Chapter 11: Endocrine Disorders

With an 8 a.m. dose of the following insulin forms, followed by an inadequate dietary intake and/or excessive energy use, at approximately what time would hypoglycemia be most likely to occur? REGULAR INSULIN

10-11

With an 8 a.m. dose of the following insulin forms, followed by an inadequate dietary intake and/or excessive energy use, at approximately what time would hypoglycemia be most likely to occur? NPH INSLUIN

2-10PM

With an 8 a.m. dose of the following insulin forms, followed by an inadequate dietary intake and/or excessive energy use, at approximately what time would hypoglycemia be most likely to occur? LISPRO

8:30-9:30

A first-line approach to treating Cushing's syndrome in a 56-year-old woman who has been taking oral corticosteroids to treat rheumatoid arthritis for the past 2 years is: A. gradually tapering corticosteroid use. B. referral for surgery. C. consideration of radiation therapy. D. prescribing mifepristone.

A

After use, the onset of action of lispro (Humalog®) occurs in: A. less than 30 minutes. B. approximately 1 hour. C. 1 to 2 hours. D. 3 to 4 hours.

A

Clinical presentation of type 1 DM usually includes all of the following except: A. report of recent unintended weight gain. B. ketosis. C. persistent thirst. D. polyphagia.

A

Laboratory findings in heatstroke usually include: A. elevated total creatine kinase. B. anemia. C. metabolic alkalosis. D. hypokalemia.

A

You consider prescribing insulin glargine (Toujeo®, Lantus®) because of its: A. extended duration of action. B. rapid onset of action. C. ability to prevent diabetic end-organ damage. D. ability to preserve pancreatic function.

A

You see an obese 25-year-old man with acanthosis nigricans and consider ordering: A. FBS. B. LFT. C. RPR. D. ESR.

A

Intervention in microalbuminuria for a person with DM includes which of the following? (More than one can apply.) A. improved glycemic control B. strict dyslipidemia control C. use of an optimized dose of an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) D. use of an ACEI with an ARB

ABC

Which of the following best describes the physical activity recommendations such as brisk walking for a 55-year-old woman with newly diagnosed type 2 diabetes mellitus? (More than one can apply.) A. The goal should be for a total increased physical activity of 150 min per week or more. B. Increased physical activity is recommended at least three times per week with no more than 48 hours without exercise C. Some form of resistance exercise such as lifting dumbbells or using an exercise band should be included at least two times per week. D. Vigorous aerobic or resistance activity is potentially contraindicated in the presence of proliferative or severe nonproliferative retinopathy because of the possible risk of vitreous hemorrhage or retinal detachment.

ABCD

A 46-year-old woman complains of fatigue, weakness, lethargy, decreased concentration and memory, and increased facial hair over the past 12 months. She also reports gaining over 30 pounds (13.6 kg) in the past 2 months. She has a history of asthma with repeated flares during the past 6 months requiring multiple courses of prednisone therapy. A likely diagnosis for this patient is: A. type 2 diabetes. B. Cushing's syndrome. C. Cushing's disease. D. central obesity.

B

All the following medications are recommended as possible first-line medications for treatment of concomitant hypertension when seen with type 2 DM in a 48-year-old man of European ancestry except: A. thiazide diuretic. B. calcium channel blocker. C. alpha-adrenergic receptor antagonist. D. angiotensin receptor blocker.

C

Cardiovascular effects of hyperinsulinemia include: A. decreased renal sodium reabsorption. B. constricted circulating volume. C. greater responsiveness to angiotensin II. D. diminished sympathetic activation.

C

Cushing's disease is the specific type of Cushing's syndrome that is caused by: A. long-term exposure to corticosteroids. B. a benign tumor of the adrenal gland. C. a benign pituitary tumor. D. an ectopic tumor that produces ACTH.

C

Cushing's syndrome results from an excess of: A. luteinizing hormone. B. follicle-stimulating hormone. C. cortisol. D. aldosterone.

C

Five years or more after type 2 diabetes mellitus diagnosis, which of the following medications is less likely to be effective in controlling plasma glucose? A. metformin B. pioglitazone C. glipizide D. insulin

C

Hypothyroidism most often develops as a result of: A. primary pituitary failure. B. thyroid neoplasia. C. autoimmune thyroiditis. D. radioactive iodine exposure.

C

In a healthy person, what percentage of the body's total daily physiological insulin secretion is released as basally? A. 10%-20% B. 25%-35% C. 50%-60% D. 75%-85%

C

In caring for a patient with DM, microalbuminuria measurement should be obtained: A. annually if urine protein is present. B. periodically in relationship to glycemia control. C. yearly. D. with each office visit related to DM.

