Sole Ch 19
A patient is receiving hydrocortisone sodium succinate for adrenal crisis. What other medication does the nurse prepare to administer? a) Regular insulin b) A proton pump inhibitor c) Canagliflozin d) Propranolol
B Patients receiving hydrocortisone sodium succinate need to be on a regime to prevent GI bleeding. A proton pump inhibitor would be a good choice.
The nurse is caring for a patient who underwent pituitary surgery 12 hours ago. The nurse will give priority to monitoring the patient carefully for which of the following? a) CHF b) Hypovolemic shock c) Infection d) Volume overload
B Pituitary surgery or manipulation of the pituitary stalk during surgery may precipitate diabetes insipidus. Profound diuresis that accompanies diabetes insipidus may result in hypovolemic shock. Fluid volume deficit, not overload, accompanies diabetes insipidus.
The nurse is assigned to care for a patient who presented to the emergency department with diabetic ketoacidosis. A continuous insulin intravenous infusion is started, and hourly bedside glucose monitoring is ordered. The targeted blood glucose value after the first hour of therapy is a) 70-120 mg/dL b) a decrease of 25-50 mg/dL compared with admitting values c) a decrease of 35-90 mg/dL compared with admitting values d) less than 200 mg/dL
C Initial insulin infusions should be administered with a target blood glucose reduction of 35 to 90 mg/dL per hour. Decreases of less than this rate may be associated with inadequate insulin replacement and allow for the persistence of the ketotic state. Rapid reductions of blood glucose may precipitate life-threatening cerebral edema; thus, controlled reduction of glucose is required.
The nurse is providing insulin education for an elderly patient with longstanding diabetes. A prescription has been written for the patient to take 20 units of insulin glargine at 10 PM nightly. The nurse should instruct the patient that the peak of the insulin action for this agent is a) 0200 b) 0400 c) 0800 d) peakless
D Insulin glargine is a long-acting insulin that has no specific peak in action. The remaining times are associated with peaks of other short-acting and intermediate-acting insulin products.
In the management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, when is an intravenous (IV) solution that contains dextrose started? a) Never; normal saline is the only appropriate solution in diabetes management b) When the blood sugar reaches 70 mg/dL c) When the blood sugar reaches 150 mg/dL d) When the blood glucose reaches 250 mg/dL
D Normal saline is the best initial fluid choice for management of hyperglycemic states. However, when the glucose reaches about 250 mg/dL, solutions containing dextrose are added to prevent hypoglycemia.
An elderly female patient has presented to the emergency department with altered mental status, hypothermia, and clinical signs of heart failure. Myxedema is suspected. Which of the following laboratory findings support this diagnosis? a) Elevated adrenocorticotropic hormone b) Elevated cortisol levels c) Elevated T3 and T4 d) Elevated TSH
D Thyroid hormones are low in myxedema. Thyroid-stimulating hormone is usually high in relation to the feedback mechanisms for hormone regulation if myxedema is caused by primary hypothyroidism.
Which of the following statements is true about the medical management of diabetic ketoacidosis? a) Serum lactate levels are used to guide insulin administration b) Sodium bicarbonate is a first-line medication for treatment c) The degree of acidosis is assessed through continuous pulse oximetry d) Volume replacement and insulin infusion often correct the acidosis
D Volume replacement promotes hemodilution in the face of a hyperosmolar state. Insulin administration promotes entry of glucose into cells and relieves ketosis. As volume is replaced and glucose normalizes, the acidosis often resolves. Insulin administration, not lactate levels, is guided by blood glucose values. Sodium bicarbonate is administered only to correct severe acidosis (pH <7.1). Degree of acidosis is assessed through arterial blood gas readings and serum ketone levels.
A patient with a history of type 1 diabetes and an eating disorder is found unconscious. In the emergency department, the following lab values are obtained: Glucose: 648 mg/dL pH: 6.88 PaCO2: 20 mm Hg PaO2: 95 mm Hg HCO3 ¯: undetectable Anion gap: >31 Na+: 127 mEq/L K+: 3.5 mEq/L Creatinine: 1.8 mg/dL After the patient's airway and ventilation have been established, the next priority for this patient is: a) administration of a 1-L normal saline fluid bolus b) administration of 0.1 unit of regular insulin IV push followed by an insulin infusion c) administration of 20 mEq KCl in 100 mL d) IV push administration of 1 amp of sodium bicarbonate
A After airway is established, the next priority in management of DKA is fluid resuscitation with 1 liter of normal saline over 1 hour. The fluid resuscitation should begin before administration of insulin.
