orders for the hyperglycemia or notify the physician. CN: Reduction of risk potential; CL: Analyze

43. The nurse is instructing the client on insulin administration. The client is performing a return demonstration for preparing the insulin. The client's morning dose of insulin is 10 units of regular and 22 units of NPH. The nurse checks the dose accuracy with the client. The nurse determines that the client has prepared the correct dose when the syringe reads how many units? ________________________ units.

43. 32 units Clients commonly need to mix insulin, requiring careful mixing and calculation. The total dosage is 10 units plus 22 units, for a total of 32 units. CN: Pharmacological and parenteral therapies; CL: Apply

50. Galactorrhea is caused by overproduction of which hormone? ■ 1. Prolactin. ■ 2. Adrenocorticotropic hormone (ACTH). ■ 3. Growth hormone (GH). ■ 4. Thyroid-stimulating hormone (TSH)

50. 1. Galactorrhea, or abnormal flow of breast milk, results from overproduction of prolactin. Pituitary tumors are almost always secreting tumors, and they are classified by the specific hormone secreted. Pituitary tumors can cause oversecretion of ACTH, GH, or TSH. Overproduction of ACTH results in Cushing's disease. Overproduction of GH results in gigantism. Overproduction of TSH results in hyperthyroidism. CN: Physiological adaptation; CL: Apply

70. When teaching a client newly diagnosed with primary Addison's disease, the nurse should explain that the disease results from: ■ 1. Insufficient secretion of growth hormone (GH). ■ 2. Dysfunction of the hypothalamic pituitary. ■ 3. Idiopathic atrophy of the adrenal gland. ■ 4. Oversecretion of the adrenal medulla.

70. 3. Primary Addison's disease refers to a problem in the gland itself that results from idiopathic atrophy of the glands. The process is believed to be autoimmune in nature. The most common causes of primary adrenocortical insufficiency are autoimmune destruction (70%) and tuberculosis (20%). Insufficient secretion of GH causes dwarfism or growth delay. Hyposecretion of glucocorticoids, aldosterone, and androgens occur with Addison's disease. Pituitary dysfunction can cause Addison's disease, but this is not a primary disease process. Oversecretion of the adrenal medulla causes pheochromocytoma. CN: Physiological adaptation; CL: Apply

76. The nurse should tell the client to do which of the following when teaching the client about taking oral glucocorticoids? ■ 1. "Take your medication with a full glass of water." ■ 2. "Take your medication on an empty stomach." ■ 3. "Take your medication at bedtime to increase absorption." ■ 4. "Take your medication with meals or with an antacid."

76. 4. Oral steroids can cause gastric irritation and ulcers and should be administered with meals, if possible, or otherwise with an antacid. Only instructing the client to take the medication with a full glass of water will not help prevent gastric complications from steroids. Steroids should never be taken on an empty stomach. Glucocorticoids should be taken in the morning, not at bedtime. CN: Pharmacological and parenteral therapies; CL: Apply

112. A client with type 1 diabetes is admitted to the emergency department with dehydration following the flu. The client has a blood glucose level of 325 mg/dL and a serum potassium level of 3.5 mEq. The physician has ordered 1,000 mL 5% dextrose in water to be infused every 8 hours. Prior to implementing the physician orders, the nurse should contact the physician, explain the situation, provide background information, report the current assessment of the client, and: ■ 1. Suggest adding potassium to the fluids. ■ 2. Request an increase in the volume of intravenous fluids. ■ 3. Verify the order for 5% dextrose in water. ■ 4. Determine if the client should be placed in isolation.

