Chapter 32 & 33 FIB / Study Guide

Glucose that is not needed for energy is removed from the blood and stored as glycogen or converted to ___

glycogen

When blood glucose levels fall below normal as they do between meals, this process breaks down glycogen and glucose is released ___

glycogenolysis

Growth hormone cannot directly produce bone growth; instead, it acts indirectly by causing the liver to produce ___

insulin-like growth factors

Diabetic ___ most commonly occurs in persons with type 1 diabetes, in whom the lack of insulin leads to mobilization of fatty acids from adipose tissue because the unsuppressed adipose cell lipase activity that breaks down triglycerides into fatty acids and glycerol

ketoacidosis

Implies the presence of a nonpitting mucus-type edema of extracellular matrix substances in the connective tissues ___

myxedema

The adrenal gland forms the bulk of the gland and is responsible for secreting three types of hormones (name 3) ___, ___, ___

- glucocorticoids - mineralocorticoids - adrenal androgens

Thyroid hormones are bound to this protein in the blood ___

- transthyretin - albumin

Secretion of this hormone is regulated by the renin-angiotensin mechanism and by blood levels of potassium ___

Aldosterone

When growth hormone excess occurs in adulthood or after the epiphyses of the long bones have fused, the condition is referred to as ___

acromegaly

Congenital hypothyroidism is a common cause of preventable ___

preventable mental retardation

Destruction of the adrenal gland causes primary adrenal insufficiency, or ___ disease

Addison

___ are thought to produce structural defects in the basement membrane of the microcirculation and to contribute to eye, kidney, and vascular complications

Advanced glycation end products

Endocrine disorder with manifestations of hypercortisolism caused by a pituitary adenoma secreting excessive ACTH ___

Cushing Syndrome

Refers to the manifestations of hypercortisolism from any cause ___

Cushing syndrome

___ diabetes mellitus refers to any degree of glucose intolerance that is first detected during pregnancy

Gestational

Increase in the size of the thyroid gland ___

Goiter

The most common cause of hyperthyroidism is ___

Graves disease

Exophthalmos is a manifestation of ___

Graves' disease

Autoimmune disorder in which the thyroid gland may be totally destroyed ___

Hashimoto thyroiditis

Deficiency of all pituitary-derived hormones ___

Panhypopituitarism

___ is the clinical syndrome that results when tissues are exposed to high levels of circulating thyroid hormone, causing a variety of symptoms that include rapid heartbeat, sweating, anxiety, and tremor

Thyrotoxicosis

Term used to describe the combination of lesions that often occur concurrently in the diabetic kidney ___

diabetic neuropathy

Because cell membranes are impermeable to glucose, they require a special carrier called ___ to move glucose from the blood into cells

glucose transporter

Fasting plasma glucose level required for a diagnosis of diabetes mellitus ___

type 2

A client has developed the facial appearance that is characteristic of myxedema, along with an enlarged tongue, bradycardia, and voice changes. Which of the following treatment modalities is most likely to benefit this client? A) Synthetic preparations of T3 or T4 B) b-Adrenergic blocking drugs C) Corticosteroid replacement therapy D) Oral or parenteral cortisol replacement

Ans: A Feedback: Myxedema and the client's other signs are associated with hypothyroidism, which necessitates thyroid hormone replacement. b-Adrenergic blocking drugs and antithyroid drugs are indicated in the treatment of hyperthyroidism, whereas treatments relevant to adrenal cortical function are not relevant to hypothyroidism.

A young child develops type 1A diabetes. The parents ask, "They tell us this is genetic. Does that mean our other children will get diabetes?" The best response by the health care provider would be: A) "Probably not since genetically your other children have a different cellular makeup, they just might not become diabetic." B) "If you put all your children on a low-carbohydrate diet, maybe they won't get diabetes." C) "We don't know what causes diabetes, so we will just have to wait and see." D) "This autoimmune disorder causes destruction of the beta cells, placing your children at high risk of developing diabetes."

Ans: D Feedback: Type 1 diabetes is subdivided into two types: type 1A, immune-mediated diabetes, and type 1B, idiopathic diabetes. Type 1A diabetes is characterized by autoimmune destruction of beta cells. The other choices are not absolutely correct. The fact that type 1 diabetes is thought to result from an interaction between genetic and environmental factors led to research into methods directed at prevention and early control of the disease. These methods include the identification of genetically susceptible persons and early intervention in newly diagnosed persons with type 1 diabetes.

The signs and symptoms of abrupt cessation of pharmacologic glucocorticoids closely resemble those of: A) Addison disease B) Cushing disease C) Cushing syndrome D) Graves disease

Ans: A Feedback: Although the etiology differs, the adrenal cortical insufficiency resulting from the abrupt cessation of glucocorticoids is nearly identical to Addison disease in terms of physiologic effects.

The results of a 44-year-old obese man's recent diagnostic workup have culminated in a new diagnosis of type 2 diabetes. Which of the following pathophysiologic processes underlies the client's new diagnosis? A) Beta cell exhaustion due to long-standing insulin resistance B) Destruction of beta cells that is not attributable to autoimmunity C) T-lymphocyte-mediated hypersensitivity reactions D) Actions of insulin autoantibodies (IAAs) and islet cell autoantibodies (ICAs)

Ans: A Feedback: Exhaustion of the beta cells arising from insulin resistance is characteristic of type 2 diabetes. Beta cell destruction in the absence of an autoimmune reaction is associated with type 1b diabetes, while autoimmune processes contribute to type 1a diabetes.

When educating a client with possible glucocorticoid dysfunction, the nurse will explain that the CRH controls the release of ACTH. The best time to perform the blood test to measure peak ACTH levels would be: A) 06:00 to 08:00 AM B) 10:00 to 12:00 AM C) 04:00 to 6:00 PM D) 09:00 to 11:00 PM

Ans: A Feedback: Levels of cortisol increase as ACTH levels rise and decrease as ACTH levels fall. There is considerable diurnal variation in ACTH levels, which reach their peak in the early morning (around 6 to 8 AM) and decline as the day progresses.