The nurse is caring for a patient with a diagnosis of head trauma. The nurse notes that the patient's urine output has increased tremendously over the past 18 hours. The nurse suspects that the patient may be developing a) DI b) DKA c) HHS d) SIADH
A Diabetes insipidus results in large volumes of urine; dehydration and hypovolemia can result. Head trauma and resulting increased intracranial pressure are potential causes of diabetes insipidus. High urine output following head trauma is associated with diabetes insipidus.
A patient presents to the emergency department with suspected thyroid storm. The nurse should be alert to which of the following cardiac rhythms while providing care to this patient? a) Atrial fibrillation b) Idioventricular rhythm c) Junctional rhythm d) Sinus bradycardia
A Increased heart rate and tachydysrhythmia, including atrial fibrillation, may accompany thyroid storm.
What psychosocial factors may potentially contribute to the development of diabetic ketoacidosis? (Select all that apply.) a) Altered sleep/rest patterns b) Eating disorder c) Exposure to influenza d) High levels of stress e) Lack of financial resources
A, B, D, E Psychosocial factors may lead to changes in diabetes self-management practices that precipitate diabetic ketoacidosis. Eating disorders may complicate 20% of recurrent cases of DKA in young women. Changes in sleep patterns and psychosocial stressors may lead to increased insulin demands in the face of declining self-care practices. Financial and time limitations may affect the ability to monitor for changes in control. Exposure to influenza is a physiological factor; it would not be a psychosocial factor associated with DKA.
Acute adrenal crisis is caused by a) acute renal failure b) deficiency of corticosteroids c) high doses of corticosteroids d) overdose of testosterone
B
Which of the following is a high-priority nursing diagnosis for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome? a) Activity intolerance b) Fluid volume deficit c) Hyperthermia d) Impaired nutrition, more than body requirements
B Both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome result in dehydration and hypovolemia; therefore, fluid volume deficit is a priority nursing diagnosis.
A patient with type 1 diabetes who is receiving a continuous subcutaneous insulin infusion via an insulin pump contacts the clinic to report mechanical failure of the infusion pump. The nurse instructs the patient to begin monitoring for signs of: a) adrenal insufficiency b) DKA c) hyperosmolar, hyperglycemia state d) hypoglycemia
B If the insulin pump fails, the patient with type 1 diabetes will have a complete interruption of insulin delivery; diabetic ketoacidosis will occur
An individual with type 2 diabetes who takes glipizide has begun a formal exercise program at a local gym. While exercising on the treadmill, the individual becomes pale, diaphoretic, shaky, and has a headache. The individual feels as though she is going to pass out. What is the individual's priority action? a) Drink additional water to prevent dehydration b) Eat something with 15 g of simple carbohydrates c) Go to the first-aid station to have glucose checked d) Take another dose of the oral agent
B The patient is displaying classic symptoms of hypoglycemia. The patient is on sulfonylurea therapy, which carries the risk of hypoglycemia. The walking may be more exercise than she is used to and may thereby cause hypoglycemia. Fifteen grams of carbohydrate is appropriate for initial management of hypoglycemia.
Mechanisms for development of diabetes insipidus include which of the following? (Select all that apply.) a) ADH deficiency b) ADH excess c) ADH insensitivity d) ADH replacement therapy e Water deprivation
A, C Diabetes insipidus is caused by either a deficiency in ADH production (neurogenic) or impaired renal response to ADH (nephrogenic).
The most significant clinical finding of acute adrenal crisis associated with fluid and electrolyte imbalance is a) fluid volume excess b) hyperglycemia c) hyperkalemia c) hypernatremia
C Adrenal insufficiency may be characterized by inadequate amounts of cortisol and aldosterone. Aldosterone acts to retain sodium, resulting in water retention and potassium loss. Inadequate levels of aldosterone therefore result in hyponatremia, fluid loss, and hyperkalemia.
A patient with pancreatic cancer has been admitted to the critical care unit with clinical signs consistent with syndrome of inappropriate secretion of antidiuretic hormone. The nurse anticipates that clinical management of this condition will include a) administration of 3% normal saline b) administration of exogenous vasopressin c) fluid restriction d) low sodium diet
C The first treatment of this condition is volume restriction; other treatments may not be needed if restrictions work. Extreme fluid restrictions (800 to 1000 mL/day) may be required in the treatment of SIADH.
Which of the following would be seen in a patient with myxedema coma? a) Decreased reflexes b) Hyperthermia c) Hyperventilation d) Tachycardia
A Myxedema coma is characterized by a hypometabolic state, and all body functions are slowed including cardiovascular function, decreased gastrointestinal mobility, cold intolerance, and diminished reflexes.