112. 3. The client needs fluid volume replacement due to the dehydration. However, the nurse should verify the order for I.V. dextrose with the physician due to the risk of hyperglycemia that dextrose would present when administered to a client with diabetes. The potassium level is within normal limits. The client does not have restrictions on oral fluids and the nurse can encourage the client to drink fluids. The client does not need to be placed in isolation at this time. CN: Management of care; CL: Synthesize

113. Glulisine (Apidra) insulin is ordered to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client "went for a test." What should the nurse do next? ■ 1. Bring a small glass of juice, and locate the client. ■ 2. Call the client's physician. ■ 3. Check the computerized care plan to determine what test was scheduled. ■ 4. Send the nurse's assistant to the X-ray department to bring the client back to his room.

113. 3. Glulisine (Apidra) is a rapid-acting insulin with an action onset of 15 minutes. The client could experience hypoglycemia with the insulin in the bloodstream and no breakfast. It is not necessary to call the client's physician; the nurse should determine what test was scheduled and then locate the client and provide either breakfast or 4 oz of fruit juice. To bring the client back to the room would be wasting valuable time needed to prevent or correct hypoglycemia. CN: Management of care; CL: Synthesize

3. A 34-year-old female is diagnosed with hypothyroidism. The nurse should assess the client for which of the following? Select all that apply. ■ 1. Rapid pulse. ■ 2. Decreased energy and fatigue. ■ 3. Weight gain of 10 lb. ■ 4. Fine, thin hair with hair loss. ■ 5. Constipation. ■ 6. Menorrhagia.

2, 3, 5, 6. Clients with hypothyroidism exhibit symptoms indicating a lack of thyroid hormone. Bradycardia, decreased energy and lethargy, memory problems, weight gain, coarse hair, constipation, and menorrhagia are common signs and symptoms of hypothyroidism. CN: Physiological adaptation; CL: Analyze

26. A client has recently been diagnosed with type 2 diabetes mellitus and is to take tolbutamide (Orinase). When teaching the client about the drug, the nurse explains that tolbutamide is believed to lower the blood glucose level by which of the following actions? ■ 1. Potentiating the action of insulin. ■ 2. Lowering the renal threshold of glucose. ■ 3. Stimulating insulin release from functioning beta cells in the pancreas. ■ 4. Combining with glucose to render it inert.

26. 3. Oral hypoglycemic agents of the sulfonylurea group, such as tolbutamide (Orinase), lower the blood glucose level by stimulating functioning beta cells in the pancreas to release insulin. These agents also increase insulin's ability to bind to the body's cells. They may also act to increase the number of insulin receptors in the body. Tolbutamide does not potentiate the action of insulin. Tolbutamide does not lower the renal threshold of glucose, which would not be a factor in the treatment of diabetes in any case. Tolbutamide does not combine with glucose to render it inert. CN: Pharmacological and parenteral therapies; CL: Apply

59. The nurse teaches the client to report signs and symptoms of which potential complication after hypophysectomy? ■ 1. Acromegaly. ■ 2. Cushing's disease. ■ 3. Diabetes mellitus. ■ 4. Hypopituitarism

59. 4. Most clients who undergo adenoma removal experience a gradual return of normal pituitary secretion and do not experience complications. However, hypopituitarism can cause growth hormone, gonadotropin, thyroid-stimulating hormone, and adrenocorticotropic hormone deficits. The client should be taught to monitor for change in mental status, energy level, muscle strength, and cognitive function. In adults, changes in sexual function, impotence, or decreased libido should be reported. Acromegaly and Cushing's disease are conditions of hypersecretion. Diabetes mellitus is related to the function of the pancreas and is not directly related to the function of the pituitary. CN: Reduction of risk potential; CL: Analyze

83. Signs and symptoms of Cushing's disease include: ■ 1. Weight loss. ■ 2. Thin, fragile skin. ■ 3. Hypotension. ■ 4. Abdominal pain.

