C.C. Chapter 32: Endocrine Disorders and Therapeutic Management

A patient is presenting with signs of diabetes insipidus (DI). Which findings would confirm this diagnosis? a. Hyperosmolality and hypernatremia b. Hyperosmolality and hyponatremia c. Hypoosmolality and hypernatremia d. Hypoosmolality and hyponatremia

ANS: A In central diabetes insipidus (DI), there is an inability to secrete an adequate amount of antidiuretic hormone (arginine vasopressin) in response to an osmotic or nonosmotic stimuli, resulting in inappropriately dilute urine. Hypernatremia is usually associated with serum hyperosmolality.

The nurse is developing a discharge education plan for a patient with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Which topic should be included in the plan? a. Measuring intake and output b. Encouraging fluids c. A low-sodium diet d. Hypothermia management

ANS: A Patient and family education about syndrome of inappropriate secretion of antidiuretic hormone (SIADH), its effect on water balance, and the reasons for fluid restrictions using the teach back method should include how to measure intake and output.

The nurse is caring for a patient with a head injury who has developed diabetes insipidus (DI). What medication would the nurse expect to be prescribed for the patient? a. Vasopressin b. Insulin c. Glucagon d. Propylthiouracil

ANS: A Patients with central diabetes insipidus (DI) who are unable to synthesize antidiuretic hormone (ADH) require replacement ADH (vasopressin) or an ADH analog. The most commonly prescribed drug is the synthetic analog of ADH, desmopressin (DDAVP). DDAVP can be given intravenously, subcutaneously, or as a nasal spray. A typical DDAVP dose is 1 to 2 mcg intravenously or subcutaneously every 12 hours.

A patient is admitted with diabetic ketoacidosis (DKA). The patient presents with dry, cracked lips and is begging for something to drink. What reply would be the nurse's best response? a. "We can't give you anything to drink until we get your blood sugar under control." b. "You can have one cup of coffee without sugar." c. "You can drink anything you want as long as it's sugar free." d. "You can drink as much water has you can handle."

ANS: A Patients with diabetic ketoacidosis (DKA) are kept on NPO status (nothing by mouth) until the hyperglycemia is under control

A patient has been admitted with diabetic ketoacidosis, and treatment has been initiated. Which findings would lead the nurse to suspect the patient is dehydrated? a. Poor skin turgor and flat neck veins b. Dyspnea and crackles c. Presence of Chvostek and Trousseau signs d. Extra heart sounds and 3+ edema

ANS: A Poor skin turgor and flat neck veins are indicative of dehydration. Dyspnea, crackles, extra heart sounds, and 3+ edema are signs of fluid overload. Chvostek and Trousseau signs are indicative of hypocalcemia.

The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which medical intervention would the nurse expect to be ordered for this patient? a. Extensive hydration b. Oral hypoglycemic agents c. Large doses of intravenous (IV) insulin d. Limiting food and fluids

ANS: A Rapid IV fluid replacement requires the use of a volumetric pump. Insulin is administered intravenously to patients who are severely dehydrated or have poor peripheral perfusion to ensure effective absorption. Patients with diabetic ketoacidosis (DKA) are kept on NPO (nothing by mouth) status until the hyperglycemia is under control. Critical care nurses are responsible for monitoring the rate of plasma glucose decline in response to insulin.

A patient has been diagnosed with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse would expect the first line treatment to include which intervention? a. Fluid restriction b. Hypotonic intravenous fluid administration c. Administration of D5W d. Administration of vasopressin

ANS: A Reduction in fluid intake is one component of the treatment plan for syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

As a patient with diabetic ketoacidosis (DKA) receives insulin and fluids, the nurse knows careful assessment must be given to which electrolyte? a. Potassium b. Sodium c. Phosphorus d. Calcium

ANS: A Replacement of potassium by administration of potassium chloride (KCl) begins as soon as the serum potassium falls below normal. Frequent verification of the serum potassium concentration is required for the patient with diabetic ketoacidosis receiving fluid resuscitation and insulin therapy

The nurse has admitted a patient with hyperglycemic hyperosmolar state (HHS). Which medical intervention would the nurse expect to see ordered for this patient? a. Rapid rehydration with intravenous fluids b. Insertion of a pulmonary artery catheter c. Administration of high-dose intravenous insulin d. Hourly monitoring of urine glucose and ketone levels.

ANS: A The goals of medical management are rapid rehydration, insulin replacement, and correction of electrolyte abnormalities, specifically potassium replacement. The underlying stimulus of the hyperglycemic hyperosmolar state (HHS) must be discovered and treated. The same basic principles used to treat patients with diabetic ketoacidosis are used for patients with HHS.

