PrepU: Chapter 48: Nursing Care of the Child With an Alteration in Metabolism/Endocrine Disorder
During a visit to the clinic, the adolescent client with hypothyroidism tells the nurse that she takes her levothyroxine "whenever I think about it...sometimes I miss a dose, but not very often." What is the best response by the nurse? A. "Maybe you could do something to remind yourself to take the medication on a daily basis." B. "I know it's hard to remember medicines, but it is really important for you to take it before breakfast each day to control your hypothyroidism." C. "If you forget a dose you can double up the next day. We just want your thyroid level to be maintained since you don't produce enough thyroid hormone." D. "If you forget a dose you can double up the next day. We just want your thyroid level to be maintained since you don't produce enough thyroid hormone."
B. "I know it's hard to remember medicines, but it is really important for you to take it before breakfast each day to control your hypothyroidism." Levothyroxine is a thyroid hormone replacement used to treat hypothyroidism. It is important to maintain a consistent thyroid hormone level by taking the medication at the same time each day (preferably 30 minutes prior to breakfast for best absorption). Toxicity can occur if the dose is doubled. Suggesting the client "do something" to remember does not highlight the importance of taking it correctly.
A school-age child is seen in the family clinic. The parents ask the nurse if their child should start taking growth hormones to help the child grow because the parents are short. What is the best response by the nurse? A. "How tall would you like your child to be?" B. "Research shows that there must be a diagnosis of deficiency before growth hormones can be started at this age." C. "Growth hormones work only if the child has short bones." D. "Will your child be able to swallow oral pills every day?"
B. "Research shows that there must be a diagnosis of deficiency before growth hormones can be started at this age." The nurse should educate the parents about growth hormones before asking questions. The nurse needs to explain that a diagnosis of deficiency must be documented before growth hormones can be used. Only the long bones are affected. Growth hormone is given orally, IM, and SC.
The nurse is seeing a new client in the clinic who reports polyuria and polydipsia. These conditions are indicative of which endocrine disorder? A. precocious puberty B. hypopituitarism C. Diabetes Insipidus D. Syndrome of inappropriate antidiuretic hormone (SIADH) secretion
C. Diabetes Insipidus The most common symptoms of central DI are polyuria (excessive urination) and polydipsia (excessive thirst). Children with DI typically excrete 4 to 15 L per day of urine despite the fluid intake. The onset of these symptoms is usually sudden and abrupt. Ask about repeated trips to the bathroom, nocturia, and enuresis. Other symptoms may include dehydration, fever, weight loss, increased irritability, vomiting, constipation, and, potentially, hypovolemic shock.
The nurse is administering biosynthetic growth hormone, derived from recombinant DNA, by subcutaneous injection. The daily dosage is 0.2 to 0.3 mg/kg, given in divided doses. The child weighs 110 lb (49.9 kg). What is the safe dosage limit for this child on a daily basis? Record your answer using a whole number.
15 mg Use the child's weight in kilograms: 49.9 Minimum: 49.9 kg × 0.2 mg/kg = 9.98 mg, round to 10 mgMaximum: 49.9 kg × 0.3 mg/kg = 14.97 mg, round to 15 mg The safe limit is determined by using the maximum dosage. The lack of growth hormone impairs the body's ability to metabolize protein, fat, and carbohydrates. Treatment of primary growth hormone deficiency involves the use of supplemental growth hormone. Treatment continues until near-final height goal is achieved.
The nurse is teaching glucose monitoring and insulin administration to a child with type 1 diabetes and the parents. Which comment by a parent demonstrates a need for additional teaching? A. "During exercise we should wait to check blood sugars until after our child completes the activity." B. "If our child is sick we should check blood glucose levels more often." C. "We should check our child's blood glucose levels before meals." D. "Blood glucose level, food intake, and activity need to all be considered when calculating insulin dosage."
