Chap 41 Disorders of Endocrine Control
The nurse is performing an assessment for a client who has hyperthyroidism that is untreated. When obtaining vital signs, what is the expected finding?
Heart rate 110 and bounding Explanation: Cardiovascular and respiratory functions are strongly affected by thyroid function. With an increase in metabolism, there is a rise in oxygen consumption and production of metabolic end products, with an accompanying increase in vasodilation. Blood volume, cardiac output, and ventilation are all increased. Heart rate and cardiac contractility are enhanced as a means of maintaining the needed cardiac output. Blood pressure is likely to change little because the increase in vasodilation tends to offset the increase in cardiac output.
The nurse has just completed teaching a client, newly diagnosed with type 1 diabetes, about the treatment options. Which response by the client leads the nurse to conclude that addidtional teaching is needed?
"So I can stop my insulin if I start an exercise program." Explanation: Clients with type 1 diabetes require insulin therapy from the time of diagnosis. Weight loss and dietary management may be sufficient to control blood glucose levels. Treatments which involve medical nutrition therapy, exercise, and insulin will help prevent complications later on as the client ages.
A young child develops type 1A diabetes. The parents ask, "They tell us this is genetic. Does that mean our other children will get diabetes?" The best response by the health care provider would be:
"This autoimmune disorder causes destruction of the beta cells, placing your children at high risk of developing diabetes." Explanation: Type 1 diabetes is subdivided into two types: type 1A, immune-mediated diabetes, and type 1B, idiopathic diabetes. Type 1A diabetes is characterized by autoimmune destruction of beta cells. The other choices are not absolutely correct. The fact that type 1 diabetes is thought to result from an interaction between genetic and environmental factors led to research into methods directed at prevention and early control of the disease. These methods include the identification of genetically susceptible persons and early intervention in newly diagnosed persons with type 1 diabetes.
Which client would be considered to be exhibiting manifestations of "prediabetes"?
A middle-aged overweight adult with a fasting plasma glucose level of 122 with follow-up OGTT of 189 mg/dL (10.49 mmol/L). Explanation: Persons with IFG (impaired fasting plasma glucose [IFG] defined by an elevated FPG of 100 to 125 mg/dL [5.55 to 6.94 mmol/L]) and/or IGT (impaired glucose tolerance [IGT] plasma glucose levels of 140 to 199 mg/dL [7.77 to 11.04 mmol/L] with an OGTT) are often referred to as having prediabetes, meaning they are at relatively high risk for the future development of diabetes as well as cardiovascular disease.
The nurse is assessing a male client and finds abnormally large hands and feet, a bulbous nose, and a broad face with a protruding jaw. Based on these findings, which endocrine abnormality is most likely the cause for these physical changes?
Acromegaly Explanation: Enlargement of the small bones of the hands and feet and of the membranous bones of the face and skull results in a pronounced enlargement of the hands and feet, a broad and bulbous nose, a protruding jaw, and a slanting forehead. Bone overgrowth often leads to arthralgias and degenerative arthritis of the spine, hips, and knees. Virtually every organ of the body is increased in size. Enlargement of the heart and accelerated atherosclerosis may lead to an early death. Hyperthyroidism results from excess thyroid hormone. Myxedema and Cushing syndrome are the result of adrenal abnormalities and do not cause these bone changes.
Which individual displays the precursors to acromegaly?
An adult with an excess of growth hormone due to an adenoma Explanation: When growth hormone (GH) excess occurs in adulthood or after the epiphyses of the long bones have fused, it causes a condition called acromegaly, which represents an exaggerated growth of the ends of the extremities.
When educating a client about type 1 diabetes, the nurse will mention that this type is caused by which mechanism?
Autoimmune destruction of pancreatic beta cells Explanation: Type 1 diabetes involves autoimmune destruction of beta cells. The pathophysiology of type 2 diabetes has both genetic and acquired factors.
A client is to have a serum thyroxine and thyroid stimulating laboratory test performed to assess the baseline status of the hypothalamic-pituitary target cell hormones. When educating the client about the laboratory tests, when would the the nurse inform him the test should be obtained?
