588 Final: Endocrine
The nurse has admitted a patient with hyperglycemic hyperosmolar state (HHS). Which findings would the nurse expect to observe in this patient? A. Hyperglycemia with low serum osmolality B. Severe hyperglycemia with minimal or absent ketosis C. Little or no ketosis in serum with rapidly escalating ketonuria D. Hyperglycemia and ketosis
B. Severe hyperglycemia with minimal or absent ketosis The hallmarks of HHS are extremely high levels of plasma glucose with resulting elevations in serum hyperosmolality and osmotic diuresis. The disorder occurs mainly in patients with type 2 diabetes.
A patient is admitted with diabetic ketoacidosis (DKA). The patient presents with dry, cracked lips and is begging for something to drink. What reply would be the nurse's best response? a. "We can't give you anything to drink until we get your blood sugar under control." b. "You can have one cup of coffee without sugar." c. "You can drink anything you want as long as it's sugar free." d. "You can drink as much water has you can handle."
a. "We can't give you anything to drink until we get your blood sugar under control." Patients with diabetic ketoacidosis (DKA) are kept on NPO status (nothing by mouth) until the hyperglycemia is under control. Fluid replacement is done via IV.
A patient has been admitted with hyperosmolar hyperglycemic state (HHS). The nurse knows that intravenous insulin is usually administered at what dosage? a. 0.1 U/kg/h b. 1.0 U/kg/h c. 2.0 U/kg/h d. 5.0 U/kg/h
a. 0.1 U/kg/h Regular insulin infusing at an initial rate calculated as 0.1 unit per kg hourly (7 U/h for a person weighing 70 kg) should lower the plasma glucose by 50 to 70 mg/dL in the first hour of treatment. If the measured glucose does not decrease by this amount, the insulin infusion rate may be doubled until the blood glucose is declining at a rate of 50 to 70 mg/dL/h.
A patient presents with ketoacidosis and a blood glucose level of 125 mg/dL. Diabetic ketoacidosis has been ruled out. The nurse knows that ketoacidosis can occur in which condition? a. Acute pancreatitis b. Drug overdose c. Hyperglycemic hyperosmolar state d. Hyperaldosteronism
a. Acute pancreatitis Ketoacidosis also occurs with acute pancreatitis, starvation, and alcoholic ketoacidosis.
The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which medical intervention would the nurse expect to be ordered for this patient? a. Extensive hydration b. Oral hypoglycemic agents c. Large doses of intravenous (IV) insulin d. Limiting food and fluids
a. Extensive hydration Rapid IV fluid replacement requires the use of a volumetric pump. Insulin is administered intravenously to patients who are severely dehydrated or have poor peripheral perfusion to ensure effective absorption. Patients with diabetic ketoacidosis (DKA) are kept on NPO (nothing by mouth) status until the hyperglycemia is under control. Critical care nurses are responsible for monitoring the rate of plasma glucose decline in response to insulin.
A patient is admitted with diabetic ketoacidosis (DKA). The nurse knows that the dehydration associated with DKA results from which pathophysiologic mechanism? a. Increased serum osmolality and urea b. Decreased serum osmolality and hyperglycemia c. Ketones and potassium shifts d. Acute renal failure
a. Increased serum osmolality and urea Hyperglycemia increases the plasma osmolality, and the blood becomes hyperosmolar. Cellular dehydration occurs as the hyperosmolar extracellular fluid draws the more dilute intracellular and interstitial fluid into the vascular space in an attempt to return the plasma osmolality to normal.
A patient was admitted with diabetic ketoacidosis (DKA). Glucose is 349 mg/dL, K is 3.7 mEq/L, and pH is 7.10. Which of the following interventions would you expect? (Select all that apply.) a. NS 1.5 L IV fluid bolus b. Insulin infusion at 5 units/h c. Sodium bicarbonate 50 mmol IV push d. Vasopressin 10 units IM every 3 hours e. Potassium 20 mEq/L of IV fluid
a. NS 1.5 L IV fluid bolus b. Insulin infusion at 5 units/h e. Potassium 20 mEq/L of IV fluid Dehydration is a common presenting issue in diabetic ketoacidosis (DKA), so the administration of fluids and insulin will help correct the hyperglycemia and acidosis. Sodium bicarbonate is not recommended unless the pH is less than 6.9. As dehydration is reversed, potassium moves back into the cells, and hypokalemia can result, so administration of replacement potassium is necessary.
