Chapter 23: Endocrine Disorders and Therapeutic Management

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

A. "We can't give you anything to drink until we get your blood sugar under control." Rationale: Patients with DKA are kept on NPO status (nothing by mouth) until the hyperglycemia is under control.

The neuroendocrine stress response produces which findings? (Select all that apply.) A. Elevated blood pressure B. Decreased gastric motility C. Tachycardia D. Heightened pain awareness E. Increased glucose

A. Elevated blood pressure B. Decreased gastric motility C. Tachycardia E. Increased glucose Rationale: The fight-or-flight response, or sympathetic nervous response, releases catecholamine that causes an increased heart rate and blood pressure. Blood is shunted form nonessential organs such as the stomach, glucose is made available to the brain cells, and pain awareness is decreased.

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

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

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

A. Rapid rehydration with intravenous fluids Rationale: The goals of medical management are rapid rehydration, insulin replacement, and correction of electrolyte abnormalities, specifically potassium replacement. The underlying stimulus of HHS must be discovered and treated. The same basic principles used to treat patients with diabetic ketoacidosis are used for patients with HHS.

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

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

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

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

A patient has thyroid storm. The nurse is providing medication instruction for home. The patient asks "If I have a fever, should I take Tylenol or aspirin?" Which response would be the most appropriate? A. "Either one is fine because they do not affect the antithyroid medication." B. "Tylenol rather than aspirin because aspirin increases the amount of free thyroid hormone in circulation." C. "Aspirin rather than Tylenol because Tylenol increases the amount of free thyroid hormone in circulation." D. "They both prevent the antithyroid medication from working correctly. I would recommend an NSAID."

B. "Tylenol rather than aspirin because aspirin increases the amount of free thyroid hormone in circulation." Rationale: For management or elevated temperature, patients are instructed to use acetaminophen rather than salicylates because salicylates increase the amount of free thyroid hormone in circulation.

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

B. Administering intravenous fluids Rationale: A patient with DKA is dehydrated and may have lost 5% to 10% of body weight in fluids. A fluid deficit up to 6 L can exist in severe dehydration. Aggressive fluid replacement is provided to rehydrate both the intracellular and the extracellular compartments and prevent circulatory collapse.

Which pathophysiologic mechanism occurs in the patient with type 2 diabetes? A. Lack of insulin production and excessive glucose intake B. Decreased insulin secretion and insulin resistance C. Overproduction of glucose and decreased metabolism D. Increased uptake and decreased release of glucose in the cells

B. Decreased insulin secretion and insulin resistance Rationale: Type 2 diabetes is identified by decreased insulin secretion and insulin resistance, with a relative, versus absolute, insulin deficiency.

Which pathophysiologic mechanism occurs in the syndrome of inappropriate antidiuretic hormone (SIADH)? A. Hemoconcentration B. Dilutional hyponatremia C. Massive diuresis D. Hypermetabolism

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

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

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

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

B. Severe hyperglycemia with minimal or absent ketosis Rationale: The hallmarks of HHS are extremely high levels of plasma glucose with resulting elevations in serum hyperosmolality and osmotic diuresis. The disorder occurs mainly in patients with type II diabetes.

A patient with diabetes in the critical care unit is at risk for developing diabetic ketoacidosis (DKA) secondary to A. excess insulin administration. B. inadequate food intake. C physiologic and psychologic stress. D. increased release of antidiuretic hormone (ADH).

C physiologic and psychologic stress. Rationale: Major neurologic and endocrine changes occur when an individual is confronted with physiologic stress caused by any critical illness, sepsis, trauma, major surgery, or underlying cardiovascular disease.

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

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

Which nursing intervention should be initiated on all patients with the syndrome of inappropriate antidiuretic hormone (SIADH)? A. Placing the patient on an air mattress B. Encouraging oral fluids C. Initiating seizure precautions D. Applying soft restraints

C. Initiating seizure precautions Rationale: Excessive ADH dramatically alters the sodium balance in the extracellular vascular compartment. The overhydration causes a dilutional hyponatremia and reduces the sodium concentration to critically low levels. Patients with severe hyponatremia (less than 125 mEq/L serum sodium) experience severe neurologic symptoms including seizures.

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

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

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

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

A patient with a history of type 2 diabetes was admitted after aneurysm repair. The patient's serum glucose levels have been elevated for the past 2 days and the patient is concerned about becoming dependent on insulin. Which statement is the nurse's best response to the patient's concerns? A. "This surgery may have damaged your pancreas. We will have to do more evaluation." B. "Perhaps your diabetes was more serious from the beginning." C. "You will need to discuss this with your physician." D. "The stress on your body has temporarily increased your blood sugar levels."

D. "The stress on your body has temporarily increased your blood sugar levels." Rationale: Adrenal hormones released during stress elevate blood sugar by increasing insulin resistance and increasing hepatic gluconeogenesis.

A patient is admitted with diabetic ketoacidosis (DKA). The nurse knows that the lack of insulin results in which process? A. Decreased glucagon release B. Decreased glycogenolysis C. Decreased ketone production D. Increased gluconeogenesis

D. Increased gluconeogenesis Rationale: The release of glucagon from the liver is stimulated when insulin is ineffective in providing the cells with glucose for energy. Glucagon increases the amount of glucose in the bloodstream by breaking down stored glucose (glycogenolysis). In insulin deficiency states, fat is rapidly converted into glucose (gluconeogenesis). Ketoacidosis occurs when free fatty acids are metabolized into ketones: acetoacetate, beta-hydroxybutyrate, and acetone are the three ketone bodies that are produced.

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

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

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

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