Which of the following residents of a long-term facility is exhibiting clinical manifestations of hypothyroidism? A) An 80-year-old woman who has uncharacteristically lost her appetite and often complains of feeling cold B) A 90-year-old woman with a history of atrial fibrillation whose arrhythmia has recently become more severe C) An 88-year-old man with a history of Alzheimer disease who has become increasingly agitated and is wandering around the facility more frequently D) A 91-year-old man with a chronic venous ulcer and a sacral ulcer who has developed sepsis

Ans: A Feedback: Loss of appetite and cold intolerance are characteristic symptoms of hypothyroidism. Arrhythmias, agitation, and infections are not typically associated with hypofunction of the thyroid gland.

A newly diagnosed type 2 diabetic client has been prescribed metformin. When explaining the actions of this medication, the nurse should include which statement? This medication: A) Inhibits hepatic glucose production and increases the sensitivity of peripheral tissues to the actions of insulin B) Blocks the action of intestinal brush border enzymes that break down complex carbohydrates C) Increases insulin sensitivity in the insulin-responsive tissues—liver, skeletal muscle, and fat—allowing the tissues to respond to endogenous insulin more efficiently D) Acts like a hormone released into the circulation by the gastrointestinal tract after a meal, especially one high in carbohydrates, which amplify the glucose-induced release of insulin

Ans: A Feedback: Metformin, the only currently available biguanide, inhibits hepatic glucose production and increases the sensitivity of peripheral tissues to the actions of insulin. Secondary benefits of metformin therapy include weight loss and improved lipid profiles. This medication does not stimulate insulin secretion; therefore, it does not produce hypoglycemia. Distractor B relates to a-glucosidase inhibitors; distractor C relates to thiazolidinediones; and distractor D relates to incretin-based agents.

A diabetic client was visiting the endocrinologist for annual checkup. The client's blood work reveals an increased level of which lab result that reveals early signs of diabetic nephropathy? A) Microalbuminuria B) Oliguria C) Hypokalemia D) Hyperlipidemia

Ans: A Feedback: One of the first manifestations of diabetic nephropathy is increased urinary albumin excretion (i.e., microalbuminuria). Risk factors, rather than renal manifestations, include glycosylated hemoglobin levels greater than 8.1%, genetic and familial predisposition, hypertension, poor glycemic control, smoking, and hyperlipidemia. Usually, serum potassium levels are elevated (hyperkalemia) in diabetic nephropathy. The presence of ketones in the urine is a sign of ketoacidosis and severe hyperglycemia rather than nephropathy.

Which of the following clients would be considered to be exhibiting manifestations of "prediabetes"? A) A middle-aged overweight adult with a fasting plasma glucose level of 122 with follow-up OGTT of 189 mg/dL. B) A school-aged child who had a blood glucose level of 115 following lunch. C) A retired female registered nurse with a fasting plasma glucose level of 92 mg/dL. D) An elderly client who got "light-headed" when he skipped his lunch. Blood glucose level was 60 mg/dL at this time.

Ans: A Feedback: Persons with IFG (impaired fasting plasma glucose [IFG] defined by an elevated FPG of 100 to 125 mg/dL) and/or IGT (impaired glucose tolerance [IGT] plasma glucose levels of 140 to 199 mg/dL with an OGTT) are often referred to as having prediabetes, meaning they are at relatively high risk for the future development of diabetes as well as cardiovascular disease.

A client's primary care provider has ordered an oral glucose tolerance test (OGTT) as a screening measure for diabetes. Which of the following instructions should the client be given? A) "The lab tech will give you a sugar solution and then measure your blood sugar levels at specified intervals." B) "You'll have to refrain from eating after midnight and then go to the lab to have your blood taken first thing in the morning." C) "They'll take a blood sample and see how much sugar is attached to your red blood cells." D) "You can go to the lab at any time; just tell the technician when you last ate before they draw a blood sample."

Ans: A Feedback: The OGTT measures the plasma glucose response to 75 g of concentrated glucose solution at selected intervals, usually 1 and 2 hours. A fasting blood glucose test requires 8 hours without food, and A1C measures glucose binding to hemoglobin. A casual blood glucose test is administered without regard for time or last meal.

The iatrogenic form of Cushing syndrome is caused by: A) Long-term cortisone therapy B) Pituitary tumor secreting ACTH C) Benign or malignant adrenal tumor D) Ectopic ACTH-secreting lung tumor

Ans: A Feedback: Three important forms of Cushing syndrome result from excess glucocorticoid production by the body. One is a pituitary form, which results from excessive production of ACTH by a tumor of the pituitary gland, called Cushing disease. The second form is the adrenal form, caused by a benign or malignant adrenal tumor. The third form is ectopic Cushing syndrome, caused by a nonpituitary ACTH-secreting tumor, often carcinoma of the lung. Iatrogenic Cushing syndrome results from long-term therapy with one of the potent pharmacologic preparations of glucocorticoids.

Which of the following individuals displays the precursors to acromegaly? A) An adult with an excess of growth hormone due to an adenoma B) A girl who has been diagnosed with precocious puberty C) An adult who has a diagnosis of Cushing syndrome D) A client who has recently developed primary adrenal carcinoma

Ans: A Feedback: When growth hormone (GH) excess occurs in adulthood or after the epiphyses of the long bones have fused, it causes a condition called acromegaly, which represents an exaggerated growth of the ends of the extremities.

