Saunders: Endocrine | Unit X (Chapter 54 & 55)

571. A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription? 1. Endotracheal intubation 2. 100 units of NPH insulin 3. Intravenous infusion of normal saline 4. Intravenous infusion of sodium bicarbonate

571. 3 Rationale: The primary goal of treatment in hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHNS. Test-Taking Strategy: Focus on the subject, treatment of HHNS, and note the strategic word, immediately. If you can recall the treatment for DKA, you will be able to answer this question easily. Treatment for HHNS is similar to the treatment for DKA and begins with rehydration. Review: Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Adult Health—Endocrine Priority Concepts: Clinical Judgment; Glucose Regulation Reference: Ignatavicius, Workman (2013), p. 1458.

572. An external insulin pump is prescribed for a client with diabetes mellitus and the client asks the nurse about the functioning of the pump. The nurse bases the response on which information about the pump? 1. Is timed to release programmed doses of short-duration or NPH insulin into the bloodstream at specific intervals 2. Continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels 3. Is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream 4. Gives a small continuous dose of short-duration insulin subcutaneously, and the client can self-administer a bolus with an additional dose from the pump before each meal

572. 4 Rationale: An insulin pump provides a small continuous dose of short-duration (rapid or short-acting) insulin subcutaneously throughout the day and night, and the client can self-administer a bolus with an additional dose from the pump before each meal as needed. Short-duration insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas. Test-Taking Strategy: Focus on the subject, use of an insulin pump. Recalling that short-duration insulin is used in an insulin pump will assist in eliminating options 1 and 2. Noting the word external in the question will assist in eliminating option 3. Review: Insulin pumps and insulin therapy Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health—Endocrine Priority Concepts: Client Education; Glucose Regulation Reference: Lewis et al (2011), pp. 1227-1228, 1234.

573. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings would the nurse expect to note as confirming this diagnosis? Select all that apply. 1. Increase in pH 2. Comatose state 3. Deep, rapid breathing 4. Decreased urine output 5. Elevated blood glucose level 6. Low plasma bicarbonate level

573. 3, 5, 6 Rationale: In DKA, the arterial pH is lower than 7.35, plasma bicarbonate is lower than 15 mEq/L, the blood glucose level is higher than 250 mg/dL, and ketones are present in the blood and urine. The client would be experiencing polyuria, and Kussmaul's respirations (deep and rapid breathing pattern) would be present. A comatose state may occur if DKA is not treated, but coma would not confirm the diagnosis. Test-Taking Strategy: Focus on the subject, findings associated with DKA. Eliminate option 1 because in acidosis the pH would be low. Next, eliminate option 2 because a comatose state can exist in many conditions. Remember that in acidosis the pH is low as is the plasma bicarbonate and that the client exhibits Kussmaul's respirations and experiences polyuria. Review: Diabetic ketoacidosis (DKA) Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Adult Health—Endocrine Priority Concepts: Clinical Judgment; Glucose Regulation References: Lewis et al (2011), p. 1244; Swearingen (2012), pp. 358-359, 365.

574. The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply. 1. Polyuria 2. Shakiness 3. Palpitations 4. Blurred vision 5. Lightheadedness 6. Fruity breath odor

574. 2, 3, 5 Rationale: Shakiness, palpitations, and lightheadedness are signs of hypoglycemia and would indicate the need for food or glucose. Polyuria, blurred vision, and a fruity breath odor are signs of hyperglycemia. Test-Taking Strategy: Focus on the subject, the treatment of hypoglycemia. Think about its pathophysiology and the manifestations that occur. Recalling the signs of hypoglycemia will direct you to the correct option. Review: Signs of hypoglycemia Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process—Evaluation Content Area: Adult Health—Endocrine Priority Concepts: Client Education; Glucose Regulation Reference: Ignatavicius, Workman (2013), pp. 1451-1452.

575. A client with diabetes mellitus demonstrates acute anxiety when first admitted to the hospital for the treatment of hyperglycemia. What is the most appropriate intervention to decrease the client's anxiety? 1. Administer a sedative. 2. Convey empathy, trust, and respect toward the client. 3. Ignore the signs and symptoms of anxiety so that they will soon disappear. 4. Make sure that the client knows all the correct medical terms to understand what is happening.

575. 2 Rationale: The appropriate intervention is to address the client's feelings related to the anxiety. Administering a sedative is not the most appropriate intervention. The nurse should not ignore the client's anxious feelings. A client will not relate to medical terms, particularly when anxiety exists. Test-Taking Strategy: Note the strategic words most appropriate. Use therapeutic communication techniques to answer the question. Remember that the client's feelings are the priority. Keeping this in mind will direct you easily to the correct option. Review: Therapeutic communication techniques Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Adult Health—Endocrine Priority Concepts: Caregiving; Professionalism References: Ignatavicius, Workman (2013), pp. 1460-1461; Potter et al (2013), pp. 320-322.

576. The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? 1. "I will stop taking my insulin if I'm too sick to eat." 2. "I will decrease my insulin dose during times of illness." 3. "I will adjust my insulin dose according to the level of glucose in my urine." 4. "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL."

576. 4 Rationale: During illness, the client should monitor blood glucose levels and should notify the HCP if the level is higher than 250 mg/dL. Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the HCP's advice and are usually adjusted on the basis of blood glucose levels, not urinary glucose readings. Test-Taking Strategy: Use general medication guidelines to answer the question. Note that options 1, 2, and 3 are comparable or alike and all relate to adjustment of insulin doses. Review: Sick day rules for diabetic management Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process—Evaluation Content Area: Adult Health—Endocrine Priority Concepts: Client Education; Glucose Regulation Reference: Ignatavicius, Workman (2013), p. 1456.