C

In prescribing levothyroxine therapy for an elderly patient, which of the following statements is true? A. Elderly persons require a rapid initiation of levothyroxine therapy. B. TSH should be checked about 2 days after dosage adjustment. C. The levothyroxine dose needed by elderly persons is 75% or less of that needed by younger adults. D. TSH should be suppressed to a nondetectable level.

C

Metformin should be discontinued for the day of and up to 48 hours after surgery because of increased risk of: A. hypoglycemia. B. hepatic impairment. C. lactic acidosis. D. interaction with most anesthetic agents.

C

Periodic routine screening for hypothyroidism is indicated in the presence of which of the following clinical conditions? A. digoxin use B. male gender C. Down syndrome D. alcoholism

C

Physical examination findings in patients with Graves' disease include: A. muscle tenderness. B. coarse, dry skin. C. eyelid retraction. D. delayed relaxation phase of the patellar reflex.

C

Recommended A1c goal in a 79-year-old woman with a 20-year history of type 2 diabetes mellitus who has difficulty ambulating, uses a walker, and has a cardiac ejection fraction of 35% and a history of heart failure should be equal to or less than: A. 7%. B. 7.5%. C. 8%. D. 8.5%.

C

The mechanism of action of metformin (Glucophage®) is as: A. an insulin-production enhancer. B. a product virtually identical in action to sulfonylureas. C. a drug that increases insulin action in the peripheral tissues and reduces hepatic glucose production. D. a facilitator of renal glucose excretion.

C

The mechanism of action of pioglitazone is as: A. an insulin-production enhancer. B. a reducer of pancreatic glucose output. C. an insulin sensitizer. D. a facilitator of renal glucose excretion.

C

The meglitinide analogues are particularly helpful adjuncts in type 2 DM care to minimize risk of: A. fasting hypoglycemia. B. nocturnal hyperglycemia. C. postprandial hyperglycemia. D. postprandial hypoglycemia.

C

When caring for a patient with DM, hypertension, and persistent proteinuria, the nurse practitioner (NP) prioritizes the choice of antihypertension and prescribes: A. furosemide. B. methyldopa. C. fosinopril. D. nifedipine.

C

Which of the following is the most cost-effective method of distinguishing a malignant from a benign thyroid nodule? A. ultrasound B. magnetic resonance (MRI) imaging C. fine-needle aspiration biopsy D. radioactive iodine scan

C

Which of the following should be periodically monitored with the use of a thiazolidinedione? A. CK B. ALP C. ALT D. Cr

C

You are seeing 17-year-old Amanda. As part of the visit, you consider her risk factors for type 2 DM would likely include all of the following except: A. obesity. B. Native American ancestry. C. family history of type 1 DM. D. personal history of polycystic ovary syndrome.

C

With an 8 a.m. dose of the following insulin forms, followed by an inadequate dietary intake and/or excessive energy use, at approximately what time would hypoglycemia be most likely to occur? INSULINE GLARGINE (LANTUS)

EPISODE IS UNLIKELY

TSH less than 0.15 mIU/L (0.4 to 4.0 mIU/L); free T4 = 79 pmol/L (10 to 27 pmol/L)

HYPER

amenorrhea or oligomenorrhea

HYPER

frequent, low-volume, loose stools

HYPER

heat intolerance

HYPER

hyperreflexia with a characteristic "quick out-quick back" action at the patellar reflex

HYPER

proximal muscle weakness

HYPER

smooth, silky skin

HYPER

tachycardia with hypertension

HYPER

TSH = 24 mIU/L (0.4 to 4.0 mIU/L); free T4 = 3 pmol/L (10 to 27 pmol/L)

HYPO

coarse hair with tendency to break easily

HYPO

coarse, dry skin

HYPO

constipation

HYPO

hyporeflexia with a characteristic slow relaxation phase, the "hung-up" reflex

HYPO

menorrhagia

HYPO

secondary hypertriglyceridemia

HYPO

thick, dry nails

HYPO

TSH = 8.9 mIU/L (0.4 to 4.0 mIU/L); free T4 = 15 pmol/L (10 to 27 pmol/L)

SUBCLINICAL HYPO

A 34-year-old woman complains of progressive weakness, fatigue, poor appetite, and weight loss. She has also noticed the development of hyperpigmentation, mainly on the knuckles, elbows, and knees. All of the following blood tests can be used to help confirm a diagnosis of Addison's disease except: A. sodium. B. potassium. C. cortisol. D. folate.