Which of the following laboratory values would be found in a patient with syndrome of inappropriate secretion of antidiuretic hormone? a) Fasting blood glucose 156 mg/dL b) Serum potassium 5.8 mEq/L c) Serum sodium 115 mEq/L d) Serum sodium 152 mEq/L
C SIADH causes a dilutional hyponatremia, and central nervous system symptoms can occur. A low serum sodium (below 135 mEq/L) may accompany the syndrome.
The nurse is caring for a patient who suffered a head trauma following a fall. The patient's heart rate is 112 beats/min and blood pressure is 88/50 mm Hg. The patient has poor skin turgor and dry mucous membranes. The patient is confused and restless. The following laboratory values are reported: serum sodium is 115 mEq/L; blood urea nitrogen (BUN) 50 mg/dL; and creatinine 1.8 mg/dL. The findings are consistent with which disorder? a) Cerebral salt wasting b) DI c) SIADH d) Thyroid storm
A Cerebral salt wasting may occur after head trauma and is characterized by low sodium in the face of classic physical and laboratory signs of fluid volume deficit or dehydration, including tachycardia, hypotension, dry mucous membranes, weight loss, and poor skin turgor. The patient also may experience the classic signs of hyponatremia, including a serum sodium less than 135 mg/dL, confusion, lethargy, seizures, and coma.
A patient has been on daily, high-dose glucocorticoid therapy for the treatment of rheumatoid arthritis. His prescription runs out before his next appointment with his physician. Because he is asymptomatic, he thinks it is all right to withhold the medication for 3 days. What is likely to happen to this patient? a) He will go into adrenal crisis b) He will go into thyroid storm c) His autoimmune disease will go into remission d) Nothing; it is appropriate to stop the medication for 3 days
A Patients on long-term corticosteroid therapy are at high risk for adrenal crisis, because therapy suppresses the endogenous production of steroids. Adrenal crisis may be precipitated by sudden withdrawal of glucocorticoid therapy
Factors associated with the development of nephrogenic diabetes insipidus include which of the following? (Select all that apply.) a) Heredity b) Medications c) Meningitis d) Pituitary tumors e) Sickle cell disease
A, B, E Nephrogenic diabetes insipidus occurs when adequate amounts of antidiuretic hormone are produced with limited renal response. Causative factors for nephrogenic diabetes insipidus are heredity, preexisting renal disease, multisystem diseases such as multiple myeloma and sickle cell disease, chronic electrolyte disturbances, and medications such as phenytoin and lithium carbonate.
Which of the following are appropriate nursing interventions for the patient in myxedema coma? (Select all that apply.) a) Administer levothyroxine as prescribed b) Encourage the intake of foods high in sodium c) Initiate passive rewarming interventions d) Monitor airway and respiratory effort e) Monitor urine osmolality
A, C, D Myxedema coma is a severe manifestation of hypothyroidism. Treatment entails replacement of thyroid hormone, airway management related to respiratory depression and potential airway obstruction related to tongue edema, thermoregulation, management of edema and congestive heart failure symptoms, and patient education. Edema may accompany myxedema and necessitate use of sodium restriction.
A patient with newly diagnosed type 1 diabetes is being transitioned from an infusion of intravenous (IV) regular insulin to an intensive insulin therapy regimen of insulin glargine and insulin aspart. How should the nurse manage this transition in insulin delivery? a) Administer the insulin glargine and continue the IV insulin infusion for 24 hours b) Administer the insulin glargine and discontinue the IV infusion in several hours c) Discontinue the IV infusion and administer the insulin aspart with the next meal d) Discontinue the IV infusion and administer the Lantus insulin at bedtime
B Subcutaneous insulin should be administered 1 to 4 hours before discontinuing the intravenous infusion to allow the patient to reach adequate plasma insulin levels to prevent redevelopment of DKA. Continuation of the insulin infusion in conjunction with the long-acting insulin glargine would result in hypoglycemia. Discontinuation of intravenous insulin before administration of subcutaneous insulin would result in recurrence of DKA in a patient with type 1 diabetes.
The nurse has been assigned the following patients. Which patients require assessment of blood glucose control as a nursing priority? (Select all that apply.) a) 18-year-old male who has undergone surgical correction of a fractured femur b) 29-year-old female who is undergoing evaluation for pheochromocytoma c) 43-year-old male with acute pancreatitis who is receiving total parenteral nutrition (TPN) d) 62-year-old morbidly obese female who underwent a hysterectomy for ovarian cancer e) 72-year-old female who is receiving intravenous (IV) steroids for an exacerbation of chronic obstructive pulmonary disease (COPD)
B, C, D, E Risk factors for development of stress-induced hyperglycemia are a prior history of diabetes or hyperglycemia; obesity; pancreatitis; cirrhosis; glucocorticoids; excess epinephrine; advanced age; nutrition support; and various medications.