Before 0800 Explanation: The assessment of hypothalamic-pituitary function has been made possible by many newly developed imaging and radioimmunoassay methods. Assessment of the baseline status of the hypothalamic-pituitary target cell hormones involves measuring the following laboratory specimens (ideally obtained before 0800): serum cortisol, serum prolactin, serum thyroxine and TSH, serum testosterone and estrogen and serum LH/FSH, serum GH, and plasma and urine osmolality.
Which clinical manifestations would the nurse identify as indications of increased blood glucose levels? Select all that apply.
Blurred vision Thirst Fatigue Skin infections Explanation: Polyuria, polyphagia, and polydipsia are three classic signs of diabetes. Hypotension and fatigue are signs of hypovolemia that may accompany increased blood glucose levels. Skin infections occur frequently in type 2 diabetes. Blurred vision results from exposure of the lens and retina to hyperosmotic fluids.
A client with diabetes mellitus has sudden onset of slurred speech, incoordination, and cool, clammy skin. What will the nurse do first?
Check blood glucose Explanation: Hypoglycemia is a medical emergency. Because other conditions can also cause these symptoms, the blood glucose level should be checked first. Then glucose should be given. The client should follow this with a protein and complex carbohydrate to avoid a recurrence of hypoglycemia. Blood glucose should be tested about 15 minutes after the glucose is given to monitor progress.
The nurse is assessing a client who underwent a thyroidectomy earlier in the day. Assessment reveals a heart rate of 133 beats per minute, oral temperature of 101.3°F (38.5°C), and the client is uncharacteristically agitated and disoriented. After informing the primary care provider, which action by the nurse is the priority?
Closely monitor the client's cardiac status. Explanation: Thyroid storm can result from the manipulation of the gland during a thyroidectomy. It poses a serious threat to the client's cardiac status and this would likely be prioritized over neurologic assessment. Antipyretics are insufficient to prevent hyperthermia. Thyroid hormones would exacerbate the client's condition.
A client is diagnosed with adrenocorticotropic hormone deficiency (ACTH) and is to begin replacement therapy. Regarding which type of replacement will the nurse educate the client?
Cortisol replacement therapy Explanation: Cortisol replacement is started when ACTH deficiency is present; thyroid replacement when TSH deficiency is detected; and sex hormone replacement when LH and FSH are deficient. GH replacement is indicated for pediatric GH deficiency, and is increasingly being used to treat GH deficiency in adults.
The newborn nursery nurse is obtaining a blood sample to determine if a newborn has congenital hypothyroidism. What long-term complication is the nurse aware can occur if this test is not performed and the infant has congenital hypothyroidism?
Cretinism Explanation: Congenital hypothyroidism is a common cause of preventable intellectual disability. It affects approximately 1 in 4000 infants. The manifestations of untreated congenital hypothyroidism are referred to as cretinism. The term does not apply to the normally developing infant in whom replacement thyroid hormones therapy was instituted shortly after birth.
Parents of a 7-year-old girl are concerned about their daughter because she has begun to develop secondary sexual characteristics. What etiologic factor is most likely to underlie the child's condition?
Early activation of the hypothalamic-pituitary-gonadal axis Explanation: Isosexual or central precocious puberty involves early activation of the hypothalamic-pituitary-gonadal axis, resulting in the development of appropriate sexual characteristics and fertility. It is not caused by trauma such as sexual abuse and it does not involve thyroid function. Precocious puberty is not noted to be a genetic trait.
Which pathophysiologic phenomeon may result in a diagnosis of Cushing disease?
Excess ACTH production by a pituitary tumor Explanation: Three important forms of Cushing syndrome result from excess glucocorticoid production by the body. One is a pituitary form, which results from excessive production of ACTH by a tumor of the pituitary gland. Hypopituitarism and destruction of the adrenal cortex are associated with Addison disease. Disruption of the HPA system is not implicated in the etiology of Cushing disease.
A client tells the health care provider that he has been very compliant over the last 2 months in the management of his diabetes. The best diagnostic indicator that would support the client's response would be:
Glycosylated hemoglobin, hemoglobin A1C (HbA1C) Explanation: Glycosylated hemoglobin, hemoglobin A1C (HbA1C), and A1C are terms used to describe hemoglobin into which glucose has been incorporated. Glycosylation is essentially irreversible, and the level of A1C present in the blood provides an index of blood glucose levels over the previous 6 to 12 weeks. In uncontrolled diabetes or diabetes with hyperglycemia, there is an increase in the level of A1C. The other options would not reflect the 2-month period.