577. A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level was 950 mg/dL. A continuous intravenous infusion of short-acting insulin is initiated, along with intravenous rehydration with normal saline. The serum glucose level is now 240 mg/dL. The nurse would next prepare to administer which item? 1. Ampule of 50% dextrose 2. NPH insulin subcutaneously 3. Intravenous fluids containing dextrose 4. Phenytoin (Dilantin) for the prevention of seizures

577. 3 Rationale: During management of DKA, when the blood glucose level falls to 250 to 300 mg/dL, the infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL, or until the client recovers from ketosis. Fifty percent dextrose is used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin (Dilantin) is not a usual treatment measure for DKA. Test-Taking Strategy: Note the strategic word, next. Focus on the subject, management of DKA. Eliminate option 2 first, knowing that short-duration (rapid-acting) insulin is used in the management of DKA. Eliminate option 1 next, knowing that this is the treatment for hypoglycemia. Note the words the serum glucose level is now 240 mg/dL. This should indicate that the IV solution containing dextrose is the next step in the management of care. Review: Diabetic ketoacidosis (DKA) Level of Cognitive Ability: Synthesizing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Adult Health—Endocrine Priority Concepts: Clinical Judgment: Glucose Regulation Reference: Ignatavicius, Workman (2013), p. 1455.

578. The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign, if exhibited in the client, would indicate hyperglycemia? 1. Polyuria 2. Diaphoresis 3. Hypertension 4. Increased pulse rate

578. 1 Rationale: Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in hypoglycemia. Options 2, 3, and 4 are not signs of hyperglycemia. Test-Taking Strategy: Focus on the subject, signs and symptoms of hyperglycemia. Remember the three P's associated with hyperglycemia—polyuria, polydipsia, polyphagia. Review: Signs of hyperglycemia Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Adult Health—Endocrine Priority Concepts: Clinical Judgment; Glucose Regulation Reference: Ignatavicius, Workman (2013), pp. 1412-1413.

579. The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places highest priority on which client problem? 1. Lack of knowledge 2. Inadequate fluid volume 3. Compromised family coping 4. Inadequate consumption of nutrients

579. 2 Rationale: An increased blood glucose level will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Options 1, 3, and 4 are not related specifically to the subject of the question. Test-Taking Strategy: Note the strategic words highest priority. Use Maslow's Hierarchy of Needs theory. The correct option indicates a physiological need and is the priority. Options 1, 3, and 4 are problems that may need to be addressed after providing for the high-priority physiological needs. Review: Hyperglycemia Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Adult Health—Endocrine Priority Concepts: Clinical Judgment; Glucose Regulation References: Ignatavicius, Workman (2013), p. 1412; Lewis et al (2011), pp. 1242-1243.

580. The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? 1. "I need to stop my insulin." 2. "I need to increase my fluid intake." 3. "I need to monitor my blood glucose every 3 to 4 hours." 4. "I need to call the health care provider (HCP) because of these symptoms."

580. 1 Rationale: When a client with diabetes mellitus is unable to eat normally because of illness, the client still should take the prescribed insulin or oral medication. The client should consume additional fluids and should notify the HCP. The client should monitor the blood glucose level every 3 to 4 hours. The client should also monitor the urine for ketones. Test-Taking Strategy: Note the strategic words need for further teaching. These words indicate a negative event query and the need to select the incorrect statement. Remembering that the client needs to take insulin will direct you easily to the correct option. Review: Sick day guidelines Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health—Endocrine Priority Concepts: Client Education; Glucose Regulation Reference: Ignatavicius, Workman (2013), p. 1456.

581. The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? 1. Lower the head of the bed. 2. Test the drainage for glucose. 3. Obtain a culture of the drainage. 4. Continue to observe the drainage.

581. 2 Rationale: After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid leak. If this occurs, the drainage should be collected and tested for the presence of cerebrospinal fluid. The head of the bed should not be lowered to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication. Test-Taking Strategy: Note the strategic word initial. This indicates that an action is required. Option 1 can be eliminated first by recalling that this action can increase intracranial pressure. Option 3 can be eliminated also, because the drainage is clear. Because an action is required, eliminate option 4. Review: Complications following hypophysectomy Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Adult Health—Endocrine Priority Concepts: Clinical Judgment; Intracranial Regulation Reference: Ignatavicius, Workman (2013), p. 1377.

582. After several diagnostic tests, a client is diagnosed with diabetes insipidus. The nurse performs an assessment on the client, knowing that which symptom is most indicative of this disorder? 1. Fatigue 2. Diarrhea 3. Polydipsia 4. Weight gain

582. 3 Rationale: Diabetes insipidus is characterized by hyposecretion of antidiuretic hormone, and the kidney tubules fail to reabsorb water. Polydipsia and polyuria are classic symptoms of diabetes insipidus. The urine is pale, and the specific gravity is low. Anorexia and weight loss occur. Option 1 is a vague symptom. Options 2 and 4 are not specific to this disorder. Test-Taking Strategy: Note the strategic word most. Eliminate option 1 first because this symptom is rather vague and occurs in many conditions. Knowledge of the pathophysiology and manifestations of diabetes insipidus will assist you in eliminating options 2 and 4. Review: Diabetes insipidus Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Adult Health—Endocrine Priority Concepts: Clinical Judgment; Fluid and Electrolyte Balance Reference: Swearingen (2012), p. 345.

583. A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action would the nurse prepare to carry out initially? 1. Warm the client. 2. Maintain a patent airway. 3. Administer thyroid hormone. 4. Administer fluid replacement

583. 2 Rationale: The initial nursing action would be to maintain a patent airway. Oxygen would be administered, followed by fluid replacement, keeping the client warm, monitoring vital signs, and administering thyroid hormones by the intravenous route. Test-Taking Strategy: Note the strategic word initially. All the options are appropriate interventions, but use the ABCs—airway, breathing, and circulation—in selecting the correct option. Review: Myxedema coma Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Adult Health—Endocrine Priority Concepts: Clinical Judgment; Gas Exchange Reference: Ignatavicius, Workman (2013), p. 1404.