A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flulike symptoms, including vomiting, since yesterday. The patient had been up all night studying for exams. The patient used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this client? (Select all that apply.) a) Blood glucose: 43 mg/dL b) Blood glucose: 524 mg/dL c) HCO3: 10 mEq/L d) PaCO2: 37 mmHg e) pH 7.23
B, C, E The patient is presenting with laboratory evidence of diabetic ketoacidosis. Diabetic ketoacidosis is characterized by hyperglycemia and low bicarbonate levels, low CO2, and low pH.
A patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis. Following aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose begins to normalize. In addition to glucose monitoring, which of the following electrolytes requires close monitoring? a) Calcium b) Chloride c) Potassium d) Sodium
C Potassium must be closely monitored. In the early stages of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, the potassium value is often high, but it may lower to critical levels once fluid balance has been restored and glucose has returned to more normal levels. Insulin administration used in the treatment of diabetic ketoacidosis further promotes the lowering of potassium as the electrolyte is relocated to the cellular bed.
Which of the following laboratory values would be more common in patients with diabetic ketoacidosis? a) Blood glucose >1000 mg/dL b) Negative ketones in the urine c) Normal anion gap d) pH 7.24
D A pH of 7.24 is indicative of an acidotic state that may accompany diabetic ketoacidosis. Glucose values of more than 1000 mg/dL are more commonly associated with hyperosmolar hyperglycemic syndrome. Diabetic ketoacidosis is associated with positive urine ketones and an increased anion gap.
The nurse is caring for a patient with head trauma who was admitted to the surgical intensive care unit following a motorcycle crash. What is an important assessment that will assist the nurse in early identification of an endocrine disorder commonly associated with this condition? a) Daily weight b) Fingerstick glucose c) Lung sound auscultation d) Urine osmolality
D Diabetes insipidus may result from traumatic brain injury. It results in passage of large volumes of dilute urine. Urine osmolality is low in individuals with diabetes insipidus, and urine specific gravity assessments should be incorporated into the care of at-risk patients.
Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome? a) An 18-year-old college student with type 1 diabetes who exercises excessively b) A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning c) A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on insulin injections d) An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer's disease who recently developed influenza
D Hyperosmolar hyperglycemic syndrome is more common in type 2 diabetes; influenza is a stressor that would result in further increases in blood sugar. Some individuals with advanced Alzheimer's disease cannot communicate thirst needs and may be incontinent, making hypertonic fluid loss more difficult to estimate.
In hyperosmolar hyperglycemic syndrome, the laboratory results are similar to those of diabetic ketoacidosis, with three major exceptions. What differences would you expect to see in patients with hyperosmolar hyperglycemic syndrome? a) Lower serum glucose, lower osmolality, and greater ketosis b) Lower serum glucose, lower osmolality, and milder ketosis c) Higher serum glucose, higher osmolality, and greater ketosis d) Higher serum glucose, higher osmolality, and no ketosis
D In patients with hyperosmolar hyperglycemic syndrome (HHS), glucose is higher; osmotic diuresis is greater, resulting in higher osmolality; and ketosis is usually absent. Glucose values in HHS are typically higher than those of diabetic ketoacidosis and are not typically accompanied by ketosis.
A patient is admitted to the oncology unit with a small-cell lung carcinoma. During the admission, the patient is noted to have a significant decrease in urine output accompanied by shortness of breath, edema, and mental status changes. The nurse is aware that this clinical presentation is consistent with a) adrenal crisis b) DI c) myxedema coma d) SIADH
D SIADH may be induced by ectopic sources of antidiuretic hormone, including small-cell lung carcinoma. The clinical presentation of a dilutional hypervolemia is consistent with SIADH.
A patient presents to the emergency department with the following clinical signs: Pulse: 132 beats/min Blood pressure: 88/50 mm Hg Respiratory rate: 32 breaths/min Temperature: 104.8°F Chest x-ray: Findings consistent with congestive heart failure Cardiac rhythm: Atrial fibrillation with rapid ventricular response These signs are consistent with which disorder? a) Adrenal crisis b) Myxedema coma c) SIADH d) Thyroid storm
D Tachycardia, vascular collapse, rapid cardiac rhythms, congestive heart failure, and severe hyperthermia are consistent with the clinical manifestations of the hypermetabolic state of thyroid storm.