D

A 43-year-old man is experiencing an acute adrenal crisis and presents with prominent nausea, vomiting, and low blood pressure. He appears cyanotic and confused. The most appropriate treatment is an injection of: A. epinephrine. B. insulin. C. adrenaline. D. hydrocortisone.

D

A fixed, painless thyroid mass accompanied by hoarseness and dysphagia should raise the suspicion of: A. adenomatous lesion. B. Graves' disease. C. Hashimoto's disease. D. thyroid malignancy.

D

Acanthosis nigricans is commonly noted in all of the following areas except: A. groin folds. B. axilla. C. nape of the neck. D. face.

D

All of the following are risks for lactic acidosis in individuals taking metformin except: A. presence of chronic renal insufficiency. B. acute dehydration. C. recent radiographic contrast dye use. D. history of allergic reaction to sulfonamides.

D

At minimum, at what interval should TSH be reassessed after a levothyroxine dosage is adjusted? A. 1 to 2 weeks B. 2 to 4 weeks C. 4 to 6 weeks D. 6 to 8 weeks

D

Criteria for the diagnosis of type 2 DM include: A. classic symptoms regardless of fasting plasma glucose measurement. B. plasma glucose level of 126 mg/dL (7 mmol/L) as a random measurement. C. a 2-hour glucose measurement of 156 mg/dL (8.6 mmol/L) after a 75 g anhydrous glucose load. D. a plasma glucose level of 126 mg/dL (7 mmol/L) or greater after an 8 hour or greater fast on more than one occasion.

D

Hemoglobin A1c best provides information on glucose control over the past: A. 21 to 47. B. 48 to 68. C. 69 to 89. D. 90 to 120.

D

In an older adult with type 2 DM with gastroparesis, the use of which of the following medications should be avoided? A. insulin glargine (Toujeo®, Lantus®) B. insulin aspart (NovoLog®) C. glimepiride (Amaryl®) D. liraglutide (Victoza®)

D

In the report of a thyroid scan done on a 48-year-old woman with a thyroid mass, a "cold spot" is reported. This finding is most consistent with: A. autonomously functioning adenoma. B. Graves' disease. C. Hashimoto's disease. D. thyroid cyst.

D

Increased risk of thyroid disorder is found in individuals who are: A. obese. B. hypertensive. C. treated with systemic corticosteroids. D. elderly.

D

Metformin has all of the following effects except: A. improved insulin-mediated glucose uptake. B. modest weight loss with initial use. C. enhanced fibrinolysis. D. increased low-density lipoprotein (LDL) cholesterol production.

D

Risk factors for heatstroke include all of the following except: A. obesity. B. use of beta-adrenergic antagonists. C. excessive activity. D. use of a vasodilator.

D

Secondary causes of hyperglycemia potentially include the use of all of the following medications except: A. high-dose niacin. B. systemic corticosteroids. C. high-dose thiazide diuretics. D. low-dose angiotensin receptor blockers.

D

TSH is released by the: A. thyroid follicles. B. adrenal cortex. C. hypothalamus. D. anterior lobe of the pituitary.

D

The most commonly recommended treatment of Cushing's disease is: A. tapering or ceasing corticosteroid use. B. eliminating trigger medications. C. antineoplastic therapy. D. surgical intervention.

D

The use of a thiazolidinedione is not recommended in all of the following clinical scenarios except: A. a 57-year-old man who is taking a nitrate. B. a 62-year-old woman with heart failure. C. a 45-year-old man who is using insulin. D. a 35-year-old patient with newly diagnosed type 2 DM.

D

The use of which of the following medications has the potential for causing the greatest reduction in HbA1c? A. a biguanide B. a thiazolidinedione C. a sulfonylurea D. an insulin form

D

Which of the following classes of medications is commonly recommended as part of first-line therapy in the newly diagnosed person with type 2 diabetes? A. alpha-glucosidase inhibitor B. meglitinide C. thiazolidinedione D. biguanide

D

Which of the following patients has prediabetes? A. a 70-year-old man with a fasting glucose of 99 mg/dL (6.05 mmol/L) B. an 84-year-old woman with a 1-hour postprandial glucose of 98 mg/dL (5.44 mmol/L) C. a 33-year-old man with a hemoglobin A1c of 5.4% D. a 58-year-old woman with a 2-hour postprandial glucose of 152 mg/dL (8.44 mmol/L)

D

Which of the following should be periodically monitored with the use of a biguanide? A. creatine kinase (CK) B. alkaline phosphatase (ALP) C. alanine aminotransferase (ALT) D. creatinine (Cr)

D

Which of the following statements is not true concerning the effects of exercise and IR? A. Approximately 80% of the body's insulin-mediated glucose uptake occurs in skeletal muscle. B. With regular aerobic exercise, IR is reduced by approximately 40%. C. The IR-reducing effects of exercise persist for 48 hours after the activity. D. Hyperglycemia can occur as a result of aerobic exercise.