A. "During exercise we should wait to check blood sugars until after our child completes the activity." Blood glucose monitoring needs to be performed more often during prolonged exercise. Frequent glucose monitoring before, during, and after exercise is important to recognize hypoglycemia or hyperglycemia. Frequent glucose monitoring if the child is sick is also important to recognize changes in glucose levels and prevent hypoglycemia or hyperglycemia. The parents are correct that they will check their child's glucose before meals; they should also check it before bedtime snacks. Blood glucose level should never be the only factor considered when calculating insulin dosing. Food intake and recent or expected activity/exercise must be factored in.
A child has been prescribed desmopressin acetate for the treatment of diabetes insipidus. The client and the parents ask the nurse how this drug works. What is the correct response by the nurse? A. Desmopressin acetate is a synthetic antidiuretic hormone that will slow down your urine output. B.Desmopressin acetate is a synthetic form of insulin used to lower your blood sugar. C. Desmopressin acetate works on your pancreas to stimulate insulin production. D. Desmopressin acetate works to help your kidneys work more efficiently.
A. Desmopressin acetate is a synthetic antidiuretic hormone that will slow down your urine output. Desmopressin acetate is a synthetic antidiuretic hormone that promotes reabsorption of water by action on renal tubules; it is used to control diabetes insipidus by decreasing the amount of urine produced.
Prior to discharging an infant with congenital hypothyroidism to home with the parents, what should the nurse emphasize regarding the care that this child will need going forward? A. Vitamin K administration until school age B. Administration of levothyroxine indefinitely C. An increased intake of calcium beginning immediately D. Administration of vitamin C until after growth is complete
B. Administration of levothyroxine indefinitely The treatment for hypothyroidism is oral administration of synthetic thyroid hormone or sodium levothyroxine. A small dose is given at first, and then the dose is gradually increased to therapeutic levels. The child needs to continue taking the synthetic thyroid hormone indefinitely to supplement that which the thyroid does not make. Vitamin K is not needed. Supplemental vitamin D, and not calcium, may be given to prevent the development of rickets when rapid bone growth begins. Supplemental vitamin C is not indicated for this disorder.
The nurse is caring for a 10-year-old child with growth hormone (GH) deficiency. Which therapy would you anticipate will be prescribed for the child? A. Oral administration of somatotropin B. Long-term blocking of beta cells C. Short-term aldosterone provocation D. injections of GH
D. injections of GH Growth hormone (GH) deficiency occurs when the anterior pituitary is unable to produce enough hormone for usual growth. Somatotropin is the name of the growth hormone administered. Administering subcutaneous GH to the child helps correct this deficiency. The GH dosage is 0.2 to 0.3 mg/kg given daily. It is not administered orally. Aldosterone causes sodium to be retained and a provocation would be the administration of diuretics to reduce the sodium. Beta cells are found in the heart muscles, smooth muscles, airways, and arteries. They are also found in the pancreas to secrete insulin. None of these cell actions are related to the anterior pituitary.
The nurse has told the 14-year-old adolescent with diabetes that the doctor would like to have a hemoglobin A1C test performed. Which comment by the client indicates that she understands what this test is for? A. "The normal level for my hemoglobin A1C is between 60 to 100 mg/dl." B. "This will tell my doctor what my average blood glucose level has been over the last 2 to 3 months." C. "That is the test that I take after I have fasted for at least 8 hours." D. "I monitor my own blood glucose every day at home. I don't see why the doctor would want this done."
B. "This will tell my doctor what my average blood glucose level has been over the last 2 to 3 months." Hemoglobin A1C (HgbA1C) provides the physician or nurse practitioner with information regarding the long-term control of glucose levels, as it provides an average of what the blood glucose levels are over a 2 to 3 month period. No fasting is required. Desired levels for children and adolescents 13 to 19 years are less than 7.5%.
The nurse is taking a history on a 10-year-old child who has a diagnosis of hypopituitarism. Which question is important for the nurse to ask the parents? A. "How often do you test your child's blood glucose?" B. "What time each day does your child take his growth hormone?" C. "Does your child get upset about being taller than friends?" D. "Is your child taking vasopressin IM or SC?"