Which of the following clinical manifestations lead the health care worker to suspect the client is at the end-stage expression of hypothyroidism? A client: Select all that apply. A) Who takes analgesics for chronic pain that goes into a coma B) Brought to the emergency department with hypothermia who presents with low serum sodium levels C) In the emergency department presenting with tachycardia and palpitations D) Whose family took him to the health care provider complaining of shortness of breath and heat intolerance E) Who has abnormal retraction of eyelids and infrequent blinking

Ans: A, B Feedback: Myxedematous coma is a life-threatening, end-stage expression of hypothyroidism. It is characterized by coma, hypothermia, cardiovascular collapse, hypoventilation, and severe metabolic disorders including hyponatremia, hypoglycemia, and lactic acidosis. With the hypermetabolic state of hyperthyroidism, there are frequent complaints of nervousness, irritability, and fatigability. Weight loss is common despite a large appetite. Other manifestations include tachycardia, palpitations, shortness of breath, excessive sweating, muscle cramps, and heat intolerance.

A client with type 2 diabetes has routine lab work, which reveals elevated free fatty acids (FFA). The client asks, "Why is this significant?" The most accurate response would be: Select all that apply. A) This may increase the amount of triglyceride (a form of fat) stored in your liver or around your heart. B) Your pancreas is affected by increased fat (lipotoxicity), which causes beta cell dysfunction, leading to the need for insulin. C) Excess fat in the liver causes a decrease in hepatic glucose production leading to severe hypoglycemia. D) Nonalcoholic fatty liver disease may lead to needing a liver transplant. E) Excess fatty acids may interfere with the way your body responds to an infection.

Ans: A, B Feedback: Visceral obesity is accompanied by an increase in postprandial FFA concentrations and subsequent triglyceride storage, including in sites that do not normally store fat such as the liver, skeletal muscle, heart, and pancreatic beta cells. A consequence to this may a direct cause of pancreatic beta cell dysfunction (lipotoxicity). The accumulation of FFAs and triglycerides reduces hepatic insulin sensitivity, leading to increased hepatic glucose production and hyperglycemia. In the liver, the uptake of FFAs from the portal blood can lead to hepatic triglyceride accumulation and nonalcoholic fatty liver disease.

Loss of pituitary function can result in deficiencies/loss of which of the following hormones' secretions? Select all that apply. A) Growth hormone B) Luteinizing hormone C) Follicle stimulating hormone D) Corticotropin-releasing hormone E) Prolactin

Ans: A, B, C, E Feedback: Anterior pituitary hormone loss is usually gradual, especially with progressive loss of pituitary reserve due to tumors or previous pituitary radiation therapy (which may take 10 to 20 years to produce hypopituitarism). The loss of pituitary function tends to follow a classic course beginning with the loss of GH, LH, and FSH secretion followed by deficiencies in TSH, then ACTH, and finally prolactin.

A diabetic client presents to the clinic. He is concerned his lower legs are "feeling funny." Which of the following assessment findings lead the health care provider to suspect the client may have developed somatic neuropathy? Select all that apply. A) Both legs appear to be the same as far as numbness is involved. B) Bilateral cool ankles and feet. C) Right foot has a diminished perception of vibration; left foot is normal. D) With eyes closed, the client cannot identify where the HCP is touching his feet. E) One leg has a reddened area in the calf and has a positive Homan sign.

Ans: A, B, D Feedback: A distal symmetric polyneuropathy, in which loss of function typically occurs in a stocking-glove pattern, is the most common form of peripheral neuropathy. Somatic sensory involvement usually occurs first, often is bilateral and symmetric, and is associated with diminished perception of vibration, pain, and temperature, particularly in the lower extremities. The loss of feeling, touch, and position sense increases the risk of falling. A reddened area on calf with +Homan sign is diagnostic for a blood clot.

Which of the following clinical manifestations following thyroidectomy would alert the nurse that the client is going into a life-threatening thyroid storm? Select all that apply. A) Temperature of 104.2°F B) Telemetry showing heart rate of 184 C) Unable to close eyelids completely together D) Extremely agitated E) Bruising on knees and feet

Ans: A, B, D Feedback: Thyroid storm, or crisis, is an extreme and life-threatening form of thyrotoxicosis, rarely seen today. When it does occur, it is seen most often in undiagnosed cases or in person with hyperthyroidism that has not been adequately treated. It often is precipitated by stress such as an infection, diabetic ketoacidosis, physical or emotional trauma, or manipulation of a hyperactive thyroid gland during thyroidectomy. It is manifested by a very high fever, extreme cardiovascular effects (tachycardia, HF, angina), and severe CNS effects (agitation, restlessness, and delirium).

A client is admitted in the ICU with diagnosis of hyperglycemic hyperosmolar state (HHS). The nurse caring for the client knows that the client's elevated serum osmolality has pulled water out of this brain cells based on which of the following assessment findings? Select all that apply. A) Weakness one side of the body B) After the sole of the foot has been firmly stroked, the toes flex and flare out C) Increase in urine output in proportion to the increase in blood glucose D) Unable to respond verbally to questions E) Uncontrollable twitching of a muscle group

Ans: A, B, D, E Feedback: HHS is characterized by hyperglycemia (blood glucose >600 mg/dL); hyperosmolarity (plasma osmolarity >310 mOsm/L); and dehydration, the absence of ketoacidosis, and depression of the sensorium. The most prominent manifestations are weakness, dehydration, polyuria, neurologic signs and symptoms, and excessive thirst. The neurologic signs include hemiparesis (weakness on one side of the body), Babinski reflex (the sole of the foot has been firmly stroked, the toes flex and flare out), aphasia (unable to respond verbally to questions), muscle fasciculations (uncontrollable twitching of a muscle group), hyperthermia, hemianopia, nystagmus, visual hallucinations, seizures, and coma.