A patient has been admitted with diabetic ketoacidosis, and treatment has been initiated. Which findings would lead the nurse to suspect the patient is dehydrated? a. Poor skin turgor and flat neck veins b. Dyspnea and crackles c. Presence of Chvostek and Trousseau signs d. Extra heart sounds and 3+ edema
a. Poor skin turgor and flat neck veins Poor skin turgor and flat neck veins are indicative of dehydration. Dyspnea, crackles, extra heart sounds, and 3+ edema are signs of fluid overload. Chvostek and Trousseau signs are indicative of hypocalcemia.
As a patient with diabetic ketoacidosis (DKA) receives insulin and fluids, the nurse knows careful assessment must be given to which electrolyte? a. Potassium b. Sodium c. Phosphorus d. Calcium
a. Potassium Replacement of potassium by administration of potassium chloride (KCl) begins as soon as the serum potassium falls below normal. Frequent verification of the serum potassium concentration is required for the patient with diabetic ketoacidosis receiving fluid resuscitation and insulin therapy.
The nurse has admitted a patient with hyperglycemic hyperosmolar state (HHS). Which medical intervention would the nurse expect to see ordered for this patient? a. Rapid rehydration with intravenous fluids b. Insertion of a pulmonary artery catheter c. Administration of high-dose intravenous insulin d. Hourly monitoring of urine glucose and ketone levels
a. Rapid rehydration with intravenous fluids The goals of medical management are rapid rehydration, insulin replacement, and correction of electrolyte abnormalities, specifically potassium replacement. The underlying stimulus of the hyperglycemic hyperosmolar state (HHS) must be discovered and treated. The same basic principles used to treat patients with diabetic ketoacidosis are used for patients with HHS.
A patient has been admitted with diabetic ketoacidosis (DKA). The nurse knows that the top priority in the initial treatment of DKA is which intervention? a. Lowering the blood sugar as quickly as possible b. Administering intravenous fluids c. Administering sodium bicarbonate d. Determining the precipitating cause
b. Administering intravenous fluids A patient with diabetic ketoacidosis (DKA) is dehydrated and may have lost 5% to 10% of his or her body weight in fluids. A fluid deficit up to 6 L can exist in severe dehydration. Aggressive fluid replacement is provided to rehydrate both the intracellular and the extracellular compartments and prevent circulatory collapse.
A patient is admitted with diabetic ketoacidosis (DKA) and is experiencing polyuria. Which electrolyte disturbances would the nurse expect to see at this phase of DKA? a. Decreased calcium and increased phosphorus levels b. Decreased potassium and sodium levels. c. Increased sodium and decreased phosphorus levels d. Decreased calcium and potassium levels.
b. Decreased potassium and sodium levels. Polyuria results in large volumes of water, along with sodium, potassium, and phosphorus, being excreted in the urine, causing a fluid volume deficit.
The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which symptom is most suggestive of DKA? a. Irritability b. Excessive thirst c. Rapid weight gain d. Peripheral edema
b. Excessive thirst Diabetic ketoacidosis (DKA) has a predictable clinical presentation. It is usually preceded by patient complaints of malaise, headache, polyuria (excessive urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). Nausea, vomiting, extreme fatigue, dehydration, and weight loss follow. Central nervous system depression, with changes in the level of consciousness, can lead quickly to coma.
An older patient presents with a serum glucose level of 900 mg/dL, hematocrit of 55%, and no serum ketones. Immediate attention must be given to which intervention? a. Evaluating clotting factors b. Fluid administration c. Insulin administration d. Sodium replacement
b. Fluid administration The physical examination may reveal a profound fluid deficit. Signs of severe dehydration include longitudinal wrinkles in the tongue, decreased salivation, and decreased central venous pressure, with increases in heart rate and rapid respirations (Kussmaul air hunger does not occur). In older patients, assessment of clinical signs of dehydration is challenging.
Which pathophysiologic mechanism occurs in the patient with type 2 diabetes? a. Lack of insulin production b. Imbalance between insulin production and use c. Overproduction of glucose d. Increased uptake of glucose in the cells
b. Imbalance between insulin production and use Type 2 diabetes results from a progressive insulin secretory defect in addition to insulin resistance.
A patient with diabetic ketoacidosis (DKA) has an insulin drip infusing, and the nurse has just administered subcutaneous insulin. The nurse is alert for signs of hypoglycemia, which would include what findings? a. Kussmaul respirations and flushed skin b. Irritability and paresthesia c. Abdominal cramps and nausea d. Hypotension and itching
b. Irritability and paresthesia Irritability and paresthesia are seen in hypoglycemia.
When a patient with diabetic ketoacidosis (DKA) has insulin infusing intravenously, the nurse expects a drop in the serum levels of which electrolytes? a. Sodium and potassium b. Potassium and phosphate c. Bicarbonate and calcium d. Sodium and phosphate
b. Potassium and phosphate Frequent verification of the serum potassium concentration is required for patients with DKA receiving fluid resuscitation and insulin therapy. The serum phosphate level is sometimes low (hypophosphatemia) in DKA. Insulin treatment may make this more obvious as phosphate is returned to the interior of the cell. If the serum phosphate level is less than 1 mg/dL, phosphate replacement is recommended.
A patient with hyperglycemic hyperosmolar state (HHS) has a serum glucose level of 400 mg/dL and a serum sodium level of 138 mEq/L. What is the intravenous fluid of choice? a. D5W b. 0.45% NS c. 0.9% NS d. D5/NS
c. 0.9% NS The fluid deficit may be as much as 150 mL/kg of body weight. The average 150-lb adult can lose more than 7 to 10 L of fluid. Physiologic saline solution (0.9%) is infused at 1 L/h, especially for patients in hypovolemic shock if there is no cardiovascular contraindication. Several liters of volume replacement may be required to achieve a blood pressure and central venous pressure within normal range. Infusion volumes are adjusted according to the patient's hydration state and sodium level.
A patient is admitted with diabetic ketoacidosis (DKA). The patient's arterial blood gas indicates the patient has an uncompensated metabolic acidosis. The patient has rapid, regular respirations. Which medical intervention would the nurse expect to initiate to correct the acidosis? a. Initiate oxygen therapy via a face mask. b. Administer sodium bicarbonate. c. Administer insulin and fluids intravenously. d. Prepare for intubation.
c. Administer insulin and fluids intravenously. Replacement of fluid volume and insulin interrupts the ketotic cycle and reverses the metabolic acidosis. In the presence of insulin, glucose enters the cells, and the body ceases to convert fats into glucose.
The nurse knows that during the resuscitation of a patient with diabetic ketoacidosis (DKA), the intravenous (IV) line should be changed to a solution containing glucose when what happens? a. Patient becomes more alert b. IV insulin has been infusing for 4 hours c. Blood glucose drops to 200 mg/dL d. Blood glucose drops to 100 mg/dL
c. Blood glucose drops to 200 mg/dL When the serum glucose level decreases to 200 mg/dL, the infusing solution is changed to a 50/50 mix of hypotonic saline and 5% dextrose. Dextrose is added to replenish depleted cellular glucose as the circulating serum glucose level falls.
A patient in diabetic ketoacidosis (DKA) is comatose with a temperature of 102.2° F. The nurse suspects the patient may have which secondary disorder? a. Head injury b. Hypothalamus infarction c. Infection d. Heat stroke
c. Infection A patient in diabetic ketoacidosis can experience a variety of complications, including fluid volume overload, hypoglycemia, hypokalemia or hyperkalemia, hyponatremia, cerebral edema, and infection.
The nurse is caring for a critically ill patient with type 1 diabetes. The nurse understands that the patient is at risk for developing diabetic ketoacidosis (DKA) secondary to what etiology? a. Excess insulin administration b. Inadequate food intake c. Physiologic and psychologic stress d. Increased release of antidiuretic hormone (ADH)
c. Physiologic and psychologic stress Major neurologic and endocrine changes occur when an individual is confronted with physiologic stress caused by any critical illness, sepsis, trauma, major surgery, or underlying cardiovascular disease.
A patient weighs 140 kg and is 60 inches tall. The patient's blood sugar is being controlled by glipizide. Which topic would be important for the nurse to include in the patient's discharge education plan? a. Signs of hyperglycemia b. Proper injection technique c. Weight loss d. Increased caloric intake
c. Weight loss This patient weighs 308 lb and is 5 feet tall. Diet management and exercise are interventions to facilitate weight loss in patients with type 2 diabetes.