The diagnosis of type 1 diabetes would be confirmed by which principle?
Insulin is not available for use by the body. Explanation: Type 1 diabetes is a catabolic disorder characterized by an absolute lack of insulin. In type 2 diabetes, some insulin is produced.
A client with diabetic retinopathy develops a retinal bleed and asks the nurse, "How can I prevent this from happening again?" What response provides the most effective information?
Maintain healthy blood pressure and blood sugar levels. Explanation: Diabetic retinopathy occurs when blood vessels have increased permeability, develop microaneurysms, vascular proliferation, scarring, and retinal detachment. These conditions are worsened when the client has poor glycemic control, poorly controlled hypertension, and hyperlipidemia. Laser photocoagulation can be used to stop vessel proliferation and bleeding. An annual examination will evaluate the disease, but does not prevent recurrence. Eye use patterns do not change retinopathy.
A client with severe hypoglycemia is unconscious. Which method of providing glucose should be avoided?
Orange juice orally Explanation: When clients are unconscious it is not safe to attempt to have them swallow liquids. Alternate routes that reduce the risk of choking such as buccal absorption, intramuscular or intravenous injections are preferred.
A client has been experiencing elevated blood glucose levels. The nurse anticipates that which assessment data correlates with hyperglycemia?
Polydipsia Explanation: Polyuria, polyphagia, and polydipsia are three classic signs of diabetes. Thirst (polydipsia) results from the intracellular dehydration that occurs as blood glucose levels rise and water is pulled out of body cells, including those in the hypothalamic thirst center. Hypotension and dry skin and mucous membranes are signs of hypovolemia that may accompany increased blood glucose levels. FBS of 120 mg/dL is normal.
Select the most common symptoms of diabetes. Select all that apply.
Polydipsia Polyuria Polyphagia Explanation: The most commonly identified signs and symptoms of diabetes are often referred to as the three polys: (1) polyuria (i.e., excessive urination), (2) polydipsia (i.e., excessive thirst), and (3) polyphagia (i.e., excessive hunger). Polyhydramnios is a medical condition describing an excess of amniotic fluid in the amniotic sac. Polycythemia is a condition of increased red blood cells.
The nurse knows that the client with which complication of diabetes has the greatest risk for the development of foot ulcers?
Sensory neuropathy Explanation: Sensory neuropathy is a major risk factor for foot ulcers due to the fact that people have impaired pain sensation and can be unaware of foot injuries and infections. Autonomic neuropathy, microvascular disease, or diabetic ketoacidosis, while not affecting risk for foot injuries, suggest that the client's diabetes is inadequately controlled.
A client with severe hypothyroidism is presently experiencing hypothermia. What nursing intervention is a priority in the care of this client?
Slow rewarming of the client to prevent vasodilation and vascular collapse Explanation: If hypothermia is present, active rewarming of the body is contraindicated because it may induce vasodilation and vascular collapse. Prevention is preferable to treatment and entails special attention to high risk populations, such as women with a history of Hashimoto thyroiditis.
Hyperthyroidism that is inadequately treated can cause a life-threatening condition known as a thyroid storm. What are the manifestations of a thyroid storm? Select all that apply.
Tachycardia Delirium Very high fever Explanation: Thyroid storm is manifested by a very high fever, extreme cardiovascular effects (e.g., tachycardia, congestive failure, and angina), and severe CNS effects (e.g., agitation, restlessness, and delirium). The mortality rate is high. Very low fever and bradycardia are not manifestations of a thyroid storm.
A client is suspected to have increased growth hormone levels. When performing a health history, what assessment data would be important for the nurse to report to the physician? Select all that apply.
The client has fainted due to low blood glucose levels on several occasions. The client has been experiencing a great deal of emotional stress due to family issues. The client is on a weight-loss diet and is exercising excessively. Explanation: GH secretion is stimulated by hypoglycemia, fasting, starvation, increased blood levels of amino acids, and stress conditions such as trauma, excitement, emotional stress, and heavy exercise. GH is inhibited by increased glucose levels, free fatty acid release, cortisol, and obesity.
