Chapter 31
The nurse is caring for a patient who has been newly diagnosed with type 1 diabetes. The nurse notes that the patient is extremely dehydrated. To make this assessment, what did the nurse evaluate? a. Skin turgor b. Nail bed color c. Capillary refill d. Skin temperature
ANS: A A hydration assessment includes observations of skin integrity, skin turgor, and buccal membrane moisture. Moist, shiny buccal membranes indicate satisfactory fluid balance. Skin turgor that is resilient and returns to its original position in less than 3 seconds after being pinched or lifted indicates adequate skin elasticity. Skin over the forehead, clavicle, and sternum is the most reliable for testing tissue turgor because it is less affected by aging and thus more easily assessed for changes related to fluid balance.
A nurse is teaching a patient with diabetes mellitus. The patient asks the nurse what is an acceptable HbA1c level for him. What should the nurse tell the patient? a. An acceptable level is less than 5.4%. b. An acceptable level is less than 6.5%. c. An acceptable level is determined by your practitioner. d. It is dependent on your age.
ANS: A A normal HbA1C value is less than 5.4%, with an acceptable target level for patients with diabetes below 6.5%.
A patient has been admitted who is suspected of having thyrotoxicosis. Which laboratory findings would confirm this diagnosis? a. Very low thyroid-stimulating hormone (TSH) b. Decreased T3 uptake ratio c. Increased serum osmolality d. Decreased urine osmolality
ANS: A Hyperthyroidism (thyrotoxicosis) is indicated by very low thyroid-stimulating hormone level, high serum T4, and an increased T3:T4 ratio.
A patient is being evaluated for thyroid dysfunction. The patient's medications include aspirin, digoxin, chlorothiazide, and insulin. The nurse knows that the laboratory work may be affected by which of these medications? a. Aspirin b. Digoxin c. Insulin d. Chlorothiazide
ANS: A Several drugs increase the serum level of T4 by displacing protein-bound T4. Drugs that displace T4, including heparin (both unfractionated and low-molecular-weight heparins), cause an increase in serum T4 levels. Salicylates (aspirin) and furosemide (Lasix) also raise T4 serum levels by the same mechanism.
A patient is diagnosed with a pheochromocytoma. What signs or symptoms might the nurse expect to see in this patient? a. Hypertension and tachycardia b. Weight gain and acne c. Diarrhea and facial swelling d. Blurred vision and poor skin turgor
ANS: A Signs and symptoms of pheochromocytoma include hypertension and tachycardia. Weight gain and acne are signs of Cushing syndrome. Diarrhea and facial swelling are signs of hyperthyroidism. Blurred vision and poor skin turgor are signs of hyperglycemia.
A patient was admitted with asthma who has been on steroids for a long time. The nurse knows that this patient is at risk of developing secondary Cushing syndrome. What would be the cause of this condition? a. Pharmacologic glucocorticoids b. Pharmacologic mineralocorticoids c. Cortisol d. Aldosterone
ANS: A Symptoms identical to those of primary Cushing syndrome occur in patients with the secondary form who chronically take pharmacologic doses of glucocorticoids, for example, transplant recipients who take steroids to prevent solid organ rejection, patients with chronic obstructive pulmonary disease, or those with chronic inflammatory conditions. Cortisol and aldosterone are hormones released by the adrenal gland.
A patient is admitted with diabetic ketoacidosis. The nurse requests the practitioner order a glycosylated hemoglobin (HbA1C). What information does this test provide to the health care team? a. It is an indicator of the patient's average blood glucose level over the previous 3 to 4 months. b. It compares blood glucose levels with serum hemoglobin over the previous 3 to 4 weeks. c. It is an indicator of the patient's highest blood ketone level over the past month. d. It associates the serum and urine glucose levels and is an indicator of kidney involvement.
ANS: A The glycated hemoglobin test (also known as the glycosylated hemoglobin, or HbA1C or A1C) provides information about the average amount of glucose that has been present in the patient's bloodstream over the previous 3 to 4 months. During the 120-day life span of red blood cells (erythrocytes), the hemoglobin within each cell binds to the available blood glucose through a process known as glycosylation.
A patient has been admitted with abdominal pain. The nurse notes that the patient's fasting blood glucose is 120 mg/dL. Which statement regarding this finding is accurate? a. This is a normal finding in critically ill patients. b. This finding is indicative of prediabetes, but another test should be done to confirm. c. This finding is lower than what the nurse would expect in a patient receiving intravenous fluids. d. This finding is indicative of diabetic ketoacidosis.
ANS: B A normal fasting plasma glucose (FPG) level is between 70 and 110 mg/dL. An FPG level between 110 and 126 mg/dL identifies a person who is prediabetic. An FPG level of greater than 126 mg/dL (7 mmol/L) is diagnostic of diabetes. In nonurgent settings, the test is repeated on another day to make sure the result is accurate.
A patient has been admitted with uncontrolled atrial fibrillation and muscle wasting. The practitioner suspects the patient may have a thyroid disorder. The nurse auscultates a bruit over the thyroid. What does this finding indicate? a. Normal function b. Enlargement of the thyroid c. Hypoplasia of the thyroid d. Tumor of the thyroid
ANS: B Auscultation of the thyroid is accomplished by use of the bell portion of the stethoscope to identify a bruit or blowing noise from the circulation through the thyroid gland. The presence of a bruit indicates enlargement of the thyroid as evidenced by increased blood flow through the glandular tissue.
A patient has been admitted with a brain mass. The practitioner suspects it might be a pituitary tumor and orders a computed tomography (CT) scan. What area of brain should be scanned to confirm this diagnosis? a. Frontal lobe b. Base of the skull c. Temporal lobe d. Anterior fossa
ANS: B Computed tomography (CT) of the base of the skull identifies pituitary tumors, blood clots, cysts, nodules, or other soft tissue masses.
The nurse is caring for a patient with a traumatic brain injury. Yesterday the patient weighed 62 kg and today the patient weighs 60 kg. How much fluid loss does this change in weight reflect? a. 1 L b. 2 L c. 4 L d. 10 L
ANS: B Daily weight changes coincide with fluid retention and fluid loss. 1 L of fluid lost or retained is equal to approximately 2.2 lb, or 1 kg, of weight gained or lost. This patient lost 2 kg of weight, which is equivalent to 2 L of fluid.
A patient has been admitted with uncontrolled atrial fibrillation and muscle wasting. The practitioner suspects the patient may have a thyroid disorder. The nurse anticipates the practitioner will initially order which diagnostic procedure to visualize the thyroid? a. Magnetic resonance imaging (MRI) b. Ultrasound c. Biopsy d. Computed tomography (CT)
ANS: B Diagnostic tests often begin with ultrasonography to visualize a thyroid nodule or tumor.
A patient is admitted with severe hyperglycemia due to new-onset type 1 diabetes mellitus. The nurse notes a sweet-smelling odor on the patient's exhaled breath. What causes this phenomenon? a. Metabolic alkalosis b. Ketoacidosis c. Glycosylation d. Dehydration
ANS: B Ketoacidosis results in the patient's breathing becoming deep and rapid (Kussmaul respirations) and the patient's breath having a fruity odor. Metabolic alkalosis and dehydration do not cause this phenomenon. Glycosylation is when the hemoglobin within each cell binds to the available blood glucose.
A patient is admitted with hyponatremia. The practitioner suspects the patient may have syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and orders a serum ADH level for the next morning. Which medications must be stopped or withheld at least 8 hours prior to the test? a. Insulin and furosemide b. Morphine and carbamazepine c. Digoxin and potassium d. Heparin and lopressor
ANS: B To prepare the patient for the test, all drugs that may alter the release of antidiuretic hormone (ADH) are withheld for a minimum of 8 hours. Common medications that affect ADH levels include morphine sulfate, lithium carbonate, chlorothiazide, carbamazepine, oxytocin, nicotine, alcohol, and selective serotonin reuptake inhibitors.
A patient is admitted with critical hypotension, hyperkalemia, hyponatremia, and hypoglycemia. The nurse knows that these symptoms are highly suggestive of which disorder? a. Myxedema b. Diabetes insipidus c. Addisonian crisis d. Cushing syndrome
ANS: C An Addisonian crisis is a life-threatening condition in which the adrenal gland is almost nonfunctional, usually because of destruction of adrenal tissue. The patient presents acutely with critical hypotension, an elevated serum potassium level (hyperkalemia), a low serum sodium level (hyponatremia), and hypoglycemia.
A patient has been admitted with multiple trauma due to a motor vehicle accident several weeks ago. Given the prolonged critical illness, the nurse knows the patient may no longer secrete adequate amounts of what hormone? a. Aldosterone b. Adrenocorticotropic hormone (ACTH) c. Cortisol d. Antidiuretic hormone (ADH)
ANS: C Cortisol is secreted in response to physiologic stress as a result of infection, trauma, and hypoglycemia. Early in critical illness, a rise in cortisol levels can be documented. However, over time the adrenal gland may not be able to secrete adequate amounts of stress hormones, especially when critical illness is prolonged. Aldosterone is secreted in response to intravascular hypovolemia.
The nurse is caring for a patient who has been newly diagnosed with type 1 diabetes. Which laboratory results would the nurse note confirming this diagnosis? a. Hemoglobin A1C of 3% b. Absence of ketones in the urine c. Presence of ketones in the blood d. Fasting glucose of 105 mg/dL
ANS: C Ketone bodies are a byproduct of rapid fat breakdown. Ketone blood levels rise in acute illness, fasting, and with sustained elevation of blood glucose in type 1 diabetes in the absence of insulin. The patient would also have ketones in the urine, a hemoglobin A1C greater than 6%, and a fasting glucose greater than 125 mg/dL.
A nurse is initiating a patient teaching plan for a patient with hypothyroidism. The patient is currently taking salicylates, lithium, and sulfonamides. It is important that the nurse tell the patient that these medications influence thyroid levels. How are thyroid levels affected by these medications? a. They increase T3 b. They increasing T4 c. They decrease T3 d. They decrease T4
ANS: C Salicylates, lithium, and sulfonamides can cause a decrease in T3 levels.