A patient is admitted after surgery with a history of hyperthyroidism. The nurse suspects the patient may be developing thyroid storm. Which finding would confirm this suspicion? a. Tachycardia b. Hypotension c. Decreased appetite d. Hypothermia

ANS: A Thyroid storm, also called thyroid crisis, is a rare and life-threatening exacerbation of hyperthyroidism. The pathophysiology underlying the transition from hyperthyroidism to thyroid storm is not fully understood because thyroid hormone levels are not necessarily different from patients with hyperthyroidism. Atrial fibrillation is the most common dysrhythmia in patients with hyperthyroidism, and tachydysrhythmias should be anticipated in thyroid storm, especially in patients with underlying heart disease.

A patient was admitted with diabetic ketoacidosis (DKA). Glucose is 349 mg/dL, K is 3.7 mEq/L, and pH is 7.10. Which of the following interventions would you expect? (Select all that apply.) a. NS 1.5 L IV fluid bolus b. Insulin infusion at 5 units/h c. Sodium bicarbonate 50 mmol IV push d. Vasopressin 10 units IM every 3 hours e. Potassium 20 mEq/L of IV fluid

ANS: A, B, E Dehydration is a common presenting issue in diabetic ketoacidosis (DKA), so the administration of fluids and insulin will help correct the hyperglycemia and acidosis. Sodium bicarbonate is not recommended unless the pH is less than 6.9. As dehydration is reversed, potassium moves back into the cells, and hypokalemia can result, so administration of replacement potassium is necessary.

A patient has been admitted with diabetic ketoacidosis (DKA). The nurse knows that the top priority in the initial treatment of DKA is which intervention? a. Lowering the blood sugar as quickly as possible b. Administering intravenous fluids c. Administering sodium bicarbonate d. Determining the precipitating cause

ANS: B A patient with diabetic ketoacidosis (DKA) is dehydrated and may have lost 5% to 10% of his or her body weight in fluids. A fluid deficit up to 6 L can exist in severe dehydration. Aggressive fluid replacement is provided to rehydrate both the intracellular and the extracellular compartments and prevent circulatory collapse.

Which finding is expected in the patient with hypothyroidism? a. Increased T4 b. Anemia c. Decreased thyroid stimulating hormone d. Hyperglycemia

ANS: B Anemia is a common problem that is present in 25% to 50% of patients with hypothyroidism. Symptoms of fatigue and depression are associated. Erythropoiesis (red blood cell production) is impaired and inadequate. Coagulation abnormalities may coexist.

Decreased urine osmolality is a sign of which disorder? a. Hyperglycemia b. Diabetes insipidus c. Thyroid crisis d. Syndrome of inappropriate secretion of antidiuretic hormone

ANS: B Decreased urine osmolality is a sign of diabetes insipidus.

The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which symptom is most suggestive of DKA? a. Irritability b. Excessive thirst c. Rapid weight gain d. Peripheral edema

ANS: B Diabetic ketoacidosis (DKA) has a predictable clinical presentation. It is usually preceded by patient complaints of malaise, headache, polyuria (excessive urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). Nausea, vomiting, extreme fatigue, dehydration, and weight loss follow. Central nervous system depression, with changes in the level of consciousness, can lead quickly to coma.

A patient with diabetic ketoacidosis (DKA) has an insulin drip infusing, and the nurse has just administered subcutaneous insulin. The nurse is alert for signs of hypoglycemia, which would include what findings? a. Kussmaul respirations and flushed skin b. Irritability and paresthesia c. Abdominal cramps and nausea d. Hypotension and itching

ANS: B Irritability and paresthesia are seen in hypoglycemia.

Which pathophysiologic mechanism occurs in the syndrome of inappropriate antidiuretic hormone (SIADH)? a. Massive diuresis, leading to hemoconcentration b. Dilutional hyponatremia, reducing sodium concentration to critically low levels c. Hypokalemia from massive diuresis d. Serum osmolality greater than 350 mOsm/kg

ANS: B Patients with the syndrome of inappropriate antidiuretic hormone (SIADH) have an excess of antidiuretic hormone secreted into the bloodstream, more than the amount needed to maintain normal blood volume and serum osmolality. Excessive water is resorbed at the kidney tubule, leading to dilutional hyponatremia.