The nurse is providing discharge instructions for a client with Graves disease who has ophthalmopathy. What should the nurse be sure to include in the instructions to decrease exacerbation of this clinical manifestation?
The client should be strongly urged not to smoke. Explanation: Ophthalmopathy can also be aggravated by smoking, which should be strongly discouraged. It is not necessary for the client to avoid contact with others. Alcohol is not contraindicated but should be limited when taking any medication regimen. The client should not adjust the doses of medications without first consulting the physician.
A client with long-standing type 2 diabetes is surprised to see high blood sugar readings while recovering from an emergency surgery. Which factor may have contributed to the client's inordinately elevated blood glucose levels?
The stress of the event caused the release of adrenal cortical hormones. Explanation: Elevation of glucocorticoid levels (i.e., cortisol), such as during stressful events, can lead to derangements in glucose metabolism. Tissue trauma does not cause gluconeogenesis, and illness does not inhibit the action of glucagon. The dawn phenomenon is not a likely cause of the client's disruption in blood sugar levels.
The obstetrical nurse is caring for a client who has been treated for gestational diabetes. When teaching the client about the causes of gestational diabetes, the nurse should include which risk factor in the teaching?
Woman with a family history of diabetes Explanation: Gestational diabetes occurs most commonly in black, Hispanic/Latino and Native American/First Nation women. It most frequently affects women with a family history of diabetes; a history of stillbirth or spontaneous abortion; women who previously gave birth to a newborn with fetal anomaly or had a previous large-for-gestational-age infant; those who are obese; those of advanced maternal age; or those who have had five or more pregnancies.
A client with type 1 diabetes has started a new exercise routine. Knowing there may be some increased risks associated with exercise, the health care provider should encourage the client to:
carry a snack with a rapidly absorbed form of glucose to prevent profound hypoglycemia. Explanation: People with diabetes are usually aware that delayed hypoglycemia can occur after exercise. Although muscle uptake of glucose increases significantly, the ability to maintain blood glucose levels is hampered by failure to suppress the absorption of injected insulin and activate the counterregulatory mechanisms that maintain blood glucose (to cause a hyperglycemia response). Even after exercise ceases, insulin's lowering effect on blood glucose levels continues, resulting in profound symptomatic hypoglycemia. Treatment of hypoglycemia involves administration of a rapidly absorbed form of glucose. Rapid weight loss accompanies the polyuria and dehydration of hyperglycemia rather than hypoglycemia. Respiratory disorders are associated with preexisting pulmonary or vascular problems exacerbated by the period of exercise.
When educating a client about glargine, the nurse should explain that this medication:
has a prolonged absorption rate and provides a relatively constant concentration for 12-24 hours. Explanation: Glargine is long-acting insulin that has a slow, prolonged absorption rate and provides a relatively constant concentration over 12-24 hours. Rapid acting insulin has a rapid onset and peaks in about 5 minutes after injection. Short acting insulin will have a peak effect within 30 minutes, and thus it can be taken after a meal. Intermediate-acting insulin is a combination with short acting insulin so it is safe to take anytime throughout the day.
Which pregnant woman likely faces the greatest risk of developing gestational diabetes? A client who:
is morbidly obese (defined as greater than 100 pounds over ideal weight). Explanation: Obesity is among the risk factors for gestational diabetes mellitus (GDM). Obstetric complications, multiple pregnancies, high triglycerides, and hypertension are not specific risk factors for GDM.
After receiving change-of-shift report about the following four clients, which client should the nurse assess first?
70-year-old returning from PACU following partial thyroidectomy who is extremely agitated, has an irregular pulse rate of 134, and an elevated temperature of 103.2°F (39.6°C) Explanation: Manipulation of a hyperactive thyroid gland during thyroidectomy can cause thyroid storm. It is manifested by very high fever, extreme cardiovascular effects (tachycardia, HF, angina), and severe CNS effects (agitation, restlessness, and delirium). The 22-year-old has normal sodium levels. The 31-year old has a high blood glucose level but not at a critical level. The medication schedule for the 53-year-old is lower priority. It is always preferred to give medications in timely manner; however, thyroid storms are the priority for this group of clients.