83. 2. In Cushing's disease, excessive cortisol secretion causes rapid protein catabolism, depleting the collagen support of the skin. The skin becomes thin and fragile and susceptible to easy bruising. The typical "cushingoid" appearance of the client includes a moon face, buffalo hump, central obesity, and thin musculature. Weight gain, mood swings, and slow wound healing are other signs and symptoms of Cushing's disease. Hypertension, not hypotension, is a sign of Cushing's disease. Abdominal pain is not a symptom of Cushing's disease. CN: Physiological adaptation; CL: Analyze

92. Adrenal function is affected by the drug ketoconazole (Nizoral), an antifungal agent used to treat severe fungal infections. How is this effect manifested? ■ 1. Ketoconazole suppresses adrenal steroid secretion. ■ 2. Ketoconazole destroys adrenocortical cells, resulting in a "medical" adrenalectomy. ■ 3. Ketoconazole increases adrenocorticotropic hormone (ACTH)-induced corticosteroid serum levels. ■ 4. Ketoconazole decreases duration of adrenal suppression when administered with corticosteroids.

92. 1. Ketoconazole (Nizoral) suppresses adrenal steroid secretion and may cause acute hypoadrenalism. The adverse effect should reverse when the drug is discontinued. Ketoconazole does not destroy adrenal cells; mitotane (Lysodren) destroys the cells and may be used to obtain a medical adrenalectomy. Ketoconazole decreases, not increases, ACTHinduced serum corticosteroid levels. It increases the duration of adrenal suppression when given with steroids. CN: Pharmacological and parenteral therapies; CL: Apply

4. Propylthiouracil (PTU) is prescribed for a client with Graves' disease. The nurse should teach the client to immediately report which of the following? ■ 1. Sore throat. ■ 2. Painful, excessive menstruation. ■ 3. Constipation. ■ 4. Increased urine output.

1. The most serious adverse effects of PTU are leukopenia and agranulocytosis, which usually occur within the first 3 months of treatment. The client should be taught to promptly report to the health care provider signs and symptoms of infection, such as a sore throat and fever. Clients complaining of a sore throat and fever should have an immediate white blood cell count and differential performed, and the drug must be withheld until the results are obtained. Painful menstruation, constipation, and increased urine output are not associated with PTU therapy. CN: Pharmacological and parenteral therapies; CL: Synthesize

15. Which of the following medications should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy? ■ 1. Sodium phosphate. ■ 2. Calcium gluconate. ■ 3. Echothiophate iodide. ■ 4. Sodium bicarbonate.

15. 2. The client with tetany is suffering from hypocalcemia, which is treated by administering an I.V. preparation of calcium, such as calcium gluconate or calcium chloride. Oral calcium is then necessary until normal parathyroid function returns. Sodium phosphate is a laxative. Echothiophate iodide is an eye preparation used as a miotic for an antiglaucoma effect. Sodium bicarbonate is a potent systemic antacid. CN: Pharmacological and parenteral therapies; CL: Apply

18. When discussing recent onset of feelings of sadness and depression in a client with hypothyroidism, the nurse should inform the client that these feelings are: ■ 1. The effects of thyroid hormone replacement therapy and will diminish over time. ■ 2. Related to thyroid hormone replacement therapy and will not diminish over time. ■ 3. A normal part of having a chronic illness. ■ 4. Most likely related to low thyroid hormone levels and will improve with treatment.

18. 4. Hypothyroidism may contribute to sadness and depression. It is good practice for clients with newly diagnosed depression to be monitored for hypothyroidism by checking serum thyroid hormone and thyroid-stimulating hormone levels. This client needs to know that these feelings may be related to her low thyroid hormone levels and may improve with treatment. Replacement therapy does not cause depression. Depression may accompany chronic illness, but it is not "normal." CN: Psychosocial adaptation; CL: Analyze

1. The nurse is completing a health assessment of a 42-year-old female with suspected Graves' disease. The nurse should assess this client for: ■ 1. Anorexia. ■ 2. Tachycardia. ■ 3. Weight gain. ■ 4. Cold skin.

