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b) Monitor blood glucose levels throughout the day and administer exogenous insulin replacement as needed Pg. 1075 Type 1 Diabetes Mellitus Because of the loss of insulin response, all people with immune-mediated type 1 diabetes require exogenous insulin replacement to reverse the catabolic state, control blood glucose levels, and prevent ketosis.
9. Which treatment regimen is most likely to result in stable blood glucose levels for a client with a diagnosis of type 1 diabetes? a) Initially try to control blood glucose levels with diet and exercise routines along with weight reduction b) Monitor blood glucose levels throughout the day and administer exogenous insulin replacement as needed c) Wait until after eating the first meal of the day before checking blood glucose and then calculate insulin dose d) Perform a daily moderate exercise routine prior to insulin administration
c) Sparse axillary and pubic hair Pg. 1066 Clinical Manifestations A common finding would be sparse axillary and pubic hair. Other signs/symptoms would include dehydration, weakness, fatigue, anorexia, nausea, and weight loss. Skin would have increased pigmentation. Weight gain and fluid retention may be the result of Cushing syndrome.
1. The nurse is assessing a female client with a diagnosis of primary adrenal cortical insufficiency. Which manifestation should the nurse anticipate? a) Pale skin and increased hunger b) Anorexia and increased excitability c) Sparse axillary and pubic hair d) Weight gain and fluid retention
d) Thyroid storm Pg. 1062 Thyroid Storm The symptoms this client is experiencing are related to thyroid storm and must be treated immediately to prevent death. Myxedema coma is related to hypothyroidism but typically does not occur after a thyroidectomy. Addisonian crisis is related to hypoadrenalism.
10. A client who has just undergone a thyroidectomy is experiencing high fever, tachycardia, and extreme restlessness. The nurse would interpret these findings as manifestations of which complication? a) Hypothyroidism b) Addisonian crisis c) Myxedema coma d) Thyroid storm
c) Acromegaly Pg. 1053 Clinical Manifestations Enlargement of the small bones of the hands and feet and of the membranous bones of the face and skull results in a pronounced enlargement of the hands and feet, a broad and bulbous nose, a protruding jaw, and a slanting forehead. Bone overgrowth often leads to arthralgias and degenerative arthritis of the spine, hips, and knees. Virtually every organ of the body is increased in size. Enlargement of the heart and accelerated atherosclerosis may lead to an early death. Hyperthyroidism results from excess thyroid hormone. Myxedema and Cushing syndrome are the result of adrenal abnormalities and do not cause these bone changes.
11. The nurse is assessing a male client and finds abnormally large hands and feet, a bulbous nose, and a broad face with a protruding jaw. Based on these findings, which endocrine abnormality is most likely the cause for these physical changes? a) Myxedema b) Hyperthyroidism c) Acromegaly d) Cushing syndrome
c) Beta cell exhaustion due to long-standing insulin resistance Pg. 1076 Type 2 Diabetes Mellitus and the Metabolic Syndrome 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.
12. The results of a 44-year-old obese man's recent diagnostic workup have culminated in a new diagnosis of type 2 diabetes. Which pathophysiologic process underlies the client's new diagnosis? a) Actions of insulin autoantibodies (IAAs) and islet cell autoantibodies (ICAs) b) T-lymphocyte-mediated hypersensitivity reactions c) Beta cell exhaustion due to long-standing insulin resistance d) Destruction of beta cells that is not attributable to autoimmunity
a) Cardiac structures increase in size Pg. 1052 Growth Hormone Excess in Adults While all the complications can exist, it is the enlargement of the heart and accelerated atherosclerosis that may lead to an early death. The teeth become splayed, causing a disturbed bite and difficulty in chewing. Vertebral changes often lead to kyphosis, or hunchback. Bone overgrowth often leads to arthralgias and degenerative arthritis of the spine, hips, and knees. Virtually every organ of the body is increased in size.