D

lithium

D

Pertaining to the use of sliding-scale insulin in response to elevated blood glucose, which of the following best describes current best practice? A. The use of this type of sliding-scale insulin therapy is discouraged as this method treats hyperglycemia after it has already occurred. B. Sliding-scale insulin in response to elevated glucose is a safe and helpful method of treating hyperglycemia. C. Delivering insulin in this manner is acceptable within the acute care hospital setting only. D. The use of the sliding insulin scale is appropriate in the treatment of type 1 DM only.

A

Possible adverse outcomes from heatstroke include: A. rhabdomyolysis. B. thrombocytopenia. C. hypernatremia. D. leukopenia.

A

Possible consequences of excessive levothyroxine use include: A. bone thinning. B. fatigue. C. renal impairment. D. constipation.

A

Secondary adrenal insufficiency can occur with the presence of a diseased or malfunctioning: A. pituitary gland. B. thyroid. C. pancreatic beta cells. D. hypothalamus.

A

The findings of a painless thyroid mass and TSH level of less than 0.1 IU/mL in a 35-year-old woman is most consistent with: A. autonomously functioning adenoma. B. Graves' disease. C. Hashimoto's disease. D. thyroid malignancy.

A

The mechanism of action of a GLP-1 agonist such as exenatide (Byetta®) is as: A. a drug that stimulates insulin production in response to an increase in plasma glucose. B. a product virtually identical in action to sulfonylureas. C. a drug that increases insulin action in the peripheral tissues and reduces hepatic glucose production. D. a facilitator of renal glucose excretion

A

The mechanism of action of radioactive iodine in the treatment of Graves' disease is to: A. destroy the overactive thyroid tissue. B. reduce production of TSH. C. alter thyroid metabolic rate. D. relieve distress caused by increased thyroid size

A

The mechanism of action of the DPP-4 inhibitors is as: A. a drug that increases levels of incretin, increasing synthesis and release of insulin from pancreatic beta cells. B. a product virtually identical in action to sulfonylureas. C. a drug that increases insulin action in the peripheral tissues and reduces hepatic glucose production. D. a facilitator of renal glucose excretion.

A

Untreated Cushing's syndrome can lead to all of the following except: A. rheumatoid arthritis. B. hypertension. C. type 2 diabetes. D. osteoporosis.

A

What is the most common adverse effect noted with alpha-glucosidase inhibitor use? A. gastrointestinal upset B. hepatotoxicity C. renal impairment D. symptomatic hypoglycemia

A

Which is following is the least helpful test for the assessment of thyroid disease? A. total T4 B. thyroid-stimulating hormone (TSH) C. free T4 D. thyroid peroxidase (TPO) antibodies

A

Which of the following characteristics applies to type 1 diabetes mellitus (DM)? A. Significant hyperglycemia and ketoacidosis result from lack of insulin. B. This condition is commonly diagnosed on routine examination or workup for other health problems. C. Initial response to oral sulfonylureas is usually favorable. D. Insulin resistance (IR) is a significant part of the disease.

A

Which of the following characteristics applies to type 2 DM? A. Major risk factors are heredity and obesity. B. Pear-shaped body type is commonly found. C. Exogenous insulin is needed for control of disease. D. Physical activity enhances IR.

A

Which of the following is an unlikely consequence of untreated metabolic syndrome and IR in a woman of reproductive age? A. hyperovulation B. irregular menses C. acne D. hirsutism

A

Which of the following medications is a helpful treatment option for relief of tremor and tachycardia seen with untreated hyperthyroidism? A. propranolol B. diazepam C. carbamazepine D. verapamil

A

Which of the following should be the goal measurement in treating a 45-year-old man with DM and hypertension? A. blood pressure less than 140 mm Hg systolic and less than 90 mm Hg diastolic B. hemoglobin A1c equal to or greater than 7% C. triglyceride 200 to 300 mg/dL (11.1 to 16.6 mmol/L) D. high-density lipoprotein (HDL) 35 to 40 mg/dL (0.9 to 1.03 mmol/L)

A

Which of the following statements best describes the Somogyi effect? A. Insulin-induced hypoglycemia triggers excess secretion of glucagon and cortisol, leading to hyperglycemia. B. Early morning elevated blood glucose levels result in part from growth hormone and cortisol-triggering hepatic glucose release. C. Late evening hyperglycemia is induced by inadequate insulin dose. D. Episodes of postprandial hypoglycemia occur as a result of inadequate food intake.