A patient is admitted with diabetic ketoacidosis (DKA) and is experiencing polyuria. Which electrolyte disturbances would the nurse expect to see at this phase of DKA? a. Decreased calcium and increased phosphorus levels b. Decreased potassium and sodium levels. c. Increased sodium and decreased phosphorus levels d. Decreased calcium and potassium levels.

ANS: B Polyuria results in large volumes of water, along with sodium, potassium, and phosphorus, being excreted in the urine, causing a fluid volume deficit.

A patient has been diagnosed with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse is administering hypertonic saline. The nurse knows that the serum sodium should not be raised more than how many milliequivalents per day? a. 5 mEq/day b. 10 mEq/day c. 20 mEq/day d. 25 mEq/day

ANS: B Serum sodium levels must be evaluated at least every 4 hours during the acute phase of sodium replacement. The serum sodium should not be raised more than 10 mEq/L in 24 hours.

The nurse has admitted a patient with hyperglycemic hyperosmolar state (HHS). Which findings would the nurse expect to observe in this patient? a. Hyperglycemia with low serum osmolality b. Severe hyperglycemia with absent ketosis c. Little or no ketosis in serum with rapidly escalating ketonuria d. Hyperglycemia and ketosis

ANS: B The hallmarks of HHS are extremely high levels of plasma glucose with resulting elevations in serum hyperosmolality and osmotic diuresis. The disorder occurs mainly in patients with type 2 diabetes.

A patient is admitted with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse understands that the hyponatremia associated with this disorder is the result of which mechanism? a. Increased cortisol release b. Excessive water reabsorption c. Excessive sodium excretion d. Decreased glucagon release

ANS: B The patient with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) has an excess of ADH secreted into the bloodstream, more than the amount needed to maintain normal blood volume and serum osmolality. Excessive water is resorbed at the kidney tubule, leading to dilutional hyponatremia.

An older patient presents with a serum glucose level of 900 mg/dL, hematocrit of 55%, and no serum ketones. Immediate attention must be given to which intervention? a. Evaluating clotting factors b. Fluid administration c. Insulin administration d. Sodium replacement

ANS: B The physical examination may reveal a profound fluid deficit. Signs of severe dehydration include longitudinal wrinkles in the tongue, decreased salivation, and decreased central venous pressure, with increases in heart rate and rapid respirations (Kussmaul air hunger does not occur). In older patients, assessment of clinical signs of dehydration is challenging.

Which pathophysiologic mechanism occurs in the patient with type 2 diabetes? a. Lack of insulin production b. Imbalance between insulin production and use c. Overproduction of glucose d. Increased uptake of glucose in the cells

ANS: B Type 2 diabetes results from a progressive insulin secretory defect in addition to insulin resistance.

A patient with bronchogenic oat cell carcinoma has a drop in urine output. The laboratory reports a serum sodium level of 120 mEq/L, a serum osmolality level of 220 mOsm/kg, and urine specific gravity of 1.035. The nurse suspects the patient may be developing what problem? a. Diabetes ketoacidosis (DKA) b. Diabetes insipidus (DI) c. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) d. Hyperaldosteronism

ANS: C A decreased urine output, hyponatremia, hypoosmolality, and high urine specific gravity are classic signs of syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Oat cell carcinoma is a precipitating factor for SIADH.

Patients who have sustained head trauma or have undergone resection of a pituitary tumor have an increased risk of developing which disorder? a. Type 1 diabetes b. Thyrotoxicosis c. Diabetes insipidus d. Myxedema coma

ANS: C Any patient who has head trauma or resection of a pituitary tumor has an increased risk of developing diabetes insipidus.

The nurse is caring for a patient with myxedema coma. The patient's temperature is 93° F. Which intervention would the nurse include in the plan of care for this patient? a. Give aggressive therapy that includes warm peritoneal lavage. b. Allow the patient to maintain this body temperature to decrease oxygen demands. c. Use warming blankets to slowly warm the patient. d. Wait until the patient shivers to start warming.

ANS: C Hypothermia will gradually improve as the patient is treated with thyroid hormone. Several warm blankets comfortably wrapped around the patient (with mild hypothermia) may be sufficient to help raise the body temperature to normal. Active warming devices are also used. Continuous assessments are important to avoid too-rapid heating and vasodilation.

The nursing management plan for a patient with thyrotoxicosis would include which intervention? a. Providing diversional stimuli b. Restricting fluids c. Maintaining a quiet, restful environment d. Administering thyroid supplements at the same time each day

ANS: C Patients in thyroid storm are agitated, anxious, and unable to rest, and they benefit from an environment that is calm. Gradually, the effects of the antithyroid medications, iodides, and -adrenergic blocking drugs will decrease the neurologic symptoms related to the catecholamine sensitivity. Frequent reassurance and clear, simple explanations of the patient's condition help decrease the fear brought on by the onset thyroid storm.