584. The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention? 1. Correct the acidosis. 2. Administer 5% dextrose intravenously. 3. Apply a monitor for an electrocardiogram. 4. Administer short-duration insulin intravenously.

584. 4 Rationale: Lack (absolute or relative) of insulin is the primary cause of DKA. Treatment consists of insulin administration (short or rapid-acting), intravenous fluid administration (normal saline initially), and potassium replacement, followed by correcting acidosis. Applying an electrocardiogram monitor is not the priority action. Test-Taking Strategy: Focus on the client's diagnosis. Note the strategic word priority. Remember that in DKA, the initial treatment is short or rapid-acting insulin. Normal saline is administered initially; therefore, option 2 is incorrect. Options 1 and 3 may be components of the treatment plan but are not the priority. Review: Diabetic ketoacidosis Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Adult Health—Endocrine Priority Concepts: Clinical Judgment; Glucose Regulation Reference: Ignatavicius, Workman (2013), p. 1455

585. A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an inadequate understanding of the peak action of NPH insulin and exercise? 1. "The best time for me to exercise is after I eat." 2. "The best time for me to exercise is after breakfast." 3. "The best time for me to exercise is mid- to late afternoon." 4. "The best time for me to exercise is after my morning snack."

585. 3 Rationale: A hypoglycemic reaction may occur in response to increased exercise. Clients should avoid exercise during the peak time of insulin. NPH insulin peaks at 4 to 12 hours; therefore, afternoon exercise takes place during the peak of the medication. Options 1, 2, and 4 do not address peak action times. Test-Taking Strategy: Note the words inadequate understanding. Focus on the subject, peak action of NPH insulin. Recalling that NPH insulin peaks at 4 to 12 hours will direct you to the correct option. Review: Peak action of NPH insulin Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health—Endocrine Priority Concepts: Client Education; Glucose Regulation References: Ignatavicius, Workman (2013), pp. 1441-1442; Kee, Hayes, McCuistion (2012), p. 785.

586. The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? 1. Diarrhea 2. Polyuria 3. Polyphagia 4. Weight gain

586. 2 Rationale: Hypercalcemia is the hallmark of hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis and thus polyuria. This diuresis leads to dehydration (weight loss rather than weight gain). Options 1, 3, and 4 are not associated with hyperparathyroidism. Some gastrointestinal symptoms include anorexia, nausea, vomiting, and constipation. Test-Taking Strategy: Focus on the subject, an assessment finding. Think about the pathophysiology associated with hyperparathyroidism. Remember that hypercalcemia is associated with this disorder and that hypercalcemia leads to diuresis. Review: Hyperparathyroidism Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Adult Health—Endocrine Priority Concepts: Clinical Judgment; Fluid and Electrolyte Balance Reference: Ignatavicius, Workman (2013), p. 1406.

587. The nurse is caring for a postoperative parathyroidectomy client. Which client complaint would indicate that a life-threatening complication may be developing, requiring notification of the health care provider immediately? 1. Laryngeal stridor 2. Abdominal cramps 3. Difficulty in voiding 4. Mild to moderate incisional pain

587. 1 Rationale: During the postoperative period, the nurse carefully observes the client for signs of hemorrhage, which causes swelling and compression of adjacent tissue. Laryngeal stridor is a harsh, high-pitched sound heard on inspiration and expiration; stridor is caused by compression of the trachea, leading to respiratory distress. Stridor is an acute emergency situation that requires immediate attention to avoid complete obstruction of the airway. Options 2, 3, and 4 do not identify signs of a life-threatening complication. Test-Taking Strategy: Consider the anatomical location of the surgical procedure and use the ABCs—airway, breathing, and circulation—to select the correct option. Also note the strategic word immediately. Options 2, 3, and 4 are postoperative findings that can occur but are not life-threatening. The correct option addresses the airway. Review: Parathyroidectomy Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Adult Health—Endocrine Priority Concepts: Clinical Judgment; Gas Exchange Reference: Ignatavicius, Workman (2013), pp. 1399, 1407.

588. A client is diagnosed with pheochromocytoma. The nurse understands that pheochromocytoma is a condition that has which characteristic? 1. Causes profound hypotension 2. Is manifested by severe hypoglycemia 3. Is not curable and is treated symptomatically 4. Causes the release of excessive amounts of catecholamines

588. 4 Rationale: Pheochromocytoma is a catecholamine-producing tumor and causes secretion of excessive amounts of epinephrine and norepinephrine. Hypertension is the principal manifestation, and the client has episodes of high blood pressure accompanied by pounding headaches. The excessive release of catecholamine also results in excessive conversion of glycogen into glucose in the liver. Consequently, hyperglycemia and glucosuria occur during attacks. Pheochromocytoma is curable. The primary treatment is surgical removal of one or both of the adrenal glands, depending on whether the tumor is unilateral or bilateral. Test-Taking Strategy: Focus on the subject, the characteristics of pheochromocytoma. Recalling that pheochromocytoma is a catecholamine-producing tumor will assist in answering correctly. Review: Pheochromocytoma Level of Cognitive Ability: Understanding Client Needs: Physiological Integrity Integrated Process: Nursing Process—Planning Content Area: Adult Health—Endocrine Priority Concepts: Clinical Judgment; Intracranial Regulation Reference: Lewis et al (2011), p. 1284.

589. The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which client complaint(s) would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply. 1. Tremors 2. Anorexia 3. Irritability 4. Nervousness 5. Hot, dry skin 6. Muscle cramps

589. 1, 3, 4 Rationale: Decreased blood glucose levels produce autonomic nervous system symptoms, which are manifested classically as nervousness, irritability, and tremors. Option 5 is more likely to occur with hyperglycemia. Options 2 and 6 are unrelated to the signs of hypoglycemia. In hypoglycemia, usually the client feels hunger. Test-Taking Strategy: Focus on the subject, a hypoglycemic reaction. Think about the manifestations that occur when the blood glucose is low. Recalling the signs of this type of reaction will direct you easily to the correct options. Review: Signs of hypoglycemia Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Adult Health—Endocrine Priority Concepts: Clinical Judgment; Glucose Regulation Reference: Ignatavicius, Workman (2013), p. 1452.

590. The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? 1. A coagulation time of 5 minutes 2. A urinary output of 50 mL/hour 3. A blood urea nitrogen level of 20 mg/dL 4. A heart rate that is 90 beats/minute and irregular

590. 4 Rationale: The complications associated with pheochromocytoma include hypertensive retinopathy and nephropathy, myocarditis, increased platelet aggregation, and stroke. Death can occur from shock, stroke, kidney failure, dysrhythmias, or dissecting aortic aneurysm. An irregular heart rate indicates the presence of a dysrhythmia. A coagulation time of 5 minutes is normal. A urinary output of 50 mL/hour is an adequate output. A blood urea nitrogen level of 20 mg/dL is a normal finding. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation. An irregular heart rate is associated with circulation. In addition, if you knew the normal hourly expectations associated with urinary output and the normal laboratory values for coagulation time and blood urea nitrogen level, you would be easily directed to the correct option. Review: Complications associated with pheochromocytoma Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Analysis Content Area: Adult Health—Endocrine Priority Concepts: Clinical Judgment; Intracranial Regulation Reference: Ignatavicius, Workman (2013), pp. 1390-1391.

591. The nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's disease. Which statement by the student indicates an accurate understanding of this disorder? 1. "Cushing's disease results from an oversecretion of insulin." 2. "Cushing's disease results from an undersecretion of corticotropic hormones." 3. "Cushing's disease results from an undersecretion of mineralocorticoid hormones." 4. "Cushing's disease results from an increased pituitary secretion of adrenocorticotropic hormone."

591. 4 Rationale: Cushing's disease is a metabolic disorder characterized by abnormally increased secretion (endogenous) of cortisol, caused by increased amounts of adrenocorticotropic hormone (ACTH) secreted by the pituitary gland. Addison's disease is characterized by the hyposecretion of adrenal cortex hormones (glucocorticoids and mineralocorticoids) from the adrenal gland, resulting in deficiency of the corticosteroid hormones. Options 1, 2, and 3 are inaccurate regarding Cushing's disease. Test-Taking Strategy: Focus on the subject, the pathophysiology of Cushing's disease. Options 2 and 3 can be eliminated easily if you remember that in Cushing's (up) disease there is an oversecretion and in Addison's disease (down) there is an undersecretion. Next, eliminate option 1 because this disease is unrelated to insulin. Review: Cushing's disease Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health—Endocrine Priority Concepts: Clinical Judgment; Fluid and Electrolyte Balance Reference: Lewis et al (2011), p. 1276

592. The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL, temperature of 101° F, pulse of 88 beats/minute, respirations of 22 breaths/minute, and blood pressure of 100/72 mm Hg. Which finding would be of most concern to the nurse? 1. Pulse 2. Respiration 3. Temperature 4. Blood pressure

592. 3 Rationale: An elevated temperature may indicate infection. Infection is a leading cause of hyperglycemic hyperosmolar nonketotic syndrome or diabetic ketoacidosis. The other findings noted in the question are within normal limits. Test-Taking Strategy: Note the strategic word most. Use knowledge of the normal values of vital signs to direct you to the correct option. The client's temperature is the only abnormal value. Remember that an elevated temperature can indicate an infectious process that can lead to complications in the client with diabetes mellitus. Review: Normal and abnormal findings for the client with diabetes mellitus Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Adult Health—Endocrine Priority Concepts: Glucose Regulation; Infection References: Ignatavicius, Workman (2013), p. 1455; Swearingen (2012), pp. 352-353.

593. The nurse is interviewing a client with type 2 diabetes mellitus. Which statement by the client indicates an understanding of the treatment for this disorder? 1. "I take oral insulin instead of shots." 2. "By taking these medications, I am able to eat more." 3. "When I become ill, I need to increase the number of pills I take." 4. "The medications I'm taking help release the insulin I already make."

593. 4 Rationale: Clients with type 2 diabetes mellitus have decreased or impaired insulin secretion. Oral hypoglycemic agents are given to these clients to facilitate glucose uptake. Insulin injections may be given during times of stress-induced hyperglycemia. Oral insulin is not available because of the breakdown of the insulin by digestion. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Focus on the subject, type 2 diabetes mellitus. Eliminate option 1 because oral insulin is not available. Treatment with medication does not mean that the client can eat more; therefore, eliminate option 2. Recalling that during times of illness insulin may be required will eliminate option 3. Review: Treatment measures for type 2 diabetes mellitus Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process—Evaluation Content Area: Adult Health—Endocrine Priority Concepts: Client Education; Glucose Regulation Reference: Lewis et al (2011), pp. 1235-1236

594. The nurse is providing discharge instructions to a client who has Cushing's syndrome. Which client statement indicates that instructions related to dietary management are understood? 1. "I will need to limit the amount of protein in my diet." 2. "I should eat foods that have a lot of potassium in them." 3. "I am fortunate that I can eat all the salty foods I enjoy." 4. "I am fortunate that I do not need to follow any special diet."

594. 2 Rationale: A diet low in carbohydrates and sodium but ample in protein and potassium is encouraged for a client with Cushing's syndrome. Such a diet promotes weight loss, reduction of edema and hypertension, control of hypokalemia, and rebuilding of wasted tissue. Test-Taking Strategy: Focus on the subject, dietary guidelines for Cushing's syndrome. Eliminate option 4 because it reflects that no dietary change is necessary. Eliminate option 1 next because protein most likely is limited in liver or renal disorders (not in Cushing's syndrome). From the remaining options, eliminate option 3 because excess sodium is not normally healthy. Review: Dietary management in Cushing's syndrome Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process—Evaluation Content Area: Adult Health—Endocrine Priority Concepts: Client Education; Nutrition Reference: Ignatavicius, Workman (2013), p. 1387.

595. The nurse is caring for a client who is 2 days postoperative following an abdominal hysterectomy. The client has a history of diabetes mellitus and has been receiving regular insulin according to capillary blood glucose testing four times a day. A carbohydrate-controlled diet has been prescribed but the client has been complaining of nausea and is not eating. On entering the client's room, the nurse finds the client to be confused and diaphoretic. Which action is most appropriate at this time? 1. Call a code to obtain needed assistance immediately. 2. Obtain a capillary blood glucose level and perform a focused assessment. 3. Ask the unlicensed assistive personnel (UAP) to stay with the client while obtaining 15 to 30 g of a carbohydrate snack for the client to eat. 4. Stay with the client and ask the UAP to call the health care provider (HCP) for a prescription for intravenous 50% dextrose.

595. 2 Rationale: Diaphoresis and confusion are signs of moderate hypoglycemia. A likely cause of the client's change in condition could be related to the administration of insulin without the client eating enough food. However, an assessment is necessary to confirm the presence of hypoglycemia. The nurse would obtain a capillary blood glucose level to confirm the hypoglycemia and perform a focused assessment to determine the extent and cause of the client's condition. Once hypoglycemia is confirmed, the nurse stays with the client and asks the unlicensed assistive personnel (UAP) to obtain the appropriate carbohydrate snack. A code is called if the client is not breathing or if the heart is not beating. Test-Taking Strategy: Focus on the data in the question and note the strategic words most appropriate. Eliminate option 1 because there are no data in the question indicating the need to call a code. Eliminate option 3 next because it is inappropriate to ask a UAP to call the HCP for a prescription. To select from the remaining options, use the steps of the nursing process, recalling that assessment is the first step. Review: Hypoglycemic reaction Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Adult Health—Endocrine Priority Concepts: Clinical Judgment; Glucose Regulation Reference: Swearingen (2012), p. 365.

596. The nurse is caring for a client with pheochromocytoma who is scheduled for adrenalectomy. In the preoperative period, what should the nurse monitor as the priority? 1. Vital signs 2. Intake and output 3. Blood urea nitrogen results 4. Urine for glucose and ketones

596. 1 Rationale: Pheochromocytoma is a catecholamine-producing tumor. Hypertension is the hallmark of pheochromocytoma. Severe hypertension can precipitate a stroke or sudden blindness. Although all the options are accurate nursing interventions for the client with pheochromocytoma, the priority nursing action is to monitor the vital signs, particularly the blood pressure. Test-Taking Strategy: Note the strategic word priority. Use the ABCs—airway, breathing, and circulation. Monitoring vital signs is the nursing action that would assess airway, breathing, and circulation. Also, options 2, 3, and 4 refer to the assessment of the renal system, whereas the correct option does not. Review: Preoperative care of the client with pheochromocytoma Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Adult Health—Endocrine Priority Concepts: Caregiving; Clinical Judgment Reference: Lewis et al (2011), p. 1284.

597. The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which symptoms are associated with this diagnosis? Select all that apply. 1. Tremors 2. Weight loss 3. Feeling cold 4. Loss of body hair 5. Persistent lethargy 6. Puffiness of the face

597. 3, 4, 5, 6 Rationale: Feeling cold, hair loss, lethargy, and facial puffiness are signs of hypothyroidism. Tremors and weight loss are signs of hyperthyroidism. Test-Taking Strategy: Focus on the subject, pathophysiology associated with hypothyroidism. Options 1 and 2 can be eliminated if you remember that in hypothyroidism there is an under-secretion of thyroid hormone that causes the metabolism to slow down. Review: Hypothyroidism Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process—Evaluation Content Area: Adult Health—Endocrine Priority Concepts: Client Education; Clinical Judgment Reference: Lewis et al (2011), p. 1264

598. A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? 1. Hypoglycemia 2. Level of hoarseness 3. Respiratory distress 4. Edema at the surgical site

598. 3 Rationale: Thyroidectomy is the removal of the thyroid gland, which is located in the anterior neck. It is very important to monitor airway status as any swelling to the surgical site could cause respiratory distress. Although all the options are important for the nurse to monitor, the priority nursing action is to monitor the airway. Test-Taking Strategy: Note the strategic word priority. Use the ABCs—airway, breathing, and circulation, to assist in directing you to the correct option. Review: Thyroidectomy Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Adult Health—Endocrine Priority Concepts: Clinical Judgment; Gas Exchange Reference: Lewis et al (2011), pp. 1268-1269

599. A client has been diagnosed with hyperthyroidism. Which signs and symptoms may indicate thyroid storm, a complication of this disorder? Select all that apply. 1. Fever 2. Nausea 3. Lethargy 4. Tremors 5. Confusion 6. Bradycardia

599. 1, 2, 4, 5 Rationale: Thyroid storm is an acute and life-threatening condition that occurs in a client with uncontrollable hyperthyroidism. Symptoms of thyroid storm include elevated temperature (fever), nausea, and tremors. In addition, as the condition progresses, the client becomes confused. The client is restless and anxious and experiences tachycardia. Test-Taking Strategy: Focus on the subject, signs and symptoms of thyroid storm. Options 3 and 6 can be eliminated if you remember that thyroid storm is caused by the release of thyroid hormones into the bloodstream, causing uncontrollable hyperthyroidism. Lethargy and bradycardia (think: slow down) are signs of hypothyroidism (slow metabolism). Review: Thyroid storm Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Adult Health—Endocrine Priority Concepts: Clinical Judgment; Caregiving Reference: Lewis et al (2011), p. 1265.