13. Which complication of acromegaly can be life threatening? a) Cardiac structures increase in size b) Splayed teeth result in impaired chewing c) Vertebral changes result in kyphosis d) Bone overgrowth causes arthralgias
d) Using an insulin infusion pump Pg. 1075 Type 1 Diabetes Mellitus Clients with type 1 diabetes mellitus require exogenous insulin because they have absolute lack of their own secretion. Insulin is a protein that would be digested if taken orally. To avoid injections, clients could use an insulin pump, which provides continuous infusion through a catheter placed under the skin that is changed every few days. While some herbal preparations may help lower blood glucose, they do not replace insulin. While aerobic activity helps mobilize glucose, it does not replace insulin. Metformin is an insulin sensitizer that enhances insulin utilization, but does not replace insulin.
14. A client with type 1 diabetes mellitus wishes to stop taking insulin injections. What option is appropriate? a) Taking the herb chromium picolinate b) Taking metformin c) Increasing daily aerobic activity d) Using an insulin infusion pump
c) Before 0800 Pg. 1048 Assessment o Hypothalamic-Pituitary Function The assessment of hypothalamic-pituitary function has been made possible by many newly developed imaging and radioimmunoassay methods. Assessment of the baseline status of the hypothalamic-pituitary target cell hormones involves measuring the following laboratory specimens (ideally obtained before 0800): serum cortisol, serum prolactin, serum thyroxine and TSH, serum testosterone and estrogen and serum LH/FSH, serum GH, and plasma and urine osmolality.
15. A client is to have a serum thyroxine and thyroid stimulating laboratory test performed to assess the baseline status of the hypothalamic-pituitary target cell hormones. When educating the client about the laboratory tests, when would the nurse inform him the test should be obtained? a) At noon b) After 0900 c) Before 0800 d) Prior to midnight
c) The client has been experiencing a great deal of emotional stress due to family issues d) The client has fainted due to low blood glucose levels on several occasions e) The client is on a weight-loss diet and is exercising excessively Pg. 1049 Growth and Growth Hormone Disorders GH secretion is stimulated by hypoglycemia, fasting, starvation, increased blood levels of amino acids, and stress conditions such as trauma, excitement, emotional stress, and heavy exercise. GH is inhibited by increased glucose levels, free fatty acid release, cortisol, and obesity.
16. A client is suspected to have increased growth hormone levels. When performing a health history, what assessment data would be important for the nurse to report to the physician? Select all that apply. a) The client is obese with a BMI > 35 b) The client has had consistently elevated glucose levels c) The client has been experiencing a great deal of emotional stress due to family issues d) The client has fainted due to low blood glucose levels on several occasions e) The client is on a weight-loss diet and is exercising excessively
a) A 5-year-old black female with developing breasts and pubic hair Pg. 1054 Precocious Puberty Precocious puberty is now defined as the appearance of secondary sexual development before the age of 7 years in white girls and 6 years in black girls. In boys of both races, the lower age limit remains 9 years. However, it is recognized that puberty can develop earlier in boys with obesity.
17. The nurse is working in a pediatric clinic. Which child would the nurse recognize as having isosexual precocious puberty? a) A 5-year-old black female with developing breasts and pubic hair b) A 10-year-old black female who has begun menstruating c) A 14-year old white female who has not yet developed secondary sex characteristics d) A 9-year-old white female who has small breast buds
a) Insulin resistance Pg. 1077 Insulin Resistance and the Metabolic Syndrome 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. Obese people have increased resistance to the action of insulin and impaired suppression of glucose production by the liver, resulting in both hyperglycemia and hyperinsulinemia. Lifestyle and overeating seem to be the triggering events (rather than metabolic abnormalities). Acute pancreatitis is a reversible impairment of alpha and beta cell function, with hypoinsulinemia as a complication.
18. Which metabolic abnormality can lead to the development of type 2 diabetes? a) Insulin resistance b) Chronic overeating c) Acute pancreatitis d) Recurrent hypoglycemia
a) "You could regulate your diet, exercise regularly, and lose weight" Pg. 1076 Type 2 Diabetes Mellitus and the Metabolic Syndrome Diabetes management is based on dietary regulation, exercise, and medications. Many clients with type 2 diabetes mellitus can avoid injections if they exercise regularly, follow dietary guidelines, and manage their weight.