A patient is admitted with diabetic ketoacidosis (DKA). The patient's arterial blood gas indicates the patient has an uncompensated metabolic acidosis. The patient has rapid, regular respirations. Which medical intervention would the nurse expect to initiate to correct the acidosis? a. Initiate oxygen therapy via a face mask. b. Administer sodium bicarbonate. c. Administer insulin and fluids intravenously. d. Prepare for intubation.

ANS: C Replacement of fluid volume and insulin interrupts the ketotic cycle and reverses the metabolic acidosis. In the presence of insulin, glucose enters the cells, and the body ceases to convert fats into glucose.

A patient has been admitted after surgery for removal of a brain tumor. The nurse suspects the patient may be developing diabetes insipidus (DI). Which findings would confirm the nurse's suspicion? a. Hyperglycemia and hyperosmolarity b. Hyperglycemia and peripheral edema c. Intense thirst and passage of excessively large quantities of dilute urine d. Peripheral edema and pulmonary crackles

ANS: C The clinical diagnosis is made by the dramatic increase in dilute urine output in the absence of diuretics, a fluid challenge, or hyperglycemia. Characteristics of DI are intense thirst and the passage of excessively large quantities of very dilute urine.

A patient with hyperglycemic hyperosmolar state (HHS) has a serum glucose level of 400 mg/dL and a serum sodium level of 138 mEq/L. What is the intravenous fluid of choice? a. D5W b. 0.45% NS c. 0.9% NS d. D5/NS

ANS: C The fluid deficit may be as much as 150 mL/kg of body weight. The average 150-lb adult can lose more than 7 to 10 L of fluid. Physiologic saline solution (0.9%) is infused at 1 L/h, especially for patients in hypovolemic shock if there is no cardiovascular contraindication. Several liters of volume replacement may be required to achieve a blood pressure and central venous pressure within normal range. Infusion volumes are adjusted according to the patient's hydration state and sodium level.

Which nursing intervention should be initiated on all patients with the syndrome of inappropriate antidiuretic hormone (SIADH)? a. Placing the patient on an air mattress b. Forcing fluids c. Initiating seizure precautions d. Applying soft restraints

ANS: C The patient with the syndrome of inappropriate antidiuretic hormone (SIADH) has an excess of ADH secreted into the bloodstream, more than the amount needed to maintain normal blood volume and serum osmolality. Excessive water is resorbed at the kidney tubule, leading to dilutional hyponatremia. Symptoms of severe hyponatremia include an inability to concentrate, mental confusion, apprehension, seizures, a decreased level of consciousness, coma, and death.

The nurse understands that the onset of seizures in the patient with diabetes insipidus (DI) is indicative of which situation? a. Increased potassium levels b. Hyperosmolality c. Severe dehydration d. Toxic ammonia levels

ANS: C This excessive intake of water reduces the serum osmolality to a more normal level and prevents dehydration. In the person with a decreased level of consciousness, the polyuria leads to severe hypernatremia, dehydration, decreased cerebral perfusion, seizures, loss of consciousness, and death.

A patient is admitted with severe hyperglycemia. The patient is very lethargic and has a "fruity" odor to his breath. The nurse knows the odor on the patient's breath is indicative of which situation? a. Alcohol intoxication b. Lack of sodium bicarbonate c. Hypokalemia d. Presence of ketones

ANS: D Acid ketones dissociate and yield hydrogen ions (H+) that accumulate and precipitate a decrease in serum pH. The level of serum bicarbonate also decreases, consistent with a diagnosis of metabolic acidosis. Breathing becomes deep and rapid (Kussmaul respirations) to release carbonic acid in the form of carbon dioxide. Acetone is exhaled, giving the breath its characteristic "fruity" odor.

In caring for a patient with a thyrotoxicosis, the nurse would expect to observe which neurologic symptom? a. Lethargy b. Depression c. Seizures d. Agitation

ANS: D Agitation and the inability to rest are often found in a patient with thyrotoxic crisis.