A woman who is exhibiting clinical manifestations of a pituitary adenoma will likely complain of: Select all that apply. A) Cessation of menses B) Unusual milk secretion unrelated to pregnancy C) Enlargement of the abdomen D) Pelvic pain E) Infertility

Ans: A, B, E Feedback: The signs and symptoms of pituitary adenomas include endocrine abnormalities related specifically to functional hormone-secreting adenomas and to the local mass effects from the expanding tumor. Lactotrophic adenomas are the most frequent type of hyperfunctioning pituitary adenoma. Hyperprolactinemia inhibits the pulsatile secretion of LH, which is essential for normal ovulation in women. Thus, manifestations of hyperprolactinemia are easily recognized to include amenorrhea (lack of menses), galactorrhea (spontaneous milk secretion unrelated to pregnancy), and infertility.

A client has just undergone a diagnostic cardiac angiogram. As part of their ordered labs, the physician has ordered a thyroid panel. The physiological principle behind ordering this lab tests includes which of the following correlations? Hyperthyroidism can cause: Select all that apply. A) Rise in oxygen consumption B) Sharp decrease in heart rate and blood pressure C) Increase in cardiac output D) Vasoconstriction of all arteries

Ans: A, C Feedback: Cardiovascular and respiratory functions are strongly affected by thyroid function. With an increase in metabolism, there is a rise in oxygen consumption and production of metabolic end products, with an accompanying increase in vasodilation. Blood volume, cardiac output, and ventilation all are increased as a means of maintaining blood flow and oxygen delivery to body tissues. Heart rate and cardiac contractility are enhanced as a means of maintaining the needed cardiac output, whereas there is little change in blood pressure because the increase in vasodilation tends to offset the increase in cardiac output.

Which of the following clinical manifestations would support the medical diagnosis of Cushing syndrome? Select all that apply. A) Excessive facial hair growth B) Muscle hypertrophy C) Blood glucose level in 200 mg/dL range D) "Buffalo hump" on back E) Blood pressure reading less than 90/70

Ans: A, C, D Feedback: The major manifestations of Cushing syndrome represent an exaggeration of the many actions of cortisol. There is muscle weakness, and the extremities are thin. Derangements in glucose metabolism are found in approximately 75% of clients, with clinically overt diabetes mellitus occurring in approximately 20% of clients. The glucocorticoids possess mineralocorticoid properties; this causes fluid retention and hypertension resulting from sodium retention, water retention, and hypervolemia. An increase in androgen levels causes hirsutism. Altered fat metabolism causes a peculiar deposition of fat characterized by a protruding abdomen; subclavicular fat pads or "buffalo hump" on the back; and a round, plethoric "moon face."

The most common cause of thyrotoxicosis is Graves disease. When assessing this client, the nurse should put priority on which of the following signs/symptoms? A) Complaints of muscle fatigue B) Facial myxedema with puffy eyelids C) Ophthalmopathy D) Pulse rate of 64 beats/minute

Ans: C Feedback: Graves disease is characterized by a triad of hyperthyroidism, goiter, ophthalmopathy (exophthalmos), or less commonly, dermopathy (pretibial edema due to accumulation of fluid and glycosaminoglycans). Even in persons without exophthalmos (i.e., bulging of the eyeballs seen in ophthalmopathy), there is an abnormal retraction of the eyelids and infrequent blinking such that they appear to be staring. Although the myxedema of hypothyroidism is most obvious in the face and other superficial parts, it also affects many of the body organs. Common to all types of thyrotoxicosis, rather than unique to Graves disease, cholesterol blood levels are decreased; muscle proteins are broken down and used as fuel, which accounts for the muscle fatigue that occurs with all types of hyperthyroidism.

Which of the following clients are at risk for developing hypothyroidism? Select all that apply. A) A client who is prescribed amiodarone for frequent dysrhythmias B) A client who has bulging eyeballs being treated with b-adrenergic blockers C) A client who has precancerous thyroid lesions who underwent ablation with radiation D) A female experiencing an autoimmune disorder called thyroiditis E) A bipolar client prescribed lithium carbonate

Ans: A, C, D, E Feedback: The most common cause of hypothyroidism is Hashimoto thyroiditis, an autoimmune disorder in which the thyroid gland may be totally destroyed by an immunologic process. It is the major cause of goiter and hypothyroidism in children and adults. Hypothyroidism may result from thyroidectomy (i.e., surgical removal) or ablation of the gland with radiation. Certain goitrogenic agents, such as lithium, and the antithyroid drugs propylthiouracil and methimazole in continuous dosage can block hormone synthesis and produce hypothyroidism with goiter. Large amounts of iodine (i.e., ingestion of kelp tablets or iodide-containing cough syrups, or administration of iodide-containing radiographic contrast media or the cardiac drug amiodarone, which contains 75 mg of iodine per 200-mg tablet) also can block thyroid hormone production and cause goiter, particularly in persons with autoimmune thyroid disease. Myxedema is associated with severe hypothyroidism and is characterized by a nonpitting mucus-type edema caused by the accumulation of hydrophobic extracellular matrix substances in the connective tissues of a number of body tissues. Although the myxedema is most obvious in the face and other superficial parts, it also affects many of the body organs and is responsible for many of the manifestations of the hypothyroid state.

A student nurse is taking a test on the endocrine system. From the following list of clinical manifestations, she needs to select the ones she would see in hypothyroidism. Which answers should she select? Select all that apply. A) Weight gain despite loss of appetite B) Nervousness with fine muscle tremors C) Coarse brittle hair D) Heat intolerance E) Puffy face with swollen eyelids

Ans: A, C, E Feedback: The hypometabolic state associated with hypothyroidism is characterized by a gradual onset of weakness and fatigue, a tendency to gain weight despite a loss of appetite, and cold intolerance. As the condition progresses, the skin becomes dry and rough and the hair becomes coarse and brittle. Reduced conversion of carotene to vitamin A and increased blood levels of carotene may give the skin a yellowish color. The face becomes puffy with edematous eyelids, and there is thinning of the outer third of the eyebrows. Nervousness with fine muscle tremors and heat intolerance are signs of hyperthyroidism.