19. A client with a new diagnosis of type 2 diabetes mellitus states, "I am really worried that I might need to take injections. Is there something I can do to avoid that?" What is the best response by the nurse? a) "You could regulate your diet, exercise regularly, and lose weight" b) "A support group could help you cope with stress and learn helpful tips" c) "Diabetes management is complicated; you can't avoid injections" d) "If you exercise weekly, you won't need injections"
b) The stress of the event caused the release of adrenal cortical hormones Pg. 1076 Type 2 Diabetes Mellitus and the Metabolic Syndrome Elevation of glucocorticoid levels (i.e., cortisol), such as during stressful events, can lead to derangements in glucose metabolism. 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.
2. A client with long-standing type 2 diabetes is surprised to see high blood sugar readings while recovering from an emergency surgery. Which factor may have contributed to the client's inordinately elevated blood glucose levels? a) The tissue trauma of surgery resulted in gluconeogenesis b) The stress of the event caused the release of adrenal cortical hormones c) Sleep disruption in the hospital precipitated the dawn effect d) Illness inhibited the release and uptake of glucagon
d) Woman with a family history of diabetes Pg. 1078 Gestational Diabetes Gestational diabetes occurs most commonly in black, Hispanic/Latino and Native American/First Nation women. It most frequently affects women with a family history of diabetes; a history of stillbirth or spontaneous abortion; women who previously gave birth to a newborn with fetal anomaly or had a previous large-for-gestational-age infant; those who are obese; those of advanced maternal age; or those who have had five or more pregnancies.
20. The obstetrical nurse is caring for a client who has been treated for gestational diabetes. When teaching the client about the causes of gestational diabetes, the nurse should include which risk factor in the teaching? a) First pregnancy b) First birth occurring during the teenage years c) Woman who has had a child under 5 lb (2.2 kg) d) Woman with a family history of diabetes
a) Myxedema coma Pg. 1060 Myxedematous Coma Myxedema implies the presence of a nonpitting mucous type of edema caused by an accumulation of a hydrophilic mucopolysaccharide substance in the connective tissues throughout the body. The hypothyroid state may be mild, with only a few signs and symptoms, or it may progress to a life-threatening condition called myxedema coma. Pheochromocytoma is a tumor of the adrenal gland. Thyroid storm is related to hyperthyroidism. Paraneoplastic syndrome is a separate condition.
21. An overweight, 14-year-old boy feels tired all the time. He sleeps 12 to 14 hours a day and has a voracious appetite but no energy to burn off the calories. He has been diagnosed with hypothyroidism brought about by the accumulation of a nonpitting mucosal edema. For which life-threatening condition should his care team be prepared? a) Myxedema coma b) The paraneoplastic secretion of endocrine hormones c) Thyroid storm d) Pheochromocytoma
b) Autoimmune destruction of pancreatic beta cells Pg. 1075 Type 1 Diabetes Mellitus Type 1 diabetes involves autoimmune destruction of beta cells. The pathophysiology of type 2 diabetes has both genetic and acquired factors.
22. When educating a client about type 1 diabetes, the nurse will mention that this type is caused by which mechanism? a) Overuse of steroids, making pancreatic cells resistant to glucose b) Autoimmune destruction of pancreatic beta cells c) Genetic predisposition d) Idiopathic, abnormally large pancreatic cells
c) "Insulin is destroyed by the stomach contents and has to be administered by injection" Pg. 1048 Growth and Growth Hormone Disorders Insulin is destroyed by the gastrointestinal tract and needs to be administered via injection or inhalation. Type 1 diabetes is not treated with oral medications at this time. Insulin is administered subcutaneously rather than in the vein. The statement about the mother not having to give injections once the child is older does not address the mother's concerns.