A patient was admitted with diabetic ketoacidosis (DKA) an hour ago and is on an insulin drip. Suddenly, the nurse notices frequent premature ventricular contractions (PVCs) on the electrocardiogram. The nurse notifies the practitioner. The nurse would anticipate an order for which intervention? a. A lidocaine bolus b. Stopping the insulin drip c. Synchronizing cardioversion d. Obtaining serum electrolytes

ANS: D Hypokalemia can occur within the first hours of rehydration and insulin treatment. Continuous cardiac monitoring is required, because low serum potassium (hypokalemia) can cause ventricular dysrhythmias.

A patient with type 2 diabetes is admitted. He is very lethargic and hypotensive. A diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is given. Which findings support this diagnosis? a. Decreased serum glucose and increased serum ketones b. Increased urine ketones and decreased serum osmolality c. Increased serum osmolality and increased serum potassium d. Increased serum osmolality and increased serum glucose

ANS: D Laboratory findings are used to establish the definitive diagnosis of hyperglycemic hyperosmolar syndrome (HHS). Plasma glucose levels are strikingly elevated (greater than 600 mg/dL). Serum osmolality is greater than 320 mOsm/kg.

The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which statement best describes the rationale for administrating potassium supplements with the patient's insulin therapy? a. Potassium replaces losses incurred with diuresis. b. The patient has been in a long-term malnourished state. c. Intravenous (IV) potassium renders the infused solution isotonic. d. Insulin drives the potassium back into the cells.

ANS: D Low serum potassium (hypokalemia) occurs as insulin promotes the return of potassium into the cell and metabolic acidosis is reversed. Replacement of potassium by administration of potassium chloride (KCl) begins as soon as the serum potassium falls below normal. Frequent verification of the serum potassium concentration is required for patients with diabetic ketoacidosis (DKA) who are receiving fluid resuscitation and insulin therapy.

The nurse is caring for a patient with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Which findings would confirm this diagnosis? a. Decreased ADH level and hyperkalemia b. Decreased ADH level and hypernatremia c. Increased ADH level and serum ketones d. Increased ADH level and low serum osmolality

ANS: D Secretion of antidiuretic hormone (SIADH) occurs when there are increased levels of ADH in the blood compared with a low serum osmolality.

A patient is admitted with extreme fatigue, vomiting, and headache. This patient has type 1 diabetes that has been well controlled with an insulin pump. The patient states, "I know it could not be my diabetes because my pump gives me 24-hour control." Which reply would be the nurse's best response? a. "You know a lot about your pump, and you are correct." b. "You're right. This is probably a virus." c. "We'll get an abdominal CT and see if your pancreas is inflamed." d. "We'll check your serum blood glucose and ketones."

ANS: D Subcutaneous insulin pumps can malfunction. It is critical to assess glucose and ketone levels to evaluate for diabetic ketoacidosis.

What measurements are you watching when assessing response to fluid replacement with DI?

I&Os, mucous membranes, skin turgor, daily weights, presence of thirst, and temperature

What medication is given to help with the cardiovascular affects of thyroid storm?

beta blockers!- propranolol (usually) or esmolol

What is the priority medication for a patient with thyroid storm?

beta blockers!- why? we need to focus on the symptom that can cause ACTUAL issues leading to DEATH

What can happen to a patient with myxedema coma?

cardiac tamponade due to fluid accumulation

What medication is given to a patient with DI?

desmopressin- a synthetic ADH

What is SIADH?

excess AHD secreted into blood stream

What is the treatment goal for SIADH?

fluid restriction 100mL to 500mL per day and sodium replacement with hypertonic saline

What is the antithyroid medication used for a patient with thyroid storm that can block any release of thyroid hormone already in the thyroid gland?

iodine

How does insulin affect potassium?

it pulls potassium into cells, which causes low potassium in the body

What medication is given to a patient with myxedema coma?

levothyroxine

Which is associated with insufficient thyroid hormone?

myxedema coma

What fluid is given to a patient with DKA and the amount?

normal saline (0.9%) 1 L

What are the treatment goals for thyroid storm?

prevent cardiac decompensation, reduce hyperthermia, and reverse dehydration

What are the antithyroid medications used for a patient with thyroid storm that has no effect on previously released thyroid hormone?

propylthiouracil (PTU) and methimazole

What is the speed when it comes to serum sodium being replaced when a patient has SIADH?

serum sodium must be replaced slowly 8 to 10 mEq/L in 24 hours- why? if sodium is given quickly, then it can cause demyelination

Which is associated with excess thyroid hormone?

thyroid hormone

What are the medications used for in a patient with SIADH when fluid restriction is not effective?

vasopressin (also called vaptans), conivaptan is used to preserve sodium and excrete water (hypovolemia is a contraindication), and tolvaptan is an oral med that is started in the hospital