A patient with a history of type 2 diabetes was admitted after aneurysm repair. The patient's serum glucose levels have been elevated for the past 2 days, and the patient is concerned about becoming dependent on insulin. Which statement is the nurse's best response to the patient's concerns? a. "This surgery may have damaged your pancreas. We will have to do more evaluation." b. "Perhaps your diabetes was more serious from the beginning." c. "You will need to discuss this with your physician." d. "The stress on your body has temporarily increased your blood sugar levels."
d. "The stress on your body has temporarily increased your blood sugar levels." Adrenal hormones released during stress elevate blood sugar by increasing insulin resistance and increasing hepatic gluconeogenesis.
A patient is admitted with extreme fatigue, vomiting, and headache. This patient has type 1 diabetes that has been well controlled with an insulin pump. The patient states, "I know it could not be my diabetes because my pump gives me 24-hour control." Which reply would be the nurse's best response? a. "You know a lot about your pump, and you are correct." b. "You're right. This is probably a virus." c. "We'll get an abdominal CT and see if your pancreas is inflamed." d. "We'll check your serum blood glucose and ketones."
d. "We'll check your serum blood glucose and ketones." Subcutaneous insulin pumps can malfunction. It is critical to assess glucose and ketone levels to evaluate for diabetic ketoacidosis.
A patient is admitted with diabetic ketoacidosis (DKA). The nurse knows that the lack of insulin results in which process? a. Decreased glucagon release b. Decreased glycogenolysis c. Decreased ketone production d. Increased gluconeogenesis
d. Increased gluconeogenesis The release of glucagon from the liver is stimulated when insulin is ineffective in providing the cells with glucose for energy. Glucagon increases the amount of glucose in the bloodstream by breaking down stored glucose (glycogenolysis). In insulin deficiency states, fat is rapidly converted into glucose (gluconeogenesis). Ketoacidosis occurs when free fatty acids are metabolized into ketones: Acetoacetate, â-hydroxybutyrate, and acetone are the three ketone bodies that are produced.
A patient with type 2 diabetes is admitted. He is very lethargic and hypotensive. A diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is given. Which findings support this diagnosis? a. Decreased serum glucose and increased serum ketones b. Increased urine ketones and decreased serum osmolality c. Increased serum osmolality and increased serum potassium d. Increased serum osmolality and increased serum glucose
d. Increased serum osmolality and increased serum glucose Laboratory findings are used to establish the definitive diagnosis of hyperglycemic hyperosmolar syndrome (HHS). Plasma glucose levels are strikingly elevated (greater than 600 mg/dL). Serum osmolality is greater than 320 mOsm/kg.
The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which statement best describes the rationale for administrating potassium supplements with the patient's insulin therapy? a. Potassium replaces losses incurred with diuresis. b. The patient has been in a long-term malnourished state. c. Intravenous (IV) potassium renders the infused solution isotonic. d. Insulin drives the potassium back into the cells.
d. Insulin drives the potassium back into the cells. Low serum potassium (hypokalemia) occurs as insulin promotes the return of potassium into the cell and metabolic acidosis is reversed. Replacement of potassium by administration of potassium chloride (KCl) begins as soon as the serum potassium falls below normal. Frequent verification of the serum potassium concentration is required for patients with diabetic ketoacidosis (DKA) who are receiving fluid resuscitation and insulin therapy.
A patient was admitted with diabetic ketoacidosis (DKA) an hour ago and is on an insulin drip. Suddenly, the nurse notices frequent premature ventricular contractions (PVCs) on the electrocardiogram. The nurse notifies the practitioner. The nurse would anticipate an order for which intervention? a. A lidocaine bolus b. Stopping the insulin drip c. Synchronizing cardioversion d. Obtaining serum electrolytes
d. Obtaining serum electrolytes Hypokalemia can occur within the first hours of rehydration and insulin treatment. Continuous cardiac monitoring is required, because low serum potassium (hypokalemia) can cause ventricular dysrhythmias.
A patient is admitted with severe hyperglycemia. The patient is very lethargic and has a "fruity" odor to his breath. The nurse knows the odor on the patient's breath is indicative of which situation? a. Alcohol intoxication b. Lack of sodium bicarbonate c. Hypokalemia d. Presence of acetone
d. Presence of acetone Acid ketones dissociate and yield hydrogen ions (H+) that accumulate and precipitate a decrease in serum pH. The level of serum bicarbonate also decreases, consistent with a diagnosis of metabolic acidosis. Breathing becomes deep and rapid (Kussmaul respirations) to release carbonic acid in the form of carbon dioxide. Acetone is exhaled, giving the breath its characteristic "fruity" odor.