23. The mother of a 2-year-old newly diagnosed with type 1 diabetes asks why insulin has to be given by injection. The best response by the nurse is: a) "Insulin needs to go directly into the vein to work best" b) "When your child gets old enough, you will not have to administer injections" c) "Insulin is destroyed by the stomach contents and has to be administered by injection" d) "Your child is not old enough to swallow the pills needed to treat her diabetes"
b) Cardiovascular system Pg. 1049 Growth and Growth Hormone Disorders Evidence shows that cardiovascular mortality increases in GH-deficient adults. A higher prevalence of atherosclerotic plaques and endothelial dysfunction has been reported in both childhood and adult GH deficiency. The GH deficiency syndrome is associated with a cluster of cardiovascular risk factors, including central adiposity, insulin resistance, and dyslipidemia.
24. The nurse is caring for an adult client with growth hormone deficiency. When performing an assessment of this client, which system should the nurse be sure to assess for complications related to this disorder? a) Respiratory system b) Cardiovascular system c) Renal system d) Neurologic system
a) 06:00 to 08:00 AM Pg. 1065 Tests of Adrenal Function 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.
25. 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) 04:00 to 6:00 PM c) 10:00 AM to noon d) 09:00 to 11:00 PM
c) The hypothalamus secretes GH-releasing hormone Pg. 1050 Growth and Growth Hormone Disorders Like other pituitary functions, hypothalamic stimulation precedes hormone release. In the case of GH, stimulation is the result of GH-releasing hormone by the hypothalamus. GH is then released by the pituitary gland, stimulating the liver to release insulin-like GFs, which ultimately causes the epiphyseal plates of long bones to grow.
26. A child is born with dwarfism to normal-sized parents. The nurse is explaining how growth hormone (GH) plays a central role in the increase in stature that characterizes childhood and adolescence. What is the first step in the growth hormone chain of events? a) Epiphyseal growth plates of long bones are influenced b) GH is released and circulates unbound in the plasma c) The hypothalamus secretes GH-releasing hormone d) The liver is stimulated
a) An adult with an excess of growth hormone due to an adenoma Pg. 1052-1053 Growth Hormone Excess in Adults 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.
27. Which individual displays the precursors to acromegaly? a) An adult with an excess of growth hormone due to an adenoma b) An adult who has a diagnosis of Cushing syndrome c) A client who has recently developed primary adrenal carcinoma d) A girl who has been diagnosed with precocious puberty
a) Random blood glucose 195 mg/dl (10.8 mmol/l) Pg. 1073 Diabetes Mellitus and the Metabolic Syndrome Laboratory values that are considered normal are hemoglobin A1C less than 6%, fasting plasma glucose (FPG) less than 100 mg/dl (5.5 mmol/l) or less than 140 mg/dl (7.8 mmol/l) 2 hours after an oral glucose tolerance test (GTT). Urine should be free of ketones. A hemoglobin A1C value that is greater than or equal to 6.5%, a fasting blood glucose greater than 126 mg/dl (7.0 mmol/l), or a blood glucose level greater than 200 mg/dl (11.1 mmol/l) 2 hours after a glucose tolerance test (GTT) indicate diabetes mellitus. Values between these levels are considered to place clients at increased risk for diabetes mellitus and require further evaluation. A random blood glucose level is expected to correlate with the 2-hour GTT results and should be below 200 mg/dl (11.1 mmol/l). Although the client does not have a result that meets the threshold to be diagnosed with diabetes, the elevated levels warrant assessment for prediabetes and early intervention.
28. The nurse screening for diabetes mellitus at a health fair obtains these results. Which client should be referred to a primary health care provider for further evaluation? a) Random blood glucose 195 mg/dl (10.8 mmol/l) b) Fasting blood glucose 89 mg/dl (4.9 mmol/l) c) Hemoglobin A1C 5.6% d) Urine ketones negative
d) Slow rewarming of the client to prevent vasodilation and vascular collapse Pg. 1060 Myxedematous Coma If hypothermia is present, active rewarming of the body is contraindicated because it may induce vasodilation and vascular collapse. Prevention is preferable to treatment and entails special attention to high risk populations, such as women with a history of Hashimoto thyroiditis.