Which of the following comorbidities represent the greatest risk for the development of foot ulcers in a diabetic client? Select all that apply. A) Bilateral distal loss of pain sensation B) Previous incidents of diabetic ketoacidosis with blood glucose levels of 400 mg/dL C) Diabetic renal problems with severely decreased GFR D) Motor neuropathy related to improperly fitted shoes E) Smoking history averaging 2 packs/day

Ans: A, D, E Feedback: Distal symmetric neuropathy is a major risk factor for foot ulcers due to the fact that people with sensory neuropathies have impaired pain sensation. Motor neuropathy with weakness of the intrinsic muscles of the foot may result in foot deformities, which lead to focal areas of high pressure. When the abnormal focus of pressure is coupled with loss of sensation, a foot ulcer can occur. Smoking should be avoided because it causes vasoconstriction and contributes to vascular disease. This risk factor supersedes that posed by nephropathy or DKA, although each problem suggests that the client's diabetes is inadequately controlled.

Diabetic retinopathy, the leading cause of acquired blindness in the United States, is characterized by retinal: A) Glaucoma B) Hemorrhages C) Dehydration D) Infections

Ans: B Feedback: Although people with diabetes are at increased risk for the development of cataracts and anterior chamber glaucoma, retinopathy is the most common pattern of eye disease. Diabetic retinopathy is characterized by abnormal retinal vascular permeability, microaneurysm formation, neovascularization and associated hemorrhage, scarring, and retinal detachment. In conjunction with the retinopathy, the inflammatory response causes macular edema rather than loss of vitreous fluid (dehydration). Intraocular infection is an uncommon, yet potential, complication of retinal surgery.

Which of the following physiologic processes is a direct effect of the release of growth hormone by the anterior pituitary? A) Development of cartilage and bone B) Production of insulin-like growth factors (IGFs) by the liver C) Increase in overall metabolic rate and cardiovascular function D) Positive feedback of the hypothalamic-pituitary-thyroid feedback system

Ans: B Feedback: GH cannot directly produce bone growth; instead, it acts indirectly by causing the liver to produce IGFs. It affects neither metabolic rate nor the function of the hypothalamic-pituitary-thyroid feedback system.

A hospital client with a diagnosis of type 1 diabetes has been administered a scheduled dose of regular insulin. Which of the following effects will result from the action of insulin? A) Promotion of fat breakdown B) Promotion of glucose uptake by target cells C) Promotion of gluconeogenesis D) Initiation of glycogenolysis

Ans: B Feedback: The actions of insulin are threefold: (1) it promotes glucose uptake by target cells and provides for glucose storage as glycogen; (2) it prevents fat and glycogen breakdown; and (3) it inhibits gluconeogenesis and increases protein synthesis. Glucagon, not insulin, promotes glycogenolysis.

A hospital client has been complaining of increasing fatigue for several hours, and his nurse has entered his room to find him unarousable. The nurse immediately checked the client's blood glucose level (and reverified with a second blood glucose meter), which is 22 mg/dL (1.2 mmol/L). The nurse should prepare to administer which of the following? A) A snack that combines simple sugars, protein, and complex carbohydrates B) A 50% glucose solution intravenously C) Infusion of rapid-acting insulin D) An oral solution containing glucagon and simple sugars

Ans: B Feedback: The client's presentation and low blood sugars indicate the need for aggressive treatment such as glucose (20 to 50 mL of a 50% solution) intravenously. The unconscious client cannot take anything by mouth, and glucagon can never be administered orally. Insulin would be potentially fatal.

A client with a history of diabetes presents to the emergency department following several days of polyuria and polydipsia with nausea/vomiting. On admission, the client labs show a blood glucose level of 480 mg/dL and bicarbonate level of 7.8 mEq/dL. The nurse suspects the client has diabetic ketoacidosis (DKA). The priority intervention should include: A) Limit fluid intake to only 250 mL/4 hours. B) Begin a loading dose of IV regular insulin followed by a continuous insulin infusion. C) Give at least 50 units of regular insulin IV stat and recheck blood glucose in 2 hours. D) Push a stat dose of bicarbonate followed by a double-dose (loading) of metformin.

Ans: B Feedback: The goals in treating DKA are to improve circulatory volume and tissue perfusion, decrease blood glucose, and correct the acidosis and electrolyte imbalances. These objectives usually are accomplished through the administration of insulin and intravenous fluid and electrolyte replacement solutions. An initial loading dose of short-acting (i.e., regular) or rapid-acting insulin often is given intravenously, followed by continuous low-dose short-acting insulin infusion. Frequent laboratory tests are used to monitor blood glucose. The fluids need to be replaced, not withheld. Too rapid a drop in blood glucose may cause hypoglycemia that can occur with a large dose of regular insulin. The client may require bicarbonate, but glucose levels are lowered with insulin in this emergency situation, not by oral medication.

While working on the med-surg floor, the nurse has a client who is experiencing an insulin reaction. The client is conscious and can follow directions. The most appropriate intervention would be: A) Call the physician and wait for him or her to respond to give you orders of what he or she prefers you do for this client. B) Immediately administer 15 g of glucose (preferably via oral route if the client is alert enough to swallow) and wait for 15 minutes. Then repeat this if necessary. C) Start pushing 50% glucose solution slowly and do not stop pushing until the client's repeat blood glucose level is above 100 mg/dL. D) Skip the oral glucose tablets and go directly to giving intramuscular glucagon. Repeat the glucagon in 15 minutes if the blood glucose level is not within a normal range.