600. The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching? 1. Withdraws the NPH insulin first 2. Withdraws the regular insulin first 3. Injects air into NPH insulin vial first 4. Injects an amount of air equal to the desired dose of insulin into each vial

600. 1 Rationale: When preparing a mixture of short-acting insulin such as regular insulin with another insulin preparation, the short-acting insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of short-acting insulin with insulin of another type. Options 2, 3, and 4 identify correct actions for preparing NPH and short-acting insulin. Test-Taking Strategy: Note the strategic words need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect action. Remember RN—draw up the Regular (short-acting) insulin before the NPH insulin. Review: Preparation of NPH and short-acting insulin Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology—Endocrine Medications Priority Concepts: Client Education; Glucose Regulation Reference: Kee, Hayes, McCuistion (2012), pp. 78, 80-81.

601. The home care nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should tell the client to take which action? 1. Freeze the insulin. 2. Refrigerate the insulin. 3. Store the insulin in a dark, dry place. 4. Keep the insulin at room temperature.

601. 2 Rationale: Insulin in unopened vials should be stored under refrigeration until needed. Vials should not be frozen. When stored unopened under refrigeration, insulin can be used up to the expiration date on the vial. Options 1, 3, and 4 are incorrect. Test-Taking Strategy: Note the subject, how to store unopened vials. Options 3 and 4 are comparable or alike and should be eliminated. Remembering that insulin should not be frozen will assist in eliminating option 1. Review: Storage of insulin Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology—Endocrine Medications Priority Concepts: Client Education; Safety Reference: Kee, Hayes, McCuistion (2012), pp. 783-784.

602. Glimepiride (Amaryl) is prescribed for a client with diabetes mellitus. The nurse instructs the client to avoid consuming which food while taking this medication? 1. Alcohol 2. Organ meats 3. Whole-grain cereals 4. Carbonated beverages

602. 1 Rationale: When alcohol is combined with glimepiride (Amaryl), a disulfiram-like reaction may occur. This syndrome includes flushing, palpitations, and nausea. Alcohol can also potentiate the hypoglycemic effects of the medication. Clients need to be instructed to avoid alcohol consumption while taking this medication. The items in options 2, 3, and 4 do not need to be avoided. Test-Taking Strategy: Eliminate options 2, 3, and 4 because they are comparable or alike in that these food items are allowed in a diabetic diet. Remembering that alcohol can affect the action of many medications will assist in directing you to the correct option. Review: Glimepiride (Amaryl) Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology—Endocrine Medications Priority Concepts: Client Education; Glucose Regulation Reference: Kee, Hayes, McCuistion (2012), p. 793.

603. Sildenafil (Viagra) is prescribed to treat a client with erectile dysfunction. The nurse reviews the client's medical record and should question the prescription if which data is noted in the client's history? 1. Insomnia 2. Neuralgia 3. Use of nitroglycerin 4. Use of multivitamins

603. 3 Rationale: Sildenafil (Viagra) enhances the vasodilating effect of nitric oxide in the corpus cavernosum of the penis, thus sustaining an erection. Because of the effect of the medication, it is contraindicated with concurrent use of organic nitrates and nitroglycerin. Sildenafil is not contraindicated with the use of vitamins. Insomnia and neuralgia are side effects of the medication. Test-Taking Strategy: Focus on the subject, the need to question the prescription. Recalling the action of the medication and that it enhances vasodilation will direct you to the correct option. Review: Contraindications associated with sildenafil (Viagra) Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Analysis Content Area: Pharmacology—Endocrine Medications Priority Concepts: Clinical Judgment; Safety Reference: Hodgson, Kizior (2013), pp. 1060-1061.

604. The health care provider (HCP) prescribes exenatide (Byetta) for a client with type 1 diabetes mellitus who takes insulin. The nurse should plan to take which most appropriate intervention? 1. Withhold the medication and call the HCP, questioning the prescription for the client. 2. Administer the medication within 60 minutes before the morning and evening meal. 3. Monitor the client for gastrointestinal side effects after administering the medication. 4. Withdraw the insulin from the prefilled pen into an insulin syringe to prepare for administration.

604. 1 Rationale: Exenatide (Byetta) is an incretin mimetic used for type 2 diabetes mellitus only. It is not recommended for clients taking insulin. Hence, the nurse should withhold the medication and question the HCP regarding this prescription. Although options 2 and 3 are correct statements about the medication, in this situation the medication should not be administered. The medication is packaged in prefilled pens ready for injection without the need for drawing it up into another syringe. Test-Taking Strategy: Note the strategic words most appropriate. Focus on the name of the medication, recalling that it is used for the treatment of type 2 diabetes mellitus. Eliminate option 4 because the medication is packaged in prefilled pens ready for injection without the need for drawing it up into another syringe. From the remaining options, focus on the data in the question. Although options 2 and 3 are appropriate when administering this medication, this client should not receive this medication. Review: Exenatide (Byetta) Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Planning Content Area: Pharmacology—Endocrine Medications Priority Concepts: Clinical Judgment; Glucose Regulation Reference: Lehne (2013), p. 728

605. A client is taking Humulin NPH insulin and regular insulin every morning. The nurse should provide which instructions to the client? Select all that apply. 1. Hypoglycemia may be experienced before dinnertime. 2. The insulin dose should be decreased if illness occurs. 3. The insulin should be administered at room temperature. 4. The insulin vial needs to be shaken vigorously to break up the precipitates. 5. The NPH insulin should be drawn into the syringe first, then the regular insulin.