B. "What time each day does your child take his growth hormone?" It is important for the nurse to know the time of day that the child takes his or her growth hormone. Growth hormone is the common treatment for the child with hypopituitarism who is short, not tall, in stature. Vasopressin is the treatment for diabetes insipidus. Monitoring blood glucose is not part of the treatment for hypopituitarism.
A child and parents are being seen in the office after discharge from the hospital. The child was newly diagnosed with type 2 diabetes. When talking with the child and parents, which statement by the nurse would be most appropriate? A. "A weight-loss program should be implemented and maintained." B. "Young people can usually be managed with an oral agent, meal planning, and exercise." C. "You are lucky that you did not have to learn how to give yourself a shot." D. "This will rectify itself if you follow all of the doctor's directions."
B. "Young people can usually be managed with an oral agent, meal planning, and exercise." Treating type 2 diabetes in children may require insulin at the outset if the child is acidotic and acutely ill. More commonly, the child can be managed initially with oral agents, meal planning, and increasing activity. Telling the child that she is lucky she did not have to learn how to give a shot might scare her, so it will inhibit her from seeking future health care. Additionally, insulin may be used if good control is not achieved. The condition will not rectify itself if all orders are followed. A weight-loss program might need to be implemented but that is not always the case.
The nurse is assessing a child diagnosed with Cushing disease. Which statement by the parents demonstrates a need for further teaching? A. "We need to pay close attention to any wounds our child gets to monitor for adequate healing." B. "My child may experience excessive hair growth and rapid weight gain." C. "My child's round, full face appearance is reversible with appropriate treatment." D. "This disorder is most likely due to an infection my child had recently."
D. "This disorder is most likely due to an infection my child had recently." A round, full face (moon face), rapid weight gain, excessive hair growth and poor wound healing are all seen in Cushing disease. Cushingoid appearance is reversible with appropriate treatment. The most common cause of Cushing disease is long-term corticosteroid therapy or a pituitary adenoma, not an infection.
A 6-year-old boy has a moon-face, stocky appearance but with thin arms and legs. His cheeks are unusually ruddy. He is diagnosed with Cushing syndrome. What is the most likely cause of this condition in this child? A. tumor of the parathyroid B. tumor of the pancreas C. tumor of the thyroid D. tumor of the adrenal cortex
D. tumor of the adrenal cortex Cushing syndrome is caused by overproduction of the adrenal hormone cortisol; this usually results from increased ACTH production due to either a pituitary or adrenal cortex tumor. The peak age of occurrence is 6 or 7 years. The overproduction of cortisol results in increased glucose production; this causes fat to accumulate on the cheeks, chin, and trunk, causing a moon-faced, stocky appearance. Cortisol is catabolic, so protein wasting also occurs. This leads to muscle wasting, making the extremities appear thin in contrast to the trunk, and loss of calcium in bones (osteoporosis). Other effects include hyperpigmentation (the child's face is unusually red, especially the cheeks).
The nurse measures the client's blood glucose level prior to breakfast. The measurement obtained is 130 mg/dl. The orders read to administer 2 units of Humalog insulin for a blood glucose of 100 to 150 mg/dl. How soon should the nurse ensure that the client eats breakfast after receiving insulin? A. within 5 minutes B. within 60-90 minutes C. within 2 hours D. within 15-30 minutes
D. within 15-30 minutes Humalog is a rapid-acting insulin. The onset of Humalog insulin is within 15 minutes and the peak level is achieved within 30 to 90 minutes; therefore, the client should eat within 15 to 30 minutes to avoid a hypoglycemic reaction.