Ans: B Feedback: The most effective treatment of an insulin reaction is the immediate administration of 15 g of glucose in a concentrated carbohydrate source. According to the so-called rule of 15, this 15 g of glucose can be repeated every 15 minutes for up to three doses. Alternative methods for increasing blood glucose may be required when the person having the reaction is unconscious or unable to swallow. Glucagon may be given intramuscularly or subcutaneously. Glucagon acts by hepatic glycogenolysis to raise blood glucose. In situations of severe or life-threatening hypoglycemia, administer glucose (20 to 50 mL of a 50% solution) intravenously.

Which of the following pathophysiologic phenomena may result in a diagnosis of Cushing disease? A) Hypopituitarism B) Excess ACTH production by a pituitary tumor C) Autoimmune destruction of the adrenal cortex D) Malfunction of the HPA system

Ans: B Feedback: Three important forms of Cushing syndrome result from excess glucocorticoid production by the body. One is a pituitary form, which results from excessive production of ACTH by a tumor of the pituitary gland. Hypopituitarism and destruction of the adrenal cortex are associated with Addison disease. Disruption of the HPA system is not implicated in the etiology of Cushing disease.

Which of the following insulin administration regimens is most likely to result in stable blood glucose levels for a client with a diagnosis of type 1 diabetes? A) One large dose of long-acting insulin each day before breakfast B) Intermediate-acting insulin at 8:00 AM and 8:00 PM with rapid-acting insulin before each meal C) Six to eight small doses of rapid-acting insulin each day, with capillary monitoring before each D) Long-acting insulin twice daily (breakfast and bedtime), with intermediate-acting insulin in the afternoon

Ans: B Feedback: With multiple daily injections (MDIs), the basal insulin requirements are met by an intermediate- or long-acting insulin administered once or twice daily. Boluses of rapid- or short-acting insulin are used before meals. Serial injections of short- or rapid-acting insulin are not typically used.

A client with excessive production of growth hormone level will likely exhibit which clinical manifestations? Select all that apply. A) Short stature with obesity B) Large hands and feet due to increased production of GH C) Excess thirst and urination due to decreased glucose uptake D) Difficulty chewing food E) Tendency to develop asthma

Ans: B, C, D Feedback: Growth hormone causes increased release of free fatty acids from adipose tissue, leading to increased concentration of free fatty acids in body fluids. In addition, GH exerts multiple effects on carbohydrate metabolism, including decreased glucose uptake by tissues such as skeletal muscle and adipose tissue, increased glucose production by the liver, and increased insulin secretion. Each of these changes results in GH-induced insulin resistance. Impaired glucose tolerance occurs in as many as 50% to 70% of persons with acromegaly; overt diabetes mellitus subsequently can result. The predominant effect of prolonged growth hormone (GH) excess is to increase glucose levels despite an insulin increase. Persons with classic GH deficiency have normal intelligence, short stature, and obesity with immature facial features. Exceptionally tall children (i.e., genetic tall stature and constitutional tall stature) can be treated with sex hormones—estrogens in girls and testosterone in boys—to effect early epiphyseal closure and stop bone growth.

Which of the following assessment findings of a male client constitutes a criterion for a diagnosis of metabolic syndrome? The client: A) States that he does less than 30 minutes of strenuous physical activity each week B) Has a resting heart rate between 85 and 95 beats/minute C) Has blood pressure that is consistently in the range of 150/92 mm Hg D) Has a fasting triglyceride level of 100 mg/dL

Ans: C Feedback: Diagnostic criteria for metabolic syndrome include blood pressure of greater than 130/85 mm Hg. A triglyceride level below 150 mg/dL is within normal range. Sedentary lifestyle, high resting heart rate, and a family history of type 2 diabetes are associated with other health problems, including diabetes, but these are not diagnostic criteria for metabolic syndrome.

A client with long-standing type 2 diabetes is surprised at his high blood sugar readings while recovering from an emergency surgery. Which of the following factors may have contributed to the client's inordinately elevated blood glucose levels? A) The tissue trauma of surgery resulted in gluconeogenesis. B) Illness inhibited the release and uptake of glucagon. C) The stress of the event caused the release of cortisol. D) Sleep disruption in the hospital precipitated the dawn effect.

Ans: C Feedback: Elevation of glucocorticoid levels, such as during stressful events, can lead to hyperglycemia. Tissue trauma does not cause gluconeogenesis, and illness does not inhibit the action of glucagon. The dawn phenomenon is not a likely cause of the client's disruption in blood sugar levels.

A 33-year-old client has been admitted to the hospital for the treatment of Graves disease. Which of the following assessments should the client's care team prioritize? A) Assessment of the client's level of consciousness and neurologic status B) Assessment of the client's peripheral vascular system for thromboembolism C) Assessment of the client's vision and oculomotor function D) Cardiac monitoring and assessment of peripheral perfusion

Ans: C Feedback: Ophthalmopathy occurs in a large proportion (up to one third) of clients with Graves disease and may result in permanent vision damage. This supersedes the importance of cardiac, neurologic, and peripheral vascular assessments, although these assessments are relevant to the broader effects of hyperthyroidism that the client may likely experience.

Primary adrenal insufficiency is manifested by: A) Truncal obesity and 3+ pitting edema in lower legs B) Potassium level of 2.8 mEq/L and weight gain of 3 pounds overnight C) Serum sodium level of 120 mmol/L (low) and blood glucose level of 48 mg/dL (low) D) Hypopigmentation over neck and BP greater than 150/90

Ans: C Feedback: Primary adrenal insufficiency is adrenal cortical hormone deficiency with elevated adrenocorticotropic hormone (ACTH) levels caused by a lack of feedback inhibition. Manifestations are related primarily to mineralocorticoid deficiency, causing increased urinary losses of sodium, chloride, and water, along with decreased excretion of potassium. The result is hyponatremia, loss of extracellular fluid, decreased cardiac output, and hyperkalemia. Because of a lack of glucocorticoid, the person with Addison disease has poor tolerance to stress. This deficiency causes hypoglycemia, lethargy, weakness, fever, and gastrointestinal symptoms such as anorexia, nausea, vomiting, and weight loss. Hypopigmentation results from elevated ACTH levels.