605. 1, 3 Rationale: Humulin NPH is an intermediate-acting insulin. The onset of action is 1.5 hours, it peaks in 4 to 12 hours, and its duration of action is 24 hours. Regular insulin is a short-acting insulin. Depending on the type, the onset of action is 0.5 hour, it peaks in 2 to 5.5 hours, and its duration is 5 to 8 hours. Hypoglycemic reactions most likely occur during peak time. Insulin should be at room temperature when administered. Clients may need their insulin dosages increased during times of illness. Insulin vials should never be shaken vigorously. Regular insulin is always drawn up before NPH. Test-Taking Strategy: Focus on the subject, client instructions regarding insulin. Eliminate option 4 because of the word, vigorously. Use knowledge regarding the characteristics of insulin; procedures for administration; and the onset, peak, and duration of action for insulin and insulin administration to select from the remaining options. Remember that NPH insulin peaks in 4 to 12 hours and regular insulin peaks in 0.5 hour. Review: Regular and NPH insulin Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology—Endocrine Medications Priority Concepts: Client Education; Glucose Regulation Reference: Kee, Hayes, McCuistion (2012), pp. 784-785

606. The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide (Prandin) and metformin (Glucophage) and asks the nurse to explain these medications. The nurse should provide which instructions to the client? Select all that apply. 1. Diarrhea may occur secondary to the metformin. 2. The repaglinide is not taken if a meal is skipped. 3. The repaglinide is taken 30 minutes before eating. 4. A simple sugar food item is carried and used to treat mild hypoglycemia episodes. 5. Metformin increases hepatic glucose production to prevent hypoglycemia associated with repaglinide. 6. Muscle pain is an expected effect of metformin and may be treated with acetaminophen (Tylenol).

606. 1, 2, 3, 4 Rationale: Repaglinide, a rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion, should be taken before meals (approximately 30 minutes before meals) and should be withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide and the client should always be prepared by carrying a simple sugar with her or him at all times. Metformin is an oral hypoglycemic given in combination with repaglinide and works by decreasing hepatic glucose production. A common side effect of metformin is diarrhea. Muscle pain may occur as an adverse effect from metformin but it might signify a more serious condition that warrants health care provider notification, not the use of acetaminophen. Test-Taking Strategy: Focus on the subject, oral medications to treat diabetes mellitus. Thinking about the pathophysiology of diabetes mellitus and recalling the actions and effects of these medications is needed to answer correctly. Review: Repaglinide (Prandin) and metformin (Glucophage) Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology—Endocrine Medications Priority Concepts: Client Education; Glucose Regulation Reference: Lehne (2013), pp. 735, 737.

607 The community health nurse visits a client at home. Prednisone, 10 mg orally daily, has been prescribed for the client and the nurse teaches the client about the medication. Which statement, if made by the client, indicates that further teaching is necessary? 1. "I can take aspirin or my antihistamine if I need it." 2. "I need to take the medication every day at the same time." 3. "I need to avoid coffee, tea, cola, and chocolate in my diet." 4. "If I gain more than 5 pounds a week, I will call my health care provider (HCP)."

607. 1 Rationale: Aspirin and other over-the-counter medications should not be taken unless the client consults with the HCP. The client needs to take the medication at the same time every day and should be instructed not to stop the medication. A slight weight gain as a result of an improved appetite is expected, but after the dosage is stabilized, a weight gain of 5 pounds or more weekly should be reported to the HCP. Caffeine-containing foods and fluids need to be avoided because they may contribute to steroid-ulcer development. Test-Taking Strategy: Note the strategic words further teaching is necessary. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Remember that a client taking prednisone should not take other medications, especially over-the-counter medications, without first consulting with his or her HCP. Review: Teaching points for the client taking prednisone Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology: Endocrine Medications Priority Concepts: Client Education; Safety Reference: Lehne (2013), pp. 917-918.

608. A client with hyperthyroidism has been given methimazole (Tapazole). Which nursing considerations are associated with this medication? Select all that apply. 1. Administer methimazole with food. 2. Place the client on a low-calorie, low-protein diet. 3. Assess the client for unexplained bruising or bleeding. 4. Instruct the client to report side/adverse effects such as sore throat, fever, or headaches. 5. Use special radioactive precautions when handling the client's urine for the first 24 hours following initial administration.

608. 1, 3, 4 Rationale: Common side effects of methimazole include nausea, vomiting, and diarrhea. To address these side effects, this medication should be taken with food. Because of the increase in metabolism that occurs in hyperthyroidism, the client should consume a high calorie diet. Antithyroid medications can cause agranulocytosis with leukopenia and thrombocytopenia. Sore throat, fever, headache, or bleeding may indicate agranulocytosis and the health care provider (HCP) should be notified immediately. Methimazole is not radioactive and should not be stopped abruptly, due to the risk of thyroid storm. Test-Taking Strategy: Focus on the subject, nursing considerations for administering methimazole. Focus on the client's diagnosis. Think about the pathophysiology associated with the medication and the actions and effects of antithyroid medications to assist in answering correctly. Review: Methimazole (Tapazole) Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Implementation Content Area: Pharmacology—Endocrine Medications Priority Concepts: Clinical Judgment; Safety Reference: Lehne (2013), pp. 748-749.

609. The nurse is monitoring a client receiving levothyroxine sodium (Synthroid) for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? Select all that apply. 1. Insomnia 2. Weight loss 3. Bradycardia 4. Constipation 5. Mild heat intolerance

609. 1, 2, 5 Rationale: Insomnia, weight loss, and mild heat intolerance are side effects of levothyroxine sodium. Bradycardia and constipation are not side effects associated with this medication, and rather are associated with hypothyroidism, which is the disorder that this medication is prescribed to treat. Test-Taking Strategy: Focus on the subject, side effects of levothyroxine. Thinking about the pathophysiology of hypothyroidism and the action of the medication will assist you in determining that insomnia, weight loss, and mild heat intolerance are side effects of thyroid hormones. Review: Levothyroxine sodium (Synthroid) Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Pharmacology—Endocrine Medications Priority Concepts: Clinical Judgment; Safety Reference: Lehne (2013), pp. 747-748

610. The nurse provides instructions to a client who is taking levothyroxine (Synthroid). The nurse should tell the client to take the medication at which time? 1. With food 2. At lunchtime 3. On an empty stomach 4. At bedtime with a snack

610. 3 Rationale: Oral doses of levothyroxine (Synthroid) should be taken on an empty stomach to enhance absorption. Dosing should be done in the morning before breakfast. Test-Taking Strategy: Note that options 1, 2, and 4 are comparable or alike in that these options address administering the medication with food. Review: Levothyroxine sodium (Synthroid) Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology—Endocrine Medications Priority Concepts: Client Education; Safety Reference: Lehne (2013), p. 747.

611. The nurse provides medication instructions to a client who is taking levothyroxine (Synthroid) and should tell the client to notify the health care provider (HCP) if which problem occurs? 1. Fatigue 2. Tremors 3. Cold intolerance 4. Excessively dry skin

611. 2 Rationale: Excessive doses of levothyroxine (Synthroid) can produce signs and symptoms of hyperthyroidism. These include tachycardia, chest pain, tremors, nervousness, insomnia, hyperthermia, extreme heat intolerance, and sweating. The client should be instructed to notify the HCP if these occur. Options 1, 3, and 4 are signs of hypothyroidism. Test-Taking Strategy: Focus on the subject, the need to notify the HCP. Recall the symptoms associated with hypothyroidism, the purpose of administering levothyroxine, and the effects of the medication. Options 1, 3, and 4 are symptoms related to hypothyroidism. Review: Side and adverse effects associated with levothyroxine sodium (Synthroid) Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology—Endocrine Medications Priority Concepts: Client Education; Safety Reference: Hodgson, Kizior (2013), pp. 687-688

612. The nurse performs an admission assessment on a client who visits a health care clinic for the first time. The client tells the nurse that propylthiouracil (PTU) is taken daily. The nurse continues to collect data from the client, suspecting that the client has a history of which condition? 1. Myxedema 2. Graves' disease 3. Addison's disease 4. Cushing's syndrome

612. 2 Rationale: Propylthiouracil (PTU) inhibits thyroid hormone synthesis and is used to treat hyperthyroidism, or Graves' disease. Myxedema indicates hypothyroidism. Cushing's syndrome and Addison's disease are disorders related to adrenal function. Test-Taking Strategy: Focus on the subject, the intended effect of propylthiouracil. Use knowledge regarding the action of the medication and treatment measures for Graves' disease to answer the question. Remember that propylthiouracil is used to treat Graves' disease. Review: Propylthiouracil (PTU) Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Pharmacology—Endocrine Medications Priority Concepts: Clinical Judgment; Safety References: Hodgson, Kizior (2013), pp. 980-981; Lehne (2013), p. 745

613. The nurse is instructing a client regarding intranasal desmopressin (DDAVP). The nurse should tell the client that which occurrence is a side effect of the medication? 1. Headache 2. Vulval pain 3. Runny nose 4. Flushed skin

613. 3 Rationale: Desmopressin administered by the intranasal route can cause a runny or stuffy nose. Options 1, 2, and 4 are side effects if the medication is administered by the intravenous route. Test-Taking Strategy: Focus on the subject, a side effect of desmopressin. Note the relationship between the words intranasal in the question and runny nose in the correct option. Review: Side effects of desmopressin Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology—Endocrine Medications Priority Concepts: Client Education; Safety Reference: Hodgson, Kizior (2013), pp. 324-325

614. A daily dose of prednisone is prescribed for a client. The nurse provides instructions to the client regarding administration of the medication and should instruct the client that which time is best to take this medication? 1. At noon 2. At bedtime 3. Early morning 4. Any time, at the same time, each day

614. 3 Rationale: Corticosteroids (glucocorticoids) should be administered before 9 AM. Administration at this time helps minimize adrenal insufficiency and mimics the burst of glucocorticoids released naturally by the adrenal glands each morning. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Note the strategic word best. Note the suffix -sone and recall that medication names that end with these letters are corticosteroids. Remember that a daily dose of a corticosteroid should be administered in the morning. Review: Glucocorticoids Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology—Endocrine Medications Priority Concepts: Client Education; Safety Reference: Hodgson, Kizior (2013), pp. 958-959

615. Prednisone is prescribed for a client with diabetes mellitus who is taking Humulin NPH insulin daily. Which prescription change does the nurse anticipate during therapy with the prednisone? 1. An additional dose of prednisone daily 2. A decreased amount of daily Humulin NPH insulin 3. An increased amount of daily Humulin NPH insulin 4. The addition of an oral hypoglycemic medication daily

615. 3 Rationale: Glucocorticoids can elevate blood glucose levels. Clients with diabetes mellitus may need their dosages of insulin or oral hypoglycemic medications increased during glucocorticoid therapy. Therefore, options 1, 2, and 4 are incorrect. Test-Taking Strategy: Focus on the subject, the effects of prednisone in the client taking insulin. Recalling that glucocorticoids can increase blood glucose levels will direct you to the correct option. Review: Glucocorticoids Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Analysis Content Area: Pharmacology—Endocrine Medications Priority Concepts: Clinical Judgment; Glucose Regulation Reference: Lehne (2013), p. 918

616. A client with diabetes mellitus visits a health care clinic. The client's diabetes mellitus previously had been well controlled with glyburide (DiaBeta) daily, but recently the fasting blood glucose level has been 180 to 200 mg/dL. Which medication, if added to the client's regimen, may have contributed to the hyperglycemia? 1. Prednisone 2. Phenelzine (Nardil) 3. Atenolol (Tenormin) 4. Allopurinol (Zyloprim) ANSWERS

616. 1 Rationale: Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements. Option 2, a monoamine oxidase inhibitor, and option 3, a β-blocker, have their own intrinsic hypoglycemic activity. Option 4 decreases urinary excretion of sulfonylurea agents, causing increased levels of the oral agents, which can lead to hypoglycemia. Test-Taking Strategy: Focus on the subject, an increase in the blood glucose level. Recalling that prednisone is a corticosteroid and that corticosteroids decrease the effects of oral hypoglycemics will direct you to the correct option. Review: Glyburide (DiaBeta) and prednisone Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Content Area: Pharmacology—Endocrine Medications Priority Concepts: Clinical Judgment; Glucose Regulation References: Ignatavicius, Workman (2013), p. 1384; Lilley et al (2014), pp. 516, 540-541