Chapter 29: The Child with Endocrine Dysfunction

1. The clinic nurse is reviewing hemoglobin A1c levels on several children with type 1 diabetes. Hemoglobin A1c levels of less than _____% is a goal for children with type 1 diabetes. (Record your answer in a whole number.)

ANS: 7 The measurement of glycosylated hemoglobin (hemoglobin A1c) levels is a satisfactory method for assessing control of the diabetes. As red blood cells circulate in the bloodstream, glucose molecules gradually attach to the hemoglobin A molecules and remain there for the lifetime of the red blood cell, approximately 120 days. The attachment is not reversible; therefore, this glycosylated hemoglobin reflects the average blood glucose levels over the previous 2 to 3 months. The test is a satisfactory method for assessing control, detecting incorrect testing, monitoring the effectiveness of changes in treatment, defining patients' goals, and detecting nonadherence. Hemoglobin A1c levels of less than 7% are a well-established goal at most care centers. PTS: 1 DIF: Cognitive Level: Analyze REF: 995 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

31. The nurse is implementing care for a school-age child admitted to the pediatric intensive care in diabetic ketoacidosis (DKA). Which prescribed intervention should the nurse implement first? a. Begin 0.9% saline solution intravenously as prescribed. b. Administer regular insulin intravenously as prescribed. c. Place child on a cardiac monitor. d. Place child on a pulse oximetry monitor.

ANS: A All patients with DKA experience dehydration (10% of total body weight in severe ketoacidosis) because of the osmotic diuresis, accompanied by depletion of electrolytes, sodium, potassium, chloride, phosphate, and magnesium. The initial hydrating solution is 0.9% saline solution. Insulin therapy should be started after the initial rehydration bolus because serum glucose levels fall rapidly after volume expansion. The child should be placed on the cardiac and pulse oximetry monitor after the rehydrating solution has been initiated. PTS: 1 DIF: Cognitive Level: Analyze REF: 998 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

1. Nursing care of a child diagnosed with a syndrome of inappropriate ADH should include which of the following? (Select all that apply.) a. Weigh daily b. Encourage fluids c. Turn frequently d. Maintain nothing by mouth (NPO) e. Restrict fluids

ANS: A, E Increased secretion of ADH causes the kidney to reabsorb water, which increases fluid volume and decreases serum osmolarity with a progressive reduction in sodium concentration. The immediate management of the child is to restrict fluids. The child should also be weighed at the same time each day. Encouraging fluids will worsen the child's condition. Turning frequently is not an appropriate intervention unless the child is unresponsive. Fluids, not food, should be restricted. PTS: 1 DIF: Cognitive Level: Analyze REF: 981 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

32. The nurse should teach parents of a preschool child with type 1 diabetes that which can raise the blood glucose level? a. Exercise b. Steroids c. Decreased food intake d. Lantus insulin

ANS: B Parents should understand how to adjust food, activity, and insulin at the time of illness or when the child is treated for an illness with a medication known to raise the blood glucose level (e.g., steroids). Exercise, insulin, and decreased food intake can cause hypoglycemia. PTS: 1 DIF: Cognitive Level: Apply REF: 1004 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy

28. The nurse is caring for an 11-year-old boy who has recently been diagnosed with diabetes. Which should be included in the teaching plan for daily injections? a. The parents do not need to learn the procedure. b. He is old enough to give most of his own injections. c. Self-injections will be possible when he is closer to adolescence. d. He can learn about self-injections when he is able to reach all injection sites.

ANS: B School-age children are able to give their own injections. Parents should participate in learning and giving the insulin injections. He is already old enough to administer his own insulin. The child is able to use thighs, abdomen, part of the hip, and arm. Assistance can be obtained if other sites are used. PTS: 1 DIF: Cognitive Level: Apply REF: 996 | 1002 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy

6. The nurse is conducting a staff in-service on childhood endocrine disorders. Diabetes insipidus is a disorder of: a. anterior pituitary. b. posterior pituitary. c. adrenal cortex. d. adrenal medulla.