While trying to explain the physiology behind type 2 diabetes to a group of nursing students, the instructor will mention which of the following accurate information? A) The destruction of beta cells and absolute lack of insulin in people with type 2 diabetes means that they are particularly prone to the development of diabetic complication. B) Because of the loss of insulin response, all people with type 2 diabetes require exogenous insulin replacement to control blood glucose levels. C) In skeletal muscle, insulin resistance prompts decreased uptake of glucose. Following meals (postprandial), glucose levels are higher due to diminished efficiency of glucose clearance. D) They have increased predisposition to other autoimmune disorders such as Graves disease, rheumatoid arthritis, and Addison disease.

Ans: C Feedback: The metabolic abnormalities that lead to type 2 diabetes include (1) peripheral insulin resistance, (2) deranged secretion of insulin by the pancreatic beta cells, and (3) increased glucose production by the liver. In skeletal muscle, insulin resistance prompts decreased uptake of glucose. Although muscle glucose uptake is slightly increased after a meal, the efficiency with which it is taken up is decreased, resulting in an increase in blood glucose levels following a meal. The other distractors relate to type 1 diabetes.

One of the first signs that indicates an infant may have congenital hypothyroidism is: A) No passage of meconium within the first 72 hours after birth B) Palpable mass in the neck region C) Prolonged period of physiologic jaundice D) Full, bounding fontanels

Ans: C Feedback: With congenital lack of the thyroid gland, the infant usually appears normal and functions normally at birth because of hormones supplied in utero by the mother. Prolongation of physiologic jaundice, caused by delayed maturation of the hepatic system for conjugating bilirubin, may be the first sign. There may be respiratory difficulties and a hoarse cry, feeding difficulties, and an enlarged abdomen. This condition will not interfere with meconium passage, elevated ICP resulting in full, tight fontanels, or having a palpable mass in the neck.

A client tells his health care provider that his body is changing. It used to be normal for his blood glucose to be higher during the latter part of the morning. However, now his fasting blood glucose level is elevated in the early AM (07:00). The health care provider recognizes the client may be experiencing: A) Possible stress-related hypoglycemia B) Somogyi effect C) Hyperglycemic hyperosmolar state (HHS) D) Dawn phenomenon

Ans: D Feedback: A change in the normal circadian rhythm for glucose tolerance, which usually is higher during the later part of the morning, is altered in people with diabetes, with abnormal nighttime growth hormone secretion as a possible factor. The dawn phenomenon is characterized by increased levels of fasting blood glucose or insulin requirements, or both, between 5 AM and 9 AM without preceding hypoglycemia. The Somogyi effect describes a cycle of insulin-induced posthypoglycemic episodes. The cycle begins when the increase in blood glucose and insulin resistance is treated with larger insulin doses. The insulin-induced hypoglycemia produces a compensatory increase in blood levels of catecholamines, glucagon, cortisol, and growth hormone, leading to increased blood glucose with some insulin resistance.

A diabetic client's most recent blood work indicated a decreased glomerular filtration rate and urine testing revealed + microalbuminuria. Which priority self-care measures should the client's care team prescribe for this client? A) Use of over-the-counter herbal products for natural diuretic properties B) Increased fluid intake to at least 2000 mL/day C) Decreased oral sugar intake to less than 5 tsp/day D) Diet, exercise, and prescriptions to lower blood pressure below 140/80 mm Hg

Ans: D Feedback: Both systolic hypertension and diastolic hypertension accelerate the progression of diabetic nephropathy. Even moderate lowering of blood pressure can decrease the risk of chronic kidney disease. Diuretics may exacerbate diabetes, and neither increased fluid intake nor decreased sugar intake will necessarily mitigate the potential for further kidney damage.

A client who has been taking 80 mg of prednisone, a glucocorticoid, each day has been warned by his primary care provider to carefully follow a plan for the gradual reduction of the dose rather than stopping the drug suddenly. What is the rationale for this directive? A) Sudden changes in glucocorticoid dosing may reverse the therapeutic effects of the drug. B) Stopping the drug suddenly may "shock" the HPA axis into overactivity. C) Sudden cessation of a glucocorticoid can result in adrenal gland necrosis. D) Stopping the drug suddenly may cause acute adrenal insufficiency.

Ans: D Feedback: Chronic suppression of the HPA system by the use of steroids causes atrophy of the adrenal gland, and the abrupt withdrawal of drugs can cause acute adrenal insufficiency. Activity of the HPA system is consequently insufficient. The efficacy of the drug is not the primary concern, and necrosis of the gland itself does not occur.

A diabetic client presents to a clinic for routine visit. Blood work reveals a HbA1C of 11.0% (high)? Which response by the patient may account for this abnormal lab result? A) "I've had more periods of hypoglycemia than usual over the past few months." B) "I've been doing great. I haven't needed much insulin coverage before meals." C) "To tell you the truth, my blood glucose levels have been pretty normal for me." D) "My meter broke so I have not been checking my blood glucose levels for a while."

Ans: D Feedback: Glycosylated hemoglobin is hemoglobin into which glucose has been irreversibly incorporated. Because glucose entry into the red blood cell is not insulin dependent, the rate at which glucose becomes attached to the hemoglobin molecule depends on blood glucose; the level is an index of blood glucose levels over the previous 6 to 12 weeks. If the diabetic client is not monitoring his or her blood glucose, he or she could be having more periods of hyperglycemia and just is not aware of the need for insulin coverage.