When caring for the client with diabetic ketoacidosis, the nurse recognizes that fatty acids and ketones may be used for energy by most organs. Which organ does the nurse recognize is reliant on glucose as the major energy source?
Brain Explanation: Although many tissues and organ systems are able to use other forms of fuel, such as fatty acids and ketones, the brain and nervous system rely almost exclusively on glucose as a fuel source. Because the brain can neither synthesize nor store more than a few minutes' supply of glucose, normal cerebral function requires a continuous supply from the circulation.
An adult with acromegaly presents with a very distinctive appearance. What is the distinctive feature in a person with acromegaly?
Broad, bulbous nose and a protruding lower jaw Explanation: When the production of excessive GH occurs after the epiphyses of the long bones have closed, as in the adult, the person cannot grow taller, but the soft tissues continue to grow. Enlargement of the small bones of the hands and feet and of the membranous bones of the face and skull results in a pronounced enlargement of the hands and feet, a broad and bulbous nose, a protruding lower jaw, and a slanting forehead.
A client with acromegaly comes to the clinic and informs the nurse that she is having a productive cough and a low grade fever. This is the client's fourth visit in 1 year for the same problem. What condition does the nurse understand results from this client's enlarged cartilaginous structures?
Bronchitis Explanation: The cartilaginous structures in the larynx and respiratory tract become enlarged, resulting in a deepening of the voice and tendency to develop bronchitis.
Which criterion about insulin would prompt a diagnosis of type 1 diabetes?
Complete failure of insulin secretion Explanation: In type 1 diabetes there is an absolute lack of insulin due to complete failure of the pancreas. In type 2 diabetes some insulin is produced but may not be properly used.
The nurse screening for diabetes mellitus at a health fair does not have enough supplies for all of the clients attending. Which client should be given screening priority?
Male age 45, BMI 37 Explanation: Screening should be conducted on clients age 45 and older. Priority is also given to clients who are obese, have a first-degree relative with diabetes, are members of a high-risk group (black, Latino, or Native American/First Nation), have had five or more pregnancies, delivered a child born large-for-gestational age, or have been diagnosed with gestational diabetes. Other conditions that place clients at risk for diabetes mellitus are hypertension, hyperlipidemia, or impaired glucose tolerance in previous testing.
Which manifestation indicates a client is at risk for developing diabetes mellitus?
2 hour oral GTT 175 mg/dL (9.7 mmol/L) Explanation: Laboratory values that are considered normal are hemoglobin A1C less than 6.5 percent, fasting plasma glucose of (FPG) less than 100 mg/dL or less than 140 mg/dL 2 hours after an oral glucose tolerance test (GTT). A hemoglobin A1C value that is greater than or equal to 6.5 percent; a fasting blood glucose greater than 126 mg/dL, or a blood glucose level greater than 200 mg/dL 2 hours after a glucose tolerance test (GTT) indicate diabetes mellitus. Values between these levels are considered to place clients at increased risk for diabetes mellitus. Potassium levels do not directly correlate with a diagnosis of diabetes mellitus.
A client with type 2 diabetes experiences unexplained elevations of fasting blood glucose in the early morning hours. Which conditions can account for this effect?
Dawn phenomenon Explanation: The dawn phenomenon involves increased levels of fasting blood glucose or insulin requirement during the early morning hours. It is not preceded by hypoglycemia. Circadian release of growth hormone and cortisol may be contributing factors. The other answer selections are not characterized by increased early morning levels of blood glucose
A client comes to the clinic with fatigue and muscle weakness. The client also states she has been having diarrhea. The nurse observes the skin of the client has a bronze tone and when asked, the client says she has not had any sun exposure. The mucous membranes of the gums are bluish-black. When reviewing laboratory results from this client, what does the nurse anticipate seeing?
Increased levels of ACTH Explanation: Hyperpigmentation results from elevated levels of ACTH. The skin looks bronzed or suntanned in exposed and unexposed areas, and the normal creases and pressure points tend to become especially dark. The gums and oral mucous membranes may become bluish-black. The amino acid sequence of ACTH is strikingly similar to that of melanocyte stimulating hormone; hyperpigmentation occurs in more than 90 percent of persons with Addison disease and is helpful in distinguishing the primary and secondary forms of adrenal insufficiency.