2. Graves' disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is a common feature of hyperthyroidism. Cold skin is associated with hypothyroidism. CN: Physiological adaptation; CL: Analyze

2. When conducting a health history with a female client with thyrotoxicosis, the nurse should ask about which of the following changes in the menstrual cycle? ■ 1. Dysmenorrhea. ■ 2. Metrorrhagia. ■ 3. Oligomenorrhea. ■ 4. Menorrhagia.

3. A change in the menstrual interval, diminished menstrual flow (oligomenorrhea), or even the absence of menstruation (amenorrhea) may result from the hormonal imbalances of thyrotoxicosis. Oligomenorrhea in women and decreased libido and impotence in men are common features of thyrotoxicosis. Dysmenorrhea is painful menstruation. Metrorrhagia, blood loss between menstrual periods, is a symptom of hypothyroidism. Menorrhagia, excessive bleeding during menstrual periods, is a symptom of hypothyroidism. CN: Physiological adaptation; CL: Analyze

31. The client with diabetes mellitus says, "If I could just avoid what you call carbohydrates in my diet, I guess I would be okay." The nurse should base the response to this comment on the knowledge that diabetes affects metabolism of which of the following? ■ 1. Carbohydrates only. ■ 2. Fats and carbohydrates only. ■ 3. Protein and carbohydrates only. ■ 4. Proteins, fats, and carbohydrates.

31. 4. Diabetes mellitus is a multifactorial, systemic disease associated with problems in the metabolism of all food types. The client's diet should contain appropriate amounts of all three nutrients, plus adequate minerals and vitamins. CN: Basic care and comfort; CL: Apply

40. A nurse is teaching a client with type 1 diabetes mellitus who jogs daily about the preferred sites for insulin absorption. What is the most appropriate site for a client who jogs? ■ 1. Arms. ■ 2. Legs. ■ 3. Abdomen. ■ 4. Iliac crest.

40. 3. If the client engages in an activity or exercise that focuses on one area of the body, that area may cause inconsistent absorption of insulin. A good regimen for a jogger is to inject the abdomen for 1 week and then rotate to the buttock. A jogger may have inconsistent absorption in the legs or arms with strenuous running. The iliac crest is not an appropriate site due to a lack of loose skin and subcutaneous tissue in that area. CN: Pharmacological and parenteral therapies; CL: Apply

85. The nurse should monitor the client with Cushing's disease for which of the following? ■ 1. Postprandial hypoglycemia. ■ 2. Hypokalemia. ■ 3. Hyponatremia. ■ 4. Decreased urine calcium level.

85. 2. Sodium retention is typically accompanied by potassium depletion. Hypertension, hypokalemia, edema, and heart failure may result from the hypersecretion of aldosterone. The client with Cushing's disease exhibits postprandial or persistent hyperglycemia. Clients with Cushing's disease have hypernatremia, not hyponatremia. Bone resorption of calcium increases the urine calcium level. CN: Reduction of risk potential; CL: Analyze

44. Angiotensin-converting enzyme (ACE) inhibitors may be prescribed for the client with diabetes mellitus to reduce vascular changes and possibly prevent or delay development of: ■ 1. Chronic obstructive pulmonary disease. ■ 2. Pancreatic cancer. ■ 3. Renal failure. ■ 4. Cerebrovascular accident.

44. 3. Renal failure frequently results from the vascular changes associated with diabetes mellitus. ACE inhibitors increase renal blood flow and are effective in decreasing diabetic nephropathy. Chronic obstructive pulmonary disease is not a complication of diabetes, nor is it prevented by ACE inhibitors. Pancreatic cancer is neither prevented by ACE inhibitors nor considered a complication of diabetes. Cerebrovascular accident is not directly prevented by ACE inhibitors, although management of hypertension will decrease vascular disease. CN: Pharmacological and parenteral therapies; CL: Apply

98. The client who has undergone a bilateral adrenalectomy is ready to return home. She tells the nurse that she is concerned about persistent body changes and the fact that her moods are still so unpredictable. She says, "I thought surgery was supposed to fix all that." The nurse should tell the client that: ■ 1. The body changes are permanent and the client will not be the same as before this condition. ■ 2. The body and mood will gradually return to normal. ■ 3. The physical changes are permanent, but the mood swings will disappear. ■ 4. The physical changes are temporary, but the mood swings are permanent.