A patient is admitted with hypernatremia secondary to neurogenic diabetes insipidus. The nurse notes that the patient's serum osmolality is 350 mOsm/kg. What does this finding indicate? a. The patient is overhydrated. b. The patient's serum osmolality is normal. c. The patient is dehydrated. d. The patient is hypothyroid.
ANS: C Values for serum osmolality in the bloodstream range from 275 to 295 mOsm/kg H2O. Increased serum osmolality stimulates the release of antidiuretic hormone, which in turn reduces the amount of water lost through the kidney.
A patient reports losing weight even though she eats "everything in sight." She also reports tremors and diarrhea. The nurse suspects the patient may have what problem? a. Hypothyroidism b. Diabetes mellitus c. Hyperthyroidism d. Pituitary tumor
ANS: C Weight loss, increased appetite, tremors, insomnia, and diarrhea are symptoms of hyperthyroidism.
A patient is reporting a headache, fatigue, abdominal pain, and blurred vision. The nurse knows that these signs may indicate the patient has what problem? a. Hypothyroidism b. Pituitary tumor c. Cushing syndrome d. Hyperglycemia
ANS: D Because severe hyperglycemia affects a variety of body systems, all systems are assessed. The patient may complain of blurred vision, headache, weakness, fatigue, drowsiness, anorexia, nausea, and abdominal pain.
A patient is being evaluated for thyroid dysfunction. The laboratory findings include a decreased serum free thyroxine (T4) level and an elevated thyroid-stimulating hormone (TSH) level. These findings confirm which diagnosis? a. Cushing syndrome b. Addison disease c. Thyrotoxicosis d. Hypothyroidism
ANS: D Hypothyroidism is indicated by a high thyroid-stimulating hormone (TSH) and low serum T4 levels. Thyrotoxicosis is hyperthyroidism and is indicated by very low TSH, high serum T4, and increased T3:T4 ratio. Addison disease is a rare disorder of the adrenal cortex that involves hyposecretion of glucocorticoids (cortisol), sometimes occurring with hyposecretion of mineralocorticoids (aldosterone). Cushing syndrome is caused by the excess release of the glucocorticoid hormone cortisol.
A patient is admitted with hypernatremia secondary to diabetes insipidus (DI). The practitioner suspects the patient has neurogenic DI. Which finding would confirm that diagnosis? a. A slight increase in urine osmolality b. A decrease in urine output c. A decrease in serum osmolality d. No change in urine osmolality
ANS: D In cases of severe central diabetes insipidus (DI)d the urine osmolality shows a significant increase (becomes more concentrated). Test results in which urine osmolality remains unchanged indicate nephrogenic DI.
The nurse is caring for a patient with a traumatic brain injury. The nurse suspects the patient is developing diabetes insipidus. Which test or procedure would confirm this diagnosis? a. Skull radiographs b. Serum glucose level c. Water deprivation test d. Antidiuretic hormone (ADH) stimulation test
ANS: D Serum antidiuretic hormone (ADH) levels are compared with the blood and urine osmolality to differentiate syndrome of inappropriate antidiuretic hormone (SIADH) from central diabetes insipidus (DI). Increased ADH levels in the bloodstream compared with a low serum osmolality and elevated urine osmolality confirms the diagnosis of SIADH. Reduced levels of serum ADH in a patient with high serum osmolality, hypernatremia, and reduced urine concentration signal central DI.
A patient has been admitted who is suspected of having thyrotoxicosis. Which symptom would support this diagnosis? a. Lethargy despite adequate sleep b. Bradycardia not related to medications c. Constipation despite laxatives d. Weight loss despite increased appetite
ANS: D Signs and symptoms of thyrotoxicosis include tremors, insomnia, increased appetite, diarrhea, muscle weakness or wasting, and a change in menstruation.
A patient is admitted with hypernatremia secondary to diabetes insipidus (DI). Which test would help the practitioner differentiate between central and nephrogenic DI? a. Water deprivation test b. Serum osmolality c. Serum antidiuretic hormone level d. Antidiuretic hormone (ADH) test
ANS: D The antidiuretic hormone test is used to differentiate between neurogenic diabetes insipidus (DI) (central) and nephrogenic (kidney) DI. In severe central DI, in which the pituitary is affected, the urine osmolality shows a significant increase (becomes more concentrated), which indicates that the cell receptor sites on the kidney tubules are responsive to vasopressin. Test results in which urine osmolality remains unchanged indicate nephrogenic DI, suggesting kidney dysfunction because the kidneys are no longer responsive to antidiuretic hormone.
A patient is admitted with severe hyperglycemia due to new-onset type 1 diabetes mellitus. Which signs and symptoms obtained as part of the patient's history might indicate the presence of hyperglycemia? a. Recent episodes of tachycardia and missed heart beats b. Decreased urine output accompanied by peripheral edema c. Periods of hyperactivity with weight gain d. Increased thirst and increased urinary output
ANS: D The patient or family member may relay information about recent, unexplained changes in weight, thirst, hunger, and urination patterns.