A 10-year-old child has been diagnosed with type 1 diabetes. The child is curious about the cause of the disease and asks the nurse to explain it. Which explanation will the nurse provide? A. "Special cells in a part of your body called the pancreas cannot make a chemical called insulin, which helps control the sugar level in your blood." B. "The pancreas inside your belly makes enough chemical called insulin, but your body does not want to use it to keep your blood sugar level normal." C. "The alpha and beta cells in your pancreas are fighting against each other; that is why your blood sugar stays high and you need insulin injection." D. "The part of your body called the pancreas is broken and produces too much chemical called glucagon, which makes you really thirsty and have to go to the bathroom a lot."
A. "Special cells in a part of your body called the pancreas cannot make a chemical called insulin, which helps control the sugar level in your blood." When providing instruction to a child, the nurse must consider the developmental age. Type 1 diabetes is a disorder that involves an absolute or relative deficiency of insulin, thus the blood glucose level remains high if an appropriate amount of insulin is not administered to the client. With type 2 diabetes, the body produces an adequate amount of insulin; however, the body is resistant to using the insulin properly to keep circulating blood glucose levels at a normal level. The rest of the statements provide incorrect information regarding the pathophysiology of type 1 diabetes.
The nurse is speaking with the parents of a child recently diagnosed with hypothyroidism. Which statement by a parent indicates an understanding of symptoms of this disorder? A. "When they get my son's thyroid levels normal, he won't be so tired." B. "Heat intolerance is a caused by low thyroid levels." C. "Most people with hypothyroidism have smooth, velvety skin." D. "My son's nervousness may be a symptom of his hypothyroidism."
A. "When they get my son's thyroid levels normal, he won't be so tired." Tiredness, fatigue, constipation, cold intolerance and weight gain are all symptoms of hypothyroidism. Nervousness, anxiety, heat intolerance, weight loss and smooth velvety skin are all symptoms of hyperthyroidism.
The nurse knows that disorders of the pituitary gland depend on the location of the physiologic abnormality. Caring for a child who has issues with the anterior pituitary, the nurse would expect the child to have issues with which hormone? A. GH B. oxytocin C. ADH D. Vasopressin
A. GH Disorders of the pituitary gland depend on the location of the physiologic abnormality. The anterior pituitary, or adenohypophysis, is made up of endocrine glandular tissue and secretes growth hormone (GH), adrenocorticotropic hormone (ACTH), TSH, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin. The posterior lobe is called the neurohypophysis because it is formed of neural tissue. It secretes antidiuretic hormone (ADH; vasopressin) and oxytocin. Usually, several target organs are affected when there is a disorder of the pituitary gland, especially the adenohypophysis.
Which nursing objective is most important when working with neonates who are suspected of having congenital hypothyroidism? A. early identification B. promote bonding C. allowing rooming in D. encouraging fluid intake
A. early identification The most important nursing objective is early identification of the disorder. Nurses caring for neonates must be certain that screening is performed, especially in neonates who are preterm, discharged early, or born at home. Promoting bonding, allowing rooming-in, and encouraging fluid intake are all important but are less important than early identification.
The nurse is assessing a 1-month-old girl who, according to the mother, doesn't eat well. Which assessment suggests the child has congenital hypothyroidism? A. enlarged tongue B. tachycardia C. warm, moist skin D. frequent diarrhea
A. enlarged tongue Observation of an enlarged tongue along with an enlarged posterior fontanel (fontanelle) and feeding difficulties are key findings for congenital hypothyroidism. The mother would report constipation rather than diarrhea. Auscultation would reveal bradycardia rather than tachycardia, and palpation would reveal cool, dry, and scaly skin.
The nurse working on a pediatric floor understands the importance of diagnosing inborn errors of metabolism early. A child with a suspected problem must have blood urea nitrogen (BUN) and creatinine testing done. Which is the purpose of these two tests? A. evaluate renal function B. detect changes in amino acid patterns C. evaluate metabolism D. evaluate liver function
A. evaluate renal function Tests of BUN and creatinine evaluate renal function. These tests are done to rule out chronic renal failure and to monitor the effects of treatments on the renal system. Tests of ammonia and lactic acid evaluate metabolism. Tests of plasma amino acids detect changes in amino acid pattern, while a liver function panel would help evaluate hepatic function.