The immune suppressive and anti-inflammatory effects of cortisol cause: A) Moderate insulin resistance B) Increased capillary permeability C) Increased cell-mediated immunity D) Inhibition of prostaglandin synthesis

Ans: D Feedback: Large quantities of cortisol are required for an effective anti-inflammatory action. The increased cortisol blocks inflammation at an early stage by decreasing capillary permeability and stabilizing the lysosomal membranes so that inflammatory mediators are not released. Cortisol suppresses the immune response by reducing humoral and cell-mediated immunity. Cortisol also inhibits prostaglandin synthesis, which may account in large part for its anti-inflammatory actions. Cortisol stimulates glucose production by the liver; as glucose production by the liver rises and peripheral glucose use falls, a moderate resistance to insulin and hyperglycemia develop.

Which of the following pregnant women likely faces the greatest risk of developing gestational diabetes? A client who: A) Was diagnosed with placenta previa early in her pregnancy B) Is gravida five (in her fifth pregnancy) C) Has BP of 130/85 mm Hg and pulse rate of 90 beats/minute D) Is morbidly obese defined as greater than 100 pounds over ideal weight

Ans: D Feedback: Obesity is among the risk factors for gestational diabetes mellitus (GDM). Obstetric complications, multiple pregnancies, high triglycerides, and hypertension are not specific risk factors for GDM.

A client with type 1 diabetes has started a new exercise routine. Knowing there may be some increase risks associated with exercise, the health care provider should encourage the client to: A) Watch for too rapid weight loss B) Monitor for respiratory disorders C) Be careful that you're not experiencing a rebound hyperglycemia D) Carry a snack with carbs to prevent profound hypoglycemia

Ans: D Feedback: People with diabetes are usually aware that delayed hypoglycemia can occur after exercise. Although muscle uptake of glucose increases significantly, the ability to maintain blood glucose levels is hampered by failure to suppress the absorption of injected insulin and activate the counterregulatory mechanisms that maintain blood glucose (to cause a hyperglycemia response). Even after exercise ceases, insulin's lowering effect on blood glucose levels continues, resulting in profound symptomatic hypoglycemia. Rapid weight loss accompanies the polyuria and dehydration of hyperglycemia rather than hypoglycemia. Respiratory disorders are associated with preexisting pulmonary or vascular problems exacerbated by the period of exercise.

Impaired and delayed healing in a person with diabetes is caused by long-term complications that include: A) Ketoacidosis B) Somogyi effect C) Fluid imbalances D) Chronic neuropathies

Ans: D Feedback: Suboptimal response to infection in a person with diabetes is caused by the presence of chronic complications, such as vascular disease and neuropathies, poorly controlled hyperglycemia, and altered immune cell and neutrophil function. Sensory deficits may cause a person with diabetes to ignore minor trauma and infection, and vascular disease may impair circulation and delivery of blood cells and other substances needed to produce an adequate inflammatory response and effect healing. Somogyi effect is an acute complication of diabetes, causing hypoglycemia. Ketoacidosis is an acute complication of hyperglycemia when liver ketone production exceeds cell use.

Which of the following individuals is experiencing the effects of a primary endocrine disorder? A client: A) With adrenal cortical insufficiency due to pituitary hyposecretion of ACTH B) Who has hypothyroidism as a result of low TSH production C) Whose dysfunctional hypothalamus has resulted in endocrine imbalances D) Who has low calcium levels because of the loss of his parathyroid gland

Ans: D Feedback: The loss of a gland, and the subsequent absence of the hormone that it normally produces, results in a primary endocrine disorder. The lack of a stimulating hormone such as ACTH or TSH results in a secondary disorder, whereas hypothalamic dysfunction causes tertiary endocrine disorders.

A lung cancer client with small cell carcinoma may secrete an excess of which hormone causing an ectopic form of Cushing syndrome due to a nonpituitary tumor? A) GH B) TSH C) DHEA D) ACTH

Ans: D Feedback: The third form (of Cushing syndrome) is ectopic Cushing syndrome, caused by a nonpituitary ACTH-secreting tumor. Certain extra pituitary malignant tumors such as small cell carcinoma of the lung may secrete ACTH or, rarely, CRH and produce Cushing syndrome. The adrenal sex hormone dehydroepiandrosterone (DHEA) contributes to the pubertal growth of body hair, particularly pubic and axillary hair in women. Thyroid-stimulating hormone (TSH) levels are used to differentiate between primary and secondary thyroid disorders. Although secretion of growth hormone (GH) has diurnal variations over a 24-hour period, with nocturnal sleep bursts occurring 1 to 4 hours after onset of sleep, it is unrelated to ACTH and/or CRH secretion.

Description of the type of complication of diabetes mellitus that includes coronary artery disease, cerebrovascular disease, and peripheral vascular disease ___

Macrovascular complications

Growth hormone secreting cells are called ___

Somatotropes

Type 1 diabetes is characterized by destruction of the pancreatic ___ and lack of insulin

beta cells

Severe and prolonged hypoglycemia may cause ___

brain death

Diabetes mellitus can be defined as a disorder of ___, ___, and ___ metabolism resulting from an imbalance between insulin availability and insulin need

carbohydrate, protein, fat

Describes children (particularly boys) who have moderately short stature, are thin build, have delayed skeletal and sexual maturation, and have absence of other causes of decreased growth ___

constitutional short stature

___ is characterized abnormal retinal vascular permeability, micro-aneurysm formation, neovascularization and associated hemorrhage, scarring, and retinal detachment

diabetic retinopathy

While insulin resistance seen in persons with type 2 diabetes can be caused by a number of factors, it is strongly associated with ___

obesity, physical inactivity

Type 2 diabetes is characterized by insulin ___

relative deficiency