A

A 48-year-old woman with newly diagnosed hypothyroidism asks about a "natural thyroid" medication she read about online and provides the drug's name: desiccated thyroid. As you counsel her about this medication, you consider all of the following except: A. this product contains a fixed dose of T3 and T4. B. the medication is a plant-based product. C. its pharmacokinetics differ significantly when compared to levothyroxine. D. the majority of the study on treatment for hypothyroidism has been done using levothyroxine.

B

As part of an evaluation of a 3-cm, round, mobile thyroid mass, you obtain a thyroid ultrasound scan revealing a fluid-filled structure. The most likely diagnosis is: A. adenoma. B. thyroid cyst. C. multinodular goiter. D. vascular lesion.

B

Consideration should be given to setting A1c goal in a 22-year-old man with a 8-year history of type 1 diabetes mellitus who has no comorbid conditions equal to or at less than: A. 5.5%. B. 6%. C. 6.5%. D. 7%.

B

Generally, testing for type 2 DM in asymptomatic, undiagnosed individuals older than 45 years should be conducted every _____. A. year. B. 3 years C. 5 years D. 10 years

B

Hemoglobin A1c should be tested: A. at least annually for all patients. B. at least two times a year in patients who are meeting treatment goals and who have stable glycemic control. C. monthly in patients whose therapy has changed or who are not meeting glycemic goals. D. only via standardized laboratory testing because of inaccuracies associated with point-of-service testing.

B

In teaching a patient with type 2 diabetes mellitus and taking basal insulin such as degludec (Tresiba®) about using rapid-acting insulin such as aspart (Novolog®) to help with the management of postprandial hyperglycemia, the NP advises first starting an injection of _____ unit(s) prior to the largest meal. A. 1 B. 4 C. 8 D. 12

B

Mr. Samuels is a 58-year-old man with type 2 DM who is using a single 10 unit daily dose of the long-acting insulin glargine. His fasting blood glucose has been between 141 to 180 mg/dL (7.8 to 10 mmol/L). Which of the following best describes the next step in his therapy? A. Continue on the current glargine dose. B. Increase his glargine dose by 4 units per day. C. Increase his glargine dose by 1 unit per day. D. Increase his glargine dose by 6 units per day.

B

The International Diabetes Federation's diagnostic criteria for metabolic syndrome include: A. an obligatory finding of persistent hyperglycemia. B. notation of ethnic-specific waist circumference measurements. C. documentation of microalbuminuria. D. a family history of type 2 DM.

B

The hormone cortisol plays a role in all of the following processes except: A. maintaining glucose control. B. maintaining thyroid function. C. suppressing the immune response. D. helping the body respond to stress.

B

The mechanism of action of sulfonylureas is as: A. an antagonist of insulin receptor site activity. B. a product that enhances insulin release. C. a facilitator of renal glucose excretion. D. an agent that can reduce hepatic glucose production.

B

The most commonly utilized intervention for patients with heatstroke is: A. total body ice packing. B. rehydration. C. management of hyperammonemia. D. electrolyte supplementation.

B

The use of GLP-1 agonist has been associated with the development of: A. leukopenia. B. pancreatitis. C. lymphoma. D. vitiligo.

B

Which of the following best describes ethnicity and insulin sensitivity? A. Little variation exists in insulin sensitivity among different ethnic groups. B. African Americans are typically less sensitive to the effects of insulin when compared with people of European ancestry. C. Mexican Americans are likely the most insulinsensitive ethnic group residing in North America. D. The degree of insulin sensitivity has little influence on insulin production.

B

Which of the following is a mineralocorticoid? A. cortisol B. aldosterone C. insulin D. hydrocortisone

B

Which of the following medications should be used with caution in a person with severe sulfa allergy? A. metformin B. glyburide C. rosiglitazone D. NPH insulin

B

You advise a 58-year-old woman with hypothyroidism about the correct use of levothyroxine. She also takes a calcium supplement. All of the following should be shared with the patient except which instruction? A. "Take the medication on an empty stomach." B. "To help with adherence, take your calcium supplement at the same time as your thyroid medication." C. "You should take the medication at approximately the same time every day." D. "Do not take your medication with soy milk."

B

atypical presentation in an elderly person

BOTH

change in mental status

BOTH

goiter

BOTH

A 24-year-old female runner is diagnosed with Addison's disease. In counseling her about exercise, you recommend: A. tapering her running to only 10 minutes per day for 2 to 3 days per week. B. ceasing any prolonged strenuous exercise. C. ensuring an ample amount of sodium is ingested. D. switching to a nonimpact exercise.

C