98. 2. As the body readjusts to normal cortisol levels, mood and physical changes will gradually return to a normal state. The body changes are not permanent, and the mood swings should level off. CN: Physiological adaptation; CL: Synthesize

100. Which of the following should the nurse include in the teaching plan of a female client with bilateral adrenalectomy? ■ 1. Emphasizing that the client will need steroid replacement for the rest of her life. ■ 2. Instructing the client about the importance of tapering steroid medication carefully to prevent crisis. ■ 3. Informing the client that steroids will be required only until her body can manufacture sufficient quantities. ■ 4. Emphasizing that the client will need to take steroids whenever her life involves physical or emotional stress.

100. 1. Bilateral adrenalectomy requires lifelong adrenal hormone replacement therapy. If unilateral surgery is performed, most clients gradually reestablish a normal secretion pattern. The client and family will require extensive teaching and support to maintain self-care management at home. Information on dosing, adverse effects, what to do if a dose is missed, and follow-up examinations is needed in the teaching plan. Although steroids are tapered when given for an intermittent or one-time problem, they are not discontinued when given to clients who have undergone bilateral adrenalectomy because the clients will not regain the ability to manufacture steroids. Steroids must be taken on a daily basis, not just during periods of physical or emotional stress. CN: Physiological adaptation; CL: Synthesize

5. A client with thyrotoxicosis says to the nurse, "I am so irritable. I am having problems at work because I lose my temper very easily." Which of the following responses by the nurse would give the client the most accurate explanation of her behavior? ■ 1. "Your behavior is caused by temporary confusion brought on by your illness." ■ 2. "Your behavior is caused by the excess thyroid hormone in your system." ■ 3. "Your behavior is caused by your worrying about the seriousness of your illness." ■ 4. "Your behavior is caused by the stress of trying to manage a career and cope with illness."

2. A typical sign of thyrotoxicosis is irritability caused by the high levels of circulating thyroid hormones in the body. This symptom decreases as the client responds to therapy. Thyrotoxicosis does not cause confusion. The client may be worried about her illness, and stress may influence her mood; however, irritability is a common symptom of thyrotoxicosis and the client should be informed of that fact rather than blamed. CN: Psychosocial adaptation; CL: Synthesize

32. A client with type 1 diabetes mellitus is admitted to the emergency department. Which of the following respiratory patterns requires immediate action? ■ 1. Deep, rapid respirations with long expirations. ■ 2. Shallow respirations alternating with long expirations. ■ 3. Regular depth of respirations with frequent pauses. ■ 4. Short expirations and inspirations.

32. 1. Deep, rapid respirations with long expirations is indicative of Kussmaul's respirations, which occur in metabolic acidosis. The respirations increase in rate and depth, and the breath has a "fruity" or acetone-like odor. This breathing pattern is the body's attempt to blow off carbon dioxide and acetone, thus compensating for the acidosis. The other breathing patterns listed are not related to ketoacidosis and would not compensate for the acidosis. CN: Physiological adaptation; CL: Analyze

62. Which of the following indicates that the client with diabetes insipidus understands how to manage care? ■ 1. The client will maintain normal fluid and electrolyte balance. ■ 2. The client will select American Diabetes Association diet correctly. ■ 3. The client will state dietary restrictions. ■ 4. The client will exhibit serum glucose level within normal range

62. 1. Because diabetes insipidus involves excretion of large amounts of fluid, maintaining normal fluid and electrolyte balance is a priority for this client. Special dietary programs or restrictions are not indicated in treatment of diabetes insipidus. Serum glucose levels are priorities in diabetes mellitus but not in diabetes insipidus. CN: Physiological adaptation; CL: Evaluate