ANS: B The principal disorder of posterior pituitary hypofunction is diabetes insipidus. The anterior pituitary produces hormones such as GH, thyroid-stimulating hormone, adrenocorticotropic hormone, gonadotropin, prolactin, and melanocyte-stimulating hormone. The adrenal cortex produces aldosterone, sex hormones, and glucocorticoids. The adrenal medulla produces catecholamines. PTS: 1 DIF: Cognitive Level: Understand REF: 980 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

30. To help the adolescent deal with diabetes, the nurse must consider which characteristic of adolescence? a. Desire to be unique b. Preoccupation with the future c. Need to be perfect and similar to peers d. Need to make peers aware of the seriousness of hypoglycemic reactions

ANS: C Adolescence is a time when the individual wants to be perfect and similar to peers. Having diabetes makes adolescents different from their peers. Adolescents do not wish to be unique; they desire to fit in with the peer group and are usually not future oriented. Forcing peer awareness of the seriousness of hypoglycemic reactions would further alienate the adolescent with diabetes. The peer group would focus on the differences. PTS: 1 DIF: Cognitive Level: Analyze REF: 1006 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development

23. A parent asks the nurse why self-monitoring of blood glucose is being recommended for her child with diabetes. The nurse should base the explanation on which knowledge? a. It is a less expensive method of testing. b. It is not as accurate as laboratory testing. c. Children are better able to manage the diabetes. d. Parents are better able to manage the disease.

ANS: C Blood glucose self-management has improved diabetes management and can be used successfully by children from the time of diagnosis. Insulin dosages can be adjusted based on blood glucose results. Blood glucose monitoring is more expensive but provides improved management. It is as accurate as equivalent testing done in laboratories. The ability to self-test allows the child to balance diet, exercise, and insulin. The parents are partners in the process, but the child should be taught how to manage the disease. PTS: 1 DIF: Cognitive Level: Apply REF: 1003 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

25. The parents of a child who has just been diagnosed with type 1 diabetes ask about exercise. Which should the nurse explain about exercise in type 1 diabetes? a. Exercise will increase blood glucose. b. Exercise should be restricted. c. Extra snacks are needed before exercise. d. Extra insulin is required during exercise.

ANS: C Exercise lowers blood glucose levels, which can be compensated for by extra snacks. Exercise lowers blood glucose and is encouraged and not restricted, unless indicated by other health conditions. Extra insulin is contraindicated because exercise decreases blood glucose levels. PTS: 1 DIF: Cognitive Level: Apply REF: 1004 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

19. Which is characteristic of the immune-mediated type 1 diabetes mellitus? a. Ketoacidosis is infrequent. b. Onset is gradual. c. Age at onset is usually younger than 20 years. d. Oral agents are often effective for treatment.

ANS: C The immune-mediated type 1 diabetes mellitus typically has its onset in children or young adults. Infrequent ketoacidosis, gradual onset, and effectiveness of oral agents for treatment are more consistent with type 2 diabetes. PTS: 1 DIF: Cognitive Level: Analyze REF: 992 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

3. A nurse is planning care for a school-age child with type 1 diabetes. Which insulin preparations are rapid and short acting? (Select all that apply.) a. Novolin N b. Lantus c. NovoLog d. Novolin R

ANS: C, D Rapid-acting insulin (e.g., NovoLog) reaches the blood within 15 minutes after injection. The insulin peaks 30 to 90 minutes later and may last as long as 5 hours. Short-acting (regular) insulin (e.g., Novolin R) usually reaches the blood within 30 minutes after injection. The insulin peaks 2 to 4 hours later and stays in the blood for about 4 to 8 hours. Intermediate-acting insulins (e.g., Novolin N) reach the blood 2 to 6 hours after injection. The insulins peak 4 to 14 hours later and stay in the blood for about 14 to 20 hours. Long-acting insulin (e.g., Lantus) takes 6 to 14 hours to start working. It has no peak or a very small peak 10 to 16 hours after injection. The insulin stays in the blood between 20 and 24 hours. PTS: 1 DIF: Cognitive Level: Understand REF: 995 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

21. Hyperglycemia associated with diabetic ketoacidosis is defined as a blood glucose measurement equal to or greater than _____ mg/dl. a. 100 b. 120 c. 180 d. 200