29. A client with severe hypothyroidism is presently experiencing hypothermia. What nursing intervention is a priority in the care of this client? a) Active rewarming of the client to increase body temperature rapidly b) Placing the client on a hyperthermia blanket and using heated saline in order to induce vasodilation c) Keeping the client in a hypothermic state in order to prevent renal failure d) Slow rewarming of the client to prevent vasodilation and vascular collapse
b) ACTH Pg. 1067 Glucocorticoid Hormone Excess (Cushing Syndrome) One of the earliest signs of Cushing syndrome, a disorder of cortisol excess, is the loss of diurnal variation in CRH and adrenocorticotropin hormone (ACTH) secretion, with corticotropin-releasing hormone (CRH) controlling the release of ACTH. 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.
3. One of the earliest signs of Cushing syndrome is the loss of variable diurnal secretion of cortisol-releasing hormone (CRH) and: a) DHEA b) ACTH c) GH d) TSH
d) Dawn phenomenon Pg. 1081 The Dawn Phenomenon 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.
30. 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) Hyperglycemic hyperosmolar state (HHS) b) Somogyi effect c) Possible stress-related hypoglycemia d) Dawn phenomenon
a) Excess ACTH production by a pituitary tumor Pg. 1067 Glucocorticoid Hormone Excess (Cushing Syndrome) 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.
4. Which pathophysiologic phenomenon may result in a diagnosis of Cushing disease? a) Excess ACTH production by a pituitary tumor b) Autoimmune destruction of the adrenal cortex c) Malfunction of the HPA system d) Hypopituitarism
a) Decreased sweating b) Coarse and dry skin and hair c) Intolerance to cold Pg. 1060 Hyperthyroidism The client with hypothyroidism experiences an intolerance to cold, decreased sweating, and coarse and dry skin and hair, related to the decrease in metabolic rate from the deficient thyroid secretion.
5. A client with hypothyroidism has not taken medication for several months, informing the nurse that she lost her insurance and is unable to afford the medication. When assessing the client's temperature tolerance and skin, what does the nurse anticipate finding? Select all that apply. a) Decreased sweating b) Coarse and dry skin and hair c) Intolerance to cold d) Thin and silky skin and hair e) Increased perspiration
b) Fine-needle aspiration biopsy Pg. 1057-1058 Tests of Thyroid Function Fine-needle aspiration biopsy of a thyroid nodule has proved to be the best method for differentiation of benign from malignant thyroid disease. Ultrasonography can be used to differentiate cystic from solid thyroid lesions, and CT and MRI scans are used to demonstrate tracheal compression or impingement on other neighboring structures.
6. Which test can the nurse prepare the client for to determine the differentiation between a benign and malignant thyroid disease? a) MRI b) Fine-needle aspiration biopsy c) Ultrasonography d) CT scan
a) Glycosylated hemoglobin, hemoglobin A1C (HbA1C) Pg. 1075 Glycated Hemoglobin Testing (Hemoglobin A1C) Glycosylated hemoglobin, hemoglobin A1C (HbA1C), and A1C are terms used to describe hemoglobin into which glucose has been incorporated. Glycosylation is essentially irreversible, and the level of A1C present in the blood provides an index of blood glucose levels over the previous 6 to 12 weeks. In uncontrolled diabetes or diabetes with hyperglycemia, there is an increase in the level of A1C. The other options would not reflect the 2-month period.
7. A client tells the health care provider that he has been very compliant over the last 2 months in the management of his diabetes. The best diagnostic indicator that would support the client's response would be: a) Glycosylated hemoglobin, hemoglobin A1C (HbA1C) b) Fasting blood glucose level c) Capillary blood glucose sample d) Urine test
d) Weight loss, glucose monitoring, and oral antihyperglycemic medications Pg. 1076 Type 2 Diabetes Mellitus and the Metabolic Syndrome Persons with type 2 diabetes would be unlikely to require insulin initially and oral medications are likely to be of benefit as an addition to weight loss and glucose monitoring.
8. An obese adult has recently been diagnosed with type 2 diabetes. The nurse knows that the most likely treatment plan for this client will include which topics? a) Daily monitoring for urine ketones and weight loss measures. b) Injectable insulin, nutrition management, and adequate hydration c) Continuous subcutaneous insulin infusion (CSII) and nutrition management d) Weight loss, glucose monitoring, and oral antihyperglycemic medications