The nurse is preparing teaching materials for a family whose child is prescribed somatropin for a growth hormone deficiency. What should the nurse instruct the parents about the administration of this medication? A. this medication must be given by injection B. this medication must be given in the morning before school C. this medication does not interact with any other types of medication D. hip or knee pain is an expected adverse effect of this medication
A. this medication must be given by injection Somatropin is administered by injection. It is best given at the hour of sleep because that is when growth hormone is released. Hip or knee pain could indicate a slipped capital epiphysis and should be reported to the health care provider. The nurse should urge the parents to inform all health care providers that the child is receiving this medication to avoid medication interactions.
Diabetes insipidus is a disorder of the posterior pituitary that results in deficient secretion of which hormone? A. TSH B. ADH C. LH D. ACTH
B. ADH Central diabetes insipidus (DI) is a disorder of the posterior pituitary that results from deficient secretion of ADH. ADH is responsible for the concentration of urine in the renal tubules. Without ADH there is a massive amount of water loss and an increase in serum sodium. Nephrogenic DI occurs as a genetic problem or from end-stage renal disease. It is the result of the inability of the kidney to respond to ADH and not from a pituitary gland problem. LH is produced from the anterior pituitary. In females, it stimulates ovulation and the development of the corpus luteum. TSH is secreted by the thyroid gland. ACTH is secreted by the anterior pituitary.
An infant on the pediatric floor has diabetes insipidus. Which assessment data are important for the nurse to monitor while the infant is on strict fluid precautions? A. Temperature and heart rate B. urine output C. color of mucous membranes D. oral intake
B. urine output An infant with diabetes insipidus has a decrease in antidiuretic hormone. Strict fluid precautions will not alter urine formation. This assessment is important because the infant will be at great risk for dehydration and electrolyte imbalance. It is part of a basic assessment to monitor heart rate, temperature, skin turgor, and mucous membranes. These are important but may not indicate the infant's overall health. On fluid restriction, oral intake will be specified.
A newborn was diagnosed as having hypothyroidism at birth. The parent asks the nurse how the disease could be discovered this early. Which is the nurse's best answer? A. The newborn is already severely impaired at birth, and this suggests the diagnosis. B. Hypothyroidism is usually detected at birth by the newborn's physical appearance. C. A simple blood test to diagnose hypothyroidism is required in most states. D. A newborn has a typical rash at birth that suggests the diagnosis.
C. A simple blood test to diagnose hypothyroidism is required in most states. With hypothyroidism there is insufficient production of the thyroid hormones required to meet the body's metabolic as well as growth and developmental needs. Without these hormones, cognitive impairment occurs. Hypothyroidism is diagnosed by a newborn screening procedure. This screening procedure is required by most states. With early diagnosis the condition can be treated by replacing the missing hormones. The later the diagnosis is made, the more irreversible cognitive impairment becomes. At birth, a newborn with hypothyroidism will be a poor feeder. Other symptoms, such as lethargy and hypotonicity, become evident after the first month of life. There are no other outward manifestations, such as rashes or appearances, that can be seen. These are not part of the condition.
The nurse is examining a child with hypoparathyroidism. The nurse would expect to assess which signs and symptoms? Select all that apply. A. capillary refill B. polyphagia C. Chvostek sign D. Trousseau sign E. Babinski sign
C. Chvostek sign D. Trousseau sign
Insulin deficiency, in association with increased levels of counter-regulatory hormones and dehydration, is the primary cause of: A. ketonuria B. glucosuria C. diabetic ketoacidosis D. ketone bodies
C. diabetic ketoacidosis Insulin deficiency, in association with increased levels of counter-regulatory hormones (glucagon, growth hormone, cortisol, catecholamines) and dehydration, is the primary cause of diabetic ketoacidosis (DKA), a life-threatening form of metabolic acidosis that is a frequent complication of diabetes. Liver converts triglycerides (lipolysis) to fatty acids, which in turn change to ketone bodies. The accumulation and excretion of ketone bodies by the kidneys is called ketonuria. Glucosuria is glucose that is spilled into the urine.
The nurse is teaching a group of caregivers of children diagnosed with diabetes. The nurse is explaining insulin shock and the caregivers make the following statements. Which statement indicates the best understanding of a reason an insulin reaction might occur? A. "On the weekends we encourage our child to participate in lots of sports activities and stay busy so they don't have an insulin reaction." B. "My child monitors their glucose levels to keep them from going too high." C. "If my child eats as much as their older brother eats they could have an insulin reaction." D. "My child measures their own medication but sometimes doesn't administer the correct amount."
D. "My child measures their own medication but sometimes doesn't administer the correct amount." Insulin reaction (insulin shock, hypoglycemia) is caused by insulin overload, resulting in too-rapid metabolism of the body's glucose. This may be attributable to a change in the body's requirement, carelessness in diet (such as failure to eat proper amounts of food), an error in insulin measurement, or excessive exercise.
A 12-year-old child has hyperthyroidism. The nurse understands that the most common cause of hyperthyroidism in children is: A. Plummer disease B. Addison disease C. Cushing disease D. Graves disease
D. Graves disease Hyperthyroidism occurs less often in children than hypothyroidism. Graves disease is the most common cause of hyperthyroidism in children. Hyperthyroidism occurs more often in females, and the peak incidence occurs during adolescence. Addison disease refers to chronic adrenocortical insufficiency. Cushing syndrome results from excessive levels of circulating cortisol. Plummer disease is a less common cause of hyperthyroidism.
The nurse is preparing a child suspected of having a thyroid disorder for a thyroid scan. What information regarding the child should the nurse alert the doctor or nuclear medicine department about? A. The child is taking a vitamin supplement. B. The child wears a medical alert bracelet for diabetes. C. The child has had an MRI of their leg within the past 6 weeks. D. The child is allergic to shellfish.
D. The child is allergic to shellfish. Allergies to shellfish should be reported because shellfish contains iodine; the dye used for a nuclear medicine scan is iodine based and could cause an anaphylactic reaction. The other information about the child would not need to be reported to the staff.
In a child with diabetes insipidus, which characteristic would most likely be present in the child's health history? A. vomiting early in the morning, headache, and decreased thirst B. delayed closure of the fontanels (fontanelles), coarse hair, and hypoglycemia in the morning C. gradual onset of personality changes, lethargy, and blurred vision D. abrupt onset of polyuria, nocturia, and polydipsia
D. abrupt onset of polyuria, nocturia, and polydipsia Diabetes insipidus is characterized by deficient secretion of antidiuretic hormone leading to diuresis. Most children with this disorder experience an abrupt onset of symptoms, including polyuria, nocturia, and polydipsia. The other choices reflect symptoms of pituitary hyperfunction.
An 8-year-old girl presents to the clinic for moodiness and irritability. The child has begun to develop breasts and pubic hair and the parents are concerned that the child is at too early an age for this to begin. The nurse knows that these symptoms may be indicative of what disorder? A. adrenal hyperplasia B. neurofibromatosis C. pseudopuberty D. precocious puberty
D. precocious puberty Precocious puberty occurs when the child's sexual characteristics begin to develop before the normal age of puberty. Appropriate treatment can halt, and sometimes even reverse, sexual development and can stop the rapid growth that results in severe short adult stature caused by premature closure of the epiphysis. Treatment for precocious puberty allows the child to achieve the maximum growth potential possible. Mental development in children with precocious puberty is normal, and developmental milestones are not affected. The behavior may change to that of a typical adolescent. Girls may have episodes of moodiness and irritability, whereas boys may become more aggressive. Pseudopuberty occurs when there is only partial development after testosterone is secreted. It occurs in males. Adrenal hyperplasia is an inherited disorder and it affects the production of androgen. Neurofibromatosis is a genetic disorder of the nervous system where tumors grow on the nerves.