ANS: D Diabetic ketoacidosis is a state of relative insulin insufficiency and may include the presence of hyperglycemia, a blood glucose level greater than or equal to 200 mg/dl. The values 100 mg/dl, 120 mg/dl, and 180 mg/dl are too low for the definition of ketoacidosis. PTS: 1 DIF: Cognitive Level: Understand REF: 994 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

7. The nurse is caring for a preschool child with suspected diabetes insipidus. Which clinical manifestation should the nurse expect to observe? a. Oliguria b. Glycosuria c. Nausea and vomiting d. Polyuria and polydipsia

ANS: D Excessive urination accompanied by insatiable thirst is the primary clinical manifestation of diabetes. These symptoms may be so severe that the child does little other than drink and urinate. Oliguria is decreased urine production and is not associated with diabetes insipidus. Glycosuria is associated with diabetes mellitus. Nausea and vomiting are associated with inappropriate antidiuretic hormone (ADH) secretion. PTS: 1 DIF: Cognitive Level: Apply REF: 980 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

20. Which is considered a cardinal sign of diabetes mellitus? a. Nausea b. Seizures c. Impaired vision d. Frequent urination

ANS: D Hallmarks of diabetes mellitus are glycosuria, polyuria, and polydipsia. Nausea and seizures are not clinical manifestations of diabetes mellitus. Impaired vision is a long-term complication of the disease. PTS: 1 DIF: Cognitive Level: Understand REF: 993 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

22. Type 1 diabetes mellitus is suspected in an adolescent. Which clinical manifestation may be present? a. Moist skin b. Weight gain c. Fluid overload d. Poor wound healing

ANS: D Poor wound healing may be present in an individual with type 1 diabetes mellitus. Dry skin, weight loss, and dehydration are clinical manifestations of type 1 diabetes mellitus. PTS: 1 DIF: Cognitive Level: Understand REF: 993 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

27. The nurse is caring for an 8-year-old child with type 1 diabetes. The nurse should teach the child to monitor for which manifestation of hypoglycemia? a. Lethargy b. Thirst c. Nausea and vomiting d. Shaky feeling and dizziness

ANS: D Some of the clinical manifestations of hypoglycemia include shaky feelings; dizziness; difficulty concentrating, speaking, focusing, or coordinating; sweating; and pallor. Lethargy, thirst, and nausea and vomiting are manifestations of hyperglycemia. PTS: 1 DIF: Cognitive Level: Apply REF: 996 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

26. A child eats some sugar cubes after experiencing symptoms of hypoglycemia. This rapid-releasing sugar should be followed by: a. fat. b. fruit juice. c. several glasses of water. d. complex carbohydrate and protein.

ANS: D Symptoms of hypoglycemia are treated with a rapid-releasing sugar source followed by a complex carbohydrate and protein. Fat, fruit juice, and several glasses of water do not provide the child with complex carbohydrate and protein necessary to stabilize the blood glucose. PTS: 1 DIF: Cognitive Level: Apply REF: 996 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

29. The nurse is discussing with a child and family the various sites used for insulin injections. Which site usually has the fastest rate of absorption? a. Arm b. Leg c. Buttock d. Abdomen

ANS: D The abdomen has the fastest rate of absorption but the shortest duration. The arm has a fast rate of absorption but short duration. The leg has a slow rate of absorption but a long duration. The buttock has the slowest rate of absorption and the longest duration. PTS: 1 DIF: Cognitive Level: Apply REF: 1002 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy

24. The parent of a child with diabetes mellitus asks the nurse when urine testing will be necessary. The nurse should explain that urine testing is necessary for which? a. Glucose is needed before administration of insulin. b. Glucose is needed four times a day. c. Glycosylated hemoglobin is required. d. Ketonuria is suspected.

ANS: D Urine testing is still performed to detect evidence of ketonuria. Urine testing for glucose is no longer indicated because of the poor correlation between blood glucose levels and glycosuria. Glycosylated hemoglobin analysis is performed on a blood sample. PTS: 1 DIF: Cognitive Level: Apply REF: 1004 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation