CHAPTER 64: CARE OF PATIENTS WITH DIABETES MELLITUS, CHAPTER 63: CARE OF PATIENTS WITH PROBLEMS OF THE THYROID AND PARATHYROID GLANDS, CHAPTER 62: CARE OF PATIENTS WITH PITUITARY AND ADRENAL GLAND PROBLEMS, Ch. 61 Endocrine Med-Surg

Hormones of the Hypothalamus

(1) GHRH (Growth Hormone Releasing Hormone) (2) GHIH (Growth Hormone Inhibiting Hormone) (3) TRH (Thyrotropin Releasing Hormone) (4) CRH (Corticotropin Releasing Hormone) (5) GnRH (Gonadotropin Releasing Hormone) (6) MIH (Melanocyte Inhibiting Hormone) (7) PIH (Prolactin Inhibiting Hormone)

Hormones of the Anterior Pituitary

(1) TSH (Thyroid Stimulating Hormone) (2) ACTH (Adrenocorticotropic hormone) (3) LH (Leutinizing hormone) (4) FSH (Follicle Stimulating Hormone) (5) GH (Growth hormone) (6) PRL (Prolactin)

A nurse is planning care for a pt with Cushing's disease. The nurse should recognize that this client is at increased risk for which of the following? (Select all that apply) (a) Infection (b) Gastric ulcers (c) Renal calculi (d) Bone fractures (e) Dysphagia

A,B,D

T4 target range

4-12 mcg/dL

T3 target range

70-205 ng/dL

A nurse is preparing to receive a client from the PACU who is post-op thyroidectomy. The nurse should ensure that which of the following equipment is available? (Select all that apply) (a) Suction (b) Humidified O2 (c) Flashlight (d) Tracheostomy tray (e) Chest tube tray

A,B,D

Hormones of Posterior Pituitary

ADH (antidiuretic hormone) oxytocin

A nurse is caring for a client who has SIADH. Which of the following findings should the nurse expect? (Select all that apply) (a) Decreased serum sodium (b) Urine specific gravity of 1.001 (c) Serum osmolarity of 230 (d) Polyuria (e) Increased thirst

A, C

A nurse is reviewing a health record of a client who has SIADH. Which of the following lab findings should the nurse expect? (Select all that apply) (a) Low sodium (b) High potassium (c) Increased urine osmolarity (d) High urine sodium (e) Increased urine specific gravity

A, C, D, E

A nurse in an ICU is planning care for a client who has myxedema coma. Which of the following actions should the nurse include? (Select all that apply) (a) Observe cardia monitor for dysrhythmias (b) Observe for UTI (c) Initiate IV with 0.9% NS (d) Administer IV bolus of levothyroxine (e) Provide warmth using a heating pad

A,B,C,D

A nurse is reviewing lab results on a client who has Addison's disease. Which of the following lab results should the nurse expect? (Select all that apply) (a) Sodium 130 (b) Potassium 6.1 (c) Calcium 11.6 (d) BUN 28 (e) Fasting blood glucose 148

A,B,C,D

A nurse is reviewing the lab finding of a client with Cushing's disease. Which of the following findings should the nurse expect? (Select all that apply) (a) Sodium 150 (b) Potassium 3.3 (c) Calcium 8 (d) Lymphocytes 35% (e) Fasting glucose 145

A,B,C,E

A nurse in a providers office is planning care for a client who has Graves' disease and a new prescription for methimazole. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) (a) Monitor CBC (b) Monitor T3 (triiodothyronine) (c) Instruct the client to increase consumption of shellfish (d) Advise the client to take the meds at the same time each day (e) Inform the client that an adverse effect of this med is iodine toxicity

A,B,D

18. The nurse is assessing a client with Graves' disease and finds that the client's temperature has risen 1° F. Before notifying the health care provider, which action by the nurse takes priority? a. Turn the lights down in the client's room and shut the door. b. Call for an immediate electrocardiogram (ECG). c. Calculate the client's apical-radial pulse deficit. d. Administer a dose of acetaminophen (Tylenol).

ANS: A A temperature increase of 1° F may indicate the development of thyroid storm, and the provider needs to be notified. Before notifying the provider, the nurse should take measures to reduce environmental stimuli that increase the risk of cardiac complications. The nurse can then call for an ECG. The apical-radial pulse deficit would not be necessary, and Tylenol is not needed because the temperature increase is due to thyroid activity.

25. A client is brought to the emergency department via rescue squad in acute adrenal crisis. Which action by the nurse is the priority? a. Start an IV line if the client does not already have one. b. Administer hydrocortisone sodium succinate (Solu-Cortef). c. Instruct the nursing assistant to check the client's blood glucose. d. Administer 20 units of insulin and 20 mg of dextrose in normal saline.

ANS: A All actions are appropriate for the client with adrenal crisis. However, therapy is given IV, so the priority is to establish IV access. Solu-Cortef is the drug of choice. Blood glucose is monitored hourly and treatment is provided as needed. Insulin and dextrose are used to treat any hyperkalemia.

5. When performing personal care on a middle-aged woman, the nurse observes that the client has very little pubic and axillary hair. Which is the nurse's best action? a. Ask the client if she has less pubic hair now than 5 years ago. b. Ask the client the date of her last menstrual period. c. Examine the client's scalp hair for texture and thickness. d. Draw blood for hormonal immune assays.

ANS: A Although pubic hair thickness varies from person to person, loss of pubic hair is associated with gonadotropin deficiency. The nurse needs to determine whether this manifestation is normal for this client. A middle-aged woman may be postmenopausal, which would not give the nurse helpful information. Examining the client's scalp also would not yield helpful information. Diagnostic studies should not be undertaken without further assessment.

41. A client with type 1 diabetes has a blood glucose level of 160 mg/dL on arrival at the operating room. Which is the nurse's best action? a. Document the finding in the client's chart. b. Administer a bolus of regular insulin IV. c. Call the physician to cancel the operation. d. Draw blood gases to assess the metabolic state.

ANS: A Clients who have type 1 diabetes and are having surgery have been found to have fewer complications, lower rates of infection, and better wound healing if blood glucose levels are maintained at between 140 and 180 mg/dL throughout the perioperative period. The nurse should document the finding and proceed with other operative care. The need for a bolus of insulin, for canceling the operation, or for drawing arterial blood gases (ABGs) is not present.

28. To reduce complications of diabetes, the nurse teaches a client with normal kidney function to modify intake of which nutritional group? a. Fats b. Fiber c. Proteins d. Carbohydrates

ANS: A Diabetes causes abnormalities in fat metabolism that lead to hyperlipidemia. The high lipid levels can lead to atherosclerosis and to many pathologic consequences of vascular insufficiency. Specific fat recommendations can be made by the registered dietitian according to individual client factors, but reducing fat intake is healthy for all diabetic people. The client with renal insufficiency may need to limit protein. Fiber should be increased do 25 to 30 g/day, and intake of carbohydrates must be spread out throughout the day.

21. The client has chronic hypercortisolism. Which intervention is the highest priority for the nurse? a. Wash the hands when entering the room. b. Keep the client in protective isolation. c. Observe the client for increased white blood cell counts. d. Assess the daily chest x-ray.

ANS: A Excess cortisol reduces the number of circulating lymphocytes, inhibits maturation of macrophages, reduces antibody synthesis, and inhibits production of cytokines and inflammatory chemicals. As a result, these clients are at greater risk of infection and may not have the expected inflammatory manifestations when an infection is present. The nurse needs to take precautions to decrease the client's risk. It is not necessary to keep the client in isolation. The client does not need a daily chest x-ray.

9. A client has newly diagnosed diabetes. To delay the onset of microvascular and macrovascular complications in this client, the nurse stresses that the client take which action? a. Control hyperglycemia. b. Prevent hypoglycemia. c. Restrict fluid intake. d. Prevent ketosis.

ANS: A Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications. Maintaining tight glycemic control will help delay the onset of complications. Preventing hypoglycemia and ketosis, although important, is not as important as maintaining daily glycemic control. Restricting fluid intake is not part of the treatment plan for clients with diabetes.

26. A female client has a decrease in all pituitary hormones. Which assessment question by the nurse elicits the best information? a. "Do you have any biological children?" b. "Do you have a decreased sex drive?" c. "Have you noticed increased facial hair?" d. "Are you more intolerant of heat?"

ANS: A Hypofunction of all anterior pituitary hormones is often caused by postpartum hemorrhage of the anterior pituitary gland. This usually occurs immediately after delivery but may be delayed for several years. Asking the client if she has children of her own would let the nurse know of this possibility. The other questions are assessments for specific hormone dysfunction.

38. Which statement made by a client getting ready for discharge after pancreas transplantation indicates a need for further teaching about the prescribed drug regimen? a. "If I develop an infection, I should stop taking my corticosteroid." b. "If I have pain over the transplant, I will call the surgeon immediately." c. "I should avoid people who are ill or who have an infection." d. "I should take my cyclosporine exactly the way I was taught."

ANS: A Immune suppressive agents should not be stopped without the consultation of the transplantation physician, even if an infection is present. Stopping immune suppressive therapy endangers the transplanted organ. The other statements are correct. Pain over the graft site may indicate rejection. Anti-rejection drugs cause immune suppression, and the client should avoid crowds and people who are ill. Changing the routine of anti-rejection medications may cause them to not work optimally.

20. A client with diabetes is prescribed insulin glargine once daily and regular insulin four times daily. One dose of regular insulin is scheduled at the same time as the glargine. How does the nurse instruct the client to administer the two doses of insulin? a. "Draw up and inject the insulin glargine first, then draw up and inject the regular insulin." b. "Draw up and inject the insulin glargine first, wait 20 minutes, then draw up and inject the regular insulin." c. "First draw up the dose of regular insulin, then draw up the dose of insulin glargine in the same syringe, mix, and inject the two insulins together." d. "First draw up the dose of insulin glargine, then draw up the dose of regular insulin in the same syringe, mix, and inject the two insulins together."

ANS: A Insulin glargine must not be diluted or mixed with any other insulin or solution. Mixing results in an unpredictable alteration in the onset of action and time to peak action. The correct instruction is to draw up and inject first the glargine, then the regular insulin right afterward.

22. A client with diabetes is visually impaired and wants to know whether syringes can be prefilled and stored for later use. Which is the nurse's best response? a. "Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up." b. "Yes. Prefilled syringes can be stored for up to 3 weeks in the refrigerator, placed in a horizontal position." c. "Insulin reacts with plastic, so prefilled syringes are okay, but they must be made of glass." d. "No. Insulin cannot be stored for any length of time outside of the container."

ANS: A Insulin is relatively stable when stored in a cool, dry place away from light. When refrigerated, prefilled syringes are stable for up to 3 weeks. They should be stored in the vertical position with the needle pointing up to prevent suspended insulin particles from clogging the needle. The other answers are inaccurate.

30. A client in the emergency department has been diagnosed with ketoacidosis. Which manifestation does the nurse correlate with this condition? a. Increased rate and depth of respiration b. Extremity tremors followed by seizure activity c. Oral temperature of 102° F (38.9° C) d. Severe orthostatic hypotension

ANS: A Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation.

16. The client is receiving methimazole (Tapazole). Which statement by the client indicates good understanding of teaching regarding this medication? a. "If I become pregnant, I need to notify my health care provider immediately." b. "Liver problems can occur with this drug so I need to report jaundice." c. "I will take my pulse daily, and if it is too fast, I will call my provider." d. "This medication may cause dyspnea or vertigo. I will be careful with activity."

ANS: A Methimazole can cause birth defects, and clients should not take it if they are pregnant. Liver problems can occur with propylthiouracil (PTU). The client does not need to take his or her pulse daily. Dyspnea and vertigo are not side effects of methimazole.

20. The new nurse is assessing a client with suspected pheochromocytoma. Which action by the nurse requires the precepting nurse to intervene? a. Auscultating, palpating, and percussing the client's abdomen b. Taking the client's blood pressure for reports of chest pain c. Assessing the client's diet for red wine and aged cheeses d. Limiting visitors while the client is sleeping

ANS: A Pheochromocytomas are found on the adrenal glands or in the abdomen. Palpation of a pheochromocytoma can cause intense release of catecholamines and can precipitate a hypertensive crisis. The experienced nurse should intervene if the new nurse attempts this. The other actions would be appropriate.

8. A client's father has type 1 diabetes mellitus. The client asks if she is in danger of developing the disease as well. Which is the nurse's best response? a. "Your risk of diabetes is higher than that of the general population, but it may not occur." b. "No genetic risk is associated with the development of type 1 diabetes." c. "The risk for becoming diabetic is 50% because of how it is inherited." d. "Female children do not inherit diabetes, but male children will."

ANS: A Risk for type 1 diabetes is determined by inheritance of genes coding for HLA-DR and HLA-DQ tissue types. Clients who have one parent with type 1 diabetes are at increased risk for its development. Diabetes (type 1) seems to require interaction between inherited risk and environmental factors, so not everyone with these genes develops diabetes. The other statements are not accurate.

19. A client with hyperaldosteronism is being treated with spironolactone (Aldactone) before surgery. Which precautions does the nurse teach this client? a. "Read the label before using salt substitutes." b. "Do not add salt to your food when you eat." c. "Avoid exposure to sunlight." d. "Take Tylenol instead of aspirin for pain."

ANS: A Spironolactone is a potassium-sparing diuretic used to control potassium levels. Its use can lead to hyperkalemia. Although the goal is to increase the client's potassium, unknowingly adding potassium can cause complications. Some salt substitutes are composed of potassium chloride and should be avoided by clients on spironolactone therapy. Depending on the client, he or she may benefit from a low-sodium diet before surgery, but this may not be necessary. Avoiding sunlight and Tylenol is not necessary.

18. A client has been taught to inject insulin. Which statement made by the client indicates a need for further teaching? a. "The abdominal site is best because it is closest to the pancreas." b. "I can reach my thigh the best, so I will use different areas of the same thigh." c. "By rotating the sites in one area, my chance of having a reaction is decreased." d. "Changing injection sites from the thigh to the arm will change absorption rates."

ANS: A The abdominal site has the fastest rate of absorption because of blood vessels in the area, not because of its proximity to the pancreas. The other statements are accurate assessments of insulin administration.

16. A client who has been taking pioglitazone (Actos) for 6 months reports to the nurse that his urine has become darker since starting the medication. Which is the nurse's first action? a. Review results of liver enzyme studies. b. Document the report in the client's chart. c. Instruct the client to increase water intake. d. Test a sample of urine for occult blood.

ANS: A Thiazolidinediones (including pioglitazone) can affect liver function; liver function should be assessed at the start of therapy and at regular intervals while the client continues to take these drugs. Dark urine is one indicator of liver impairment because bilirubin is increased in the blood and is excreted in the urine. The nurse should check the client's most recent liver function studies. Documentation should be done after all assessments have been completed. The client does not need to be told to increase water intake, and the nurse does not need to check the urine for occult blood.

47. The home care nurse finds a client who has diabetes awake and alert, but shaky, diaphoretic, and weak. The nurse gives the client cup of orange juice. The client's clinical manifestations have not changed 5 minutes later. Which is the nurse's best next action? a. Give the client another cup of orange juice. b. Call the rescue squad for transportation to the hospital. c. Administer 10 units of regular insulin subcutaneously. d. Administer 1 mg glucagon intramuscularly.

ANS: A This client is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, if the symptoms do not resolve immediately, repeat the treatment. The client does not need glucagon, transportation to the hospital, or insulin.

12. A client with diabetes has frequent blood glucose readings higher than 300 mg/dL. Which action does the nurse teach the client about self-care? a. Check urine ketones when blood glucose readings are high. b. Increase the insulin dose after two high glucose readings in a row. c. Change the diet to include a 10% increase in protein. d. Work out on the treadmill whenever glucose readings are high.

ANS: A Urine should be tested for ketone bodies whenever the client has a blood glucose higher than 300 mg/dL; is acutely ill, under stress, pregnant, or participating in a weight reduction program; or has symptoms of ketoacidosis (nausea, vomiting, and abdominal pain). The client should not change diet and insulin dosages without input from the health care provider. The client should not exercise when blood glucose is higher than 250 mg/dL.

2. Which conditions may cause hypopituitarism? (Select all that apply.) a. Benign pituitary tumors b. Diplopia c. Anorexia nervosa d. Hypotension e. Shock f. Weight gain

ANS: A, C, D, E These four conditions can cause hypopituitarism. The other options are not causes of hypopituitarism.

1. Which physical characteristics are indicative of anterior pituitary hyperfunction? (Select all that apply.) a. Protrusion of the lower jaw b. High-pitched voice c. Enlarged hands and feet d. Kyphosis e. Barrel-shaped chest f. Excessive sweating

ANS: A, C, D, E, F Anterior pituitary hyperfunction typically will cause protrusion of the lower jaw, deepening of the voice, enlarged hands and feet, kyphosis, barrel-shaped chest, and excessive sweating.

3. Which serum laboratory values alert the nurse to the possibility of hyperaldosteronism? (Select all that apply.) a. Sodium, 150 mEq/L b. Sodium, 130 mEq/L c. Potassium, 2.5 mEq/L d. Potassium, 5.0 mEq/L e. pH, 7.28 f. pH, 7.50

ANS: A, C, E Aldosterone increases reabsorption of sodium and excretion of potassium. Hyperaldosteronism causes hypernatremia, hypokalemia, and metabolic alkalosis. The other values are not indicative of hyperaldosteronism.

1. The nurse is performing health screening in a local mall. Which people does the nurse counsel to be tested for diabetes? (Select all that apply.) a. African-American or American Indian b. Person with history of pancreatic trauma c. Woman with a 30-pound weight gain during pregnancy d. Male with a body mass index greater than 25 kg/m2 e. Middle-aged woman with physical inactivity most days of the week f. Young woman who gave birth to a baby weighing more than 9 pounds

ANS: A, D, E, F Risk factors for type 2 diabetes include certain ethnic/racial groups (African Americans, American Indians, Hispanics), obesity and physical inactivity, and giving birth to large babies. Pancreatic trauma and a 30-pound gestational weight gain are not risk factors.

19. A client has undergone a complete thyroidectomy. Which statement by the client indicates that further instruction is needed? a. "I may need calcium replacement after surgery." b. "After surgery, I won't need to take thyroid medication." c. "I'll need to take thyroid hormones for life." d. "I can receive pain medication if I feel that I need it."

ANS: B After the client undergoes a thyroidectomy, the client must be given thyroid replacement medication for life. He or she may also need calcium if the parathyroid is damaged during surgery and can receive pain medication postoperatively.

10. A client is going home after an endoscopic transnasal hypophysectomy. Which statement by the client indicates an adequate understanding of discharge instructions? a. "I will wear dark glasses whenever I am outdoors." b. "I will keep food on upper shelves so I do not have to bend over." c. "I will wash the incision line every day with peroxide and redress it immediately." d. "I will remember to cough and deep breathe every 2 hours while I am awake."

ANS: B After this surgery, the client must take care to avoid activities that can increase intracranial pressure. The client should avoid bending from the waist and should not bear down, cough, or lie flat. With this approach, there is no incision to clean and dress.

17. A client has diabetes mellitus. Her daughter has recently been diagnosed with Graves' disease. The client asks the nurse if she is responsible for the fact that her daughter has Graves' disease. Which is the best response of the nurse? a. "No connection is known between Graves' disease and diabetes, so you can be certain that the fact that you have diabetes did not cause your daughter to have Graves' disease." b. "An association has been noted between Graves' disease and diabetes, but the fact that you have diabetes did not cause your daughter to have Graves' disease." c. "Graves' disease is associated with autoimmune diseases such as rheumatoid arthritis, but not with a disease such as diabetes." d. "Unfortunately, Graves' disease is associated with diabetes, and your diabetes could have led to your daughter having Graves' disease."

ANS: B An association between autoimmune diseases such as rheumatoid arthritis and diabetes mellitus has been noted. The predisposition is probably polygenic and the client's diabetes did not cause her daughter's Graves' disease. The other statements are inaccurate.

2. A client with diabetes asks the nurse why it is necessary to maintain blood glucose levels no lower than about 60 mg/dL. Which is the nurse's best response? a. "Glucose is the only fuel used by the body to produce the energy that it needs." b. "Your brain needs a constant supply of glucose because it cannot store it." c. "Without a minimum level of glucose, your body does not make red blood cells." d. "Glucose in the blood prevents the formation of lactic acid and prevents acidosis."

ANS: B Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the body's circulation is needed to meet the fuel demands of the central nervous system. The other statements are not accurate.

36. The nurse is teaching a client with diabetes about exercise. Which statement by the client indicates a need for further teaching? a. "I won't exercise if I find ketones in my urine." b. "If my blood glucose is over 200, I should not exercise." c. "Exercise will help me keep my blood glucose down." d. "My risks for heart disease can be modified with exercise."

ANS: B Clients should not exercise if their blood glucose is over 250 mg/dL. The other statements are correct and show good understanding.

13. The nurse is reviewing client medical histories. Which client is at greatest risk for hyperparathyroidism? a. Client with pregnancy-induced hypertension b. Client receiving dialysis for end-stage kidney disease c. Older adult client with moderate heart failure d. Older adult client on home oxygen therapy

ANS: B Clients who have chronic kidney disease do not completely activate vitamin D and poorly absorb calcium from the GI tract. They are chronically hypocalcemic, and this triggers overstimulation of the parathyroid glands. The other factors do not place a client at higher risk for hyperparathyroidism.

57. Which statement by a client with type 2 diabetes indicates a need for further teaching about diabetic management and follow-up care? a. "I need to have an annual appointment, even if my glucose levels are in good control." b. "Because my diabetes is controlled with diet and exercise, I have to be seen only if I am sick." c. "I can still develop complications, even though I do not have to take insulin at this time." d. "If I have surgery or get very ill, I may have to receive insulin injections for a short time."

ANS: B Clients with diabetes need to be seen at least annually to monitor for long-term complications, including visual changes, microalbuminuria, and lipid analysis. The other statements are correct.

22. A female client is beginning treatment with bromocriptine (Parlodel). The nurse has initiated teaching sessions about potential side effects. Which is the most important point of instruction? a. "Take and record your temperature daily." b. "Be sure to eat 20 to 30 grams of fiber daily." c. "Plan to take the medication on an empty stomach." d. "I will need to teach you how to give the injection."

ANS: B Constipation is an expected side effect of treatment with bromocriptine, so the client should be taught ways to prevent and/or manage it. Eating plenty of fiber and drinking fluids is a good plan. Taking the client's temperature daily is not necessary. The medication, which is given orally, should be taken with food to reduce side effects.

43. A client with a 20-year history of diabetes mellitus is reviewing his medications with the nurse. The client holds up the bottle of duloxetine (Cymbalta) and states, "My cousin has depression and is on this drug. Do you think I'm depressed?" What is the nurse's best response? a. "Many people with long-term diabetes become depressed after a while." b. "It's for peripheral neuropathy. Do you have burning pain in your feet or hands?" c. "This antidepressant also has anti-inflammatory properties for diabetic pain." d. "That is possible, but most medications are used for several different things."

ANS: B Damage along nerves causes peripheral neuropathy and leads to burning pain along the nerves. Many drugs, including duloxetine (Cymbalta), can be used to treat peripheral neuropathy. The nurse should assess the client for this condition and then should provide an explanation of why this drug is being used. This medication, although it is used for depression, is not being used for that reason in this case. Cymbalta does not have anti-inflammatory properties. The last option does not provide the client with enough information to be useful.

17. A client with diabetes asks why more than one injection of insulin is required each day. Which is the nurse's best response? a. "You need to start with multiple injections until you become more proficient at self-injection." b. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns closely enough." c. "A regimen of a single dose of insulin injected each day would require that you could eat no more than one meal each day." d. "A single dose of insulin would be too large to be absorbed predictably, so you would be in danger of unexpected insulin shock."

ANS: B Even when a single injection of insulin contains a combined dose of different-acting insulins, the timing of the actions and the timing of food intake may not match well enough to prevent wide variations in blood glucose levels.

48. The nurse has given a client an injection of glucagon. Which action does the nurse take next? a. Apply pressure to the injection site. b. Position the client on his or her side. c. Have a padded tongue blade available. d. Elevate the head of the bed.

ANS: B Glucagon administration often induces vomiting, increasing the client's risk for aspiration. The other actions are not required.

14. The client with type 2 diabetes has recently been changed from the oral antidiabetic agents glyburide (Micronase) and metformin (Glucophage) to glyburide-metformin (Glucovance). The nurse includes which information in the teaching about this medication? a. "Glucovance is more effective than glyburide and metformin." b. "Glucovance contains a combination of glyburide and metformin." c. "Glucovance is a new oral insulin and replaces all other oral antidiabetic agents." d. "Your diabetes is improving and you now need only one drug."

ANS: B Glucovance is composed of glyburide and metformin. It is given to enhance the convenience of antidiabetic therapy with glyburide and metformin. The other statements are not accurate.

2. An adult client has been diagnosed with a deficiency of gonadotropin and growth hormone. Which fact reported in the client's history could have contributed to this problem? a. Mother with adult-onset diabetes mellitus b. Experienced head trauma 5 years ago c. Severe allergy to shellfish and iodine d. Has used oral contraceptives for 5 years

ANS: B Gonadotropin and growth hormone are anterior pituitary hormones. Head trauma is a common cause of anterior pituitary hypofunction. The other factors do not increase the risk of this condition.

17. The client with adrenal hyperfunction screams at her husband, bursts into tears, and throws her water pitcher against the wall. She then tells the nurse, "I feel like I am going crazy." Which is the nurse's best response? a. "I will ask your doctor to order a psychiatric consult for you." b. "You feel this way because of your hormone levels." c. "Can I bring you information about support groups?" d. "I will close the door to your room and restrict visitors."

ANS: B Hypercortisolism can cause the client to show neurotic or psychotic behavior. The client needs to know that these behavior changes do not reflect a true psychiatric disorder and will resolve when therapy results in lower and steadier blood cortisol levels. The client needs to understand this effect and does not need a psychiatrist, support groups, or restricted visitors at this time.

16. A client with hypercortisolism has an irregular pulse. Which is the nurse's priority intervention? a. Documenting the finding and reassessing in 1 hour b. Assessing blood pressure in both arms c. Administering atropine sulfate d. Assessing the telemetry reading

ANS: D Hypercortisolism causes potassium imbalances, which can lead to fatal dysrhythmias. With an irregular pulse, the nurse should assess the client's cardiac rhythm. The finding should be documented, but the nurse cannot wait an hour to take further action. Assessing bilateral blood pressures will not provide useful information. No indications for atropine are known.

14. A client has hyperparathyroidism. Which intervention is the priority for the nurse to add to the client's plan of care? a. Instruct the client to place both hands behind the neck when moving. b. Use a lift sheet to assist the client with position changes. c. Instruct the client to use a soft-bristled toothbrush. d. Strain all urine for at least 24 hours and send stones to the laboratory.

ANS: B Hyperparathyroidism causes increased resorption of calcium from the bones, increasing the risk for pathologic fractures. Using a lift sheet when moving or positioning the client, instead of pulling on the client, reduces the risk of bone injury. Hyperparathyroidism can cause kidney stones, but not every client will need to have urine strained. The priority is preventing injury. Supporting the neck with movement and using a soft toothbrush are not needed for this client.

4. A client with hyperthyroidism is taking lithium carbonate. Which finding indicates that the client is having side effects of this therapy? a. Blurred vision b. Increased thirst and urination c. Increased sweating and diarrhea d. Decreased attention span and insomnia

ANS: B Lithium antagonizes antidiuretic hormone and can cause symptoms of diabetes insipidus. The other choices are not specific to lithium.

25. A client newly diagnosed with type 2 diabetes tells the nurse that since increasing fiber intake, he is having loose stools, flatulence, and abdominal cramping. Which is the nurse's best response? a. "Decrease your intake of water and other fluids until your stools firm up." b. "Decrease your intake of fiber now and gradually add it back into your diet." c. "You must have allergies to high-fiber foods and will need to avoid them." d. "Taking an antacid 1 hour before or 2 hours after meals will help this problem."

ANS: B Many people experience these side effects when first increasing dietary fiber. Gradually incorporating high-fiber foods into the diet can minimize abdominal cramping, discomfort, loose stools, and flatulence. The client needs increased water intake with fiber. The client does not have allergies, nor should he or she take antacids in the hope that they will reduce the problem.

39. The nurse correlates which laboratory value with inadequate functioning of a transplanted pancreas? a. Total white blood cell count 5000/mm3 b. 50% decrease in urine amylase level c. Blood urea nitrogen 30 mg/dL d. Elevated bilirubin level

ANS: B Most pancreas transplants are anastomosed to the bladder and drain pancreatic enzymes into the urine. When the pancreas is rejected or is functioning inadequately, the level of pancreatic enzymes in the urine decreases. The other options are not indicative of inadequate pancreatic function.

53. The nurse administers 6 units of regular insulin and 10 units NPH insulin at 7 AM. At what time does the nurse assess the client for problems related to the NPH insulin? a. 8 AM b. 4 PM c. 8 PM d. 11 PM

ANS: B NPH is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours. Checking the client at 8:00 AM would be too soon; 8:00 PM and 11:00 PM would be too late.

15. Which statement made by a client with type 2 diabetes taking nateglinide (Starlix) indicates understanding of this therapy? a. "I'll take this medicine with my meals." b. "I'll take this medicine right before I eat." c. "I'll take this medicine just before I go to bed." d. "I'll take this medicine when I wake up in the morning."

ANS: B Nateglinide is an insulin secretagogue that is designed to increase meal-related insulin secretion. It should be taken just before a meal. The other options are incorrect.

13. A client who has type 2 diabetes is prescribed glipizide (Glucotrol). Which precautions does the nurse include in the teaching plan related to this medication? a. "Change positions slowly when you get up." b. "Avoid taking nonsteroidal anti-inflammatory drugs." c. "If you miss a dose of this drug, you can double the next dose." d. "Discontinue the medication if you develop an infection."

ANS: B Nonsteroidal anti-inflammatory drugs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide.

34. The home care nurse visits an older client with diabetes. For which nutritional problem does the nurse monitor this client? a. Obesity b. Malnutrition c. Alcoholism d. Hyperglycemia

ANS: B Older adults are more at risk for developing malnutrition as a result of multiple factors. Inadequate income, poor dentition, decreased cognition, decreased motor ability, depression, and lack of understanding about which foods constitute an adequate diet all contribute to an increased risk for malnutrition in all older adult clients, including those with diabetes mellitus.

14. A client who has been taking high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition, which has now resolved, asks the nurse why she needs to continue taking corticosteroids. Which is the nurse's best response? a. "It is possible for the inflammation to recur if you stop the drugs." b. "Once you start corticosteroids, you have to be weaned off them." c. "You must decrease the dose slowly so your hormones will begin to work again." d. "The drug suppresses your immune system, which needs to be built back up."

ANS: B One of the most common causes of adrenal insufficiency, a life-threatening problem, is the sudden cessation of long-term, high-dose corticosteroid therapy. This therapy suppresses the hypothalamic-pituitary-adrenal axis and must be withdrawn gradually to allow for pituitary production of adrenocorticotropic hormone (ACTH) and adrenal production of cortisol.

45. A client with a history of diabetes mellitus has new onset of microalbuminuria. Which component of the diet must the client reduce? a. Percentage of total calories derived from carbohydrates b. Percentage of total calories derived from proteins c. Percentage of total calories derived from fats d. Total caloric intake

ANS: B Restriction of dietary protein to 0.8 g/kg body weight/day is recommended for clients with microalbuminuria to retard progression to renal failure. The other options would not be needed.

11. The nurse is teaching a client about self-monitoring of blood glucose levels. To prevent bloodborne infection, which statement by the nurse is best? a. "Wash your hands after completing the test." b. "Do not share your monitoring equipment." c. "Blot excess blood from the strip." d. "Use gloves during monitoring."

ANS: B Small particles of blood can adhere to the monitoring device, and infection can be transported from one user to another. Hepatitis B in particular can survive in a dried state for about a week. The client should be taught to avoid sharing any equipment, including the lancet holder. The client should be taught to wash hands before testing. The client would not need to blot excess blood away from the strip or to wear gloves.

24. A client has cortisol deficiency and is being treated with prednisone (Deltasone). Which instruction by the nurse is most appropriate? a. "You will need to learn how to rotate the injection sites." b. "If you work outside when it's hot, you may need another drug." c. "Be sure to stay on your salt restriction even though it's difficult." d. "Take one tablet in the morning and two tablets at night to start."

ANS: B Steroid dosage adjustment may be needed and might be difficult, especially in hot weather, when the client is sweating a great deal more than normal. Clients take prednisone orally, have no need for a salt restriction, and usually start the regimen with two tablets in the morning and one at night.

4. The male client with hypopituitarism asks the nurse how long he will have to take testosterone hormone replacement therapy. Which is the nurse's best answer? a. "When your blood levels of testosterone are normal, the therapy is no longer needed." b. "When your beard thickens and your voice deepens, the dose is decreased, but treatment will continue forever." c. "When your sperm count is high enough to demonstrate fertility, you will no longer need this therapy." d. "When you start to have undesirable side effects, the dose is decreased to the lowest possible level, and treatment is continued until you are 50 years old."

ANS: B Testosterone therapy is initiated with high-dose testosterone derivatives and is continued until virilization is achieved. The dose is then decreased, but therapy continues throughout life.

59. The nurse is caring for a critically ill client who has diabetic ketoacidosis (DKA). The nurse finds the following assessment data: blood pressure, 90/62; pulse, 120 beats/min; respirations, 28 breaths/min; urine output, 20 mL/1 hour per catheter; serum potassium, 2.6 mEq/L. The health care provider orders a 40 mEq potassium bolus and an increase in the IV flow rate. Which action by the nurse is most appropriate? a. Give the potassium after increasing the IV flow rate. b. Increase the IV rate; consult the provider about the potassium. c. Increase the IV rate; hold the potassium for now. d. Infuse the potassium first before increasing the IV flow rate.

ANS: B The client is acutely ill and is severely dehydrated and hypokalemic. The client requires more IV fluids and potassium. However, potassium should not be infused unless the urine output is at least 30 mL/hr. The nurse should first increase the IV rate, then consult with the provider about the potassium. The nurse should not just hold the potassium without consulting the provider because the client's level is dangerously low.

13. Which dietary alterations does the nurse make for a client with Cushing's disease? a. High carbohydrate, low potassium b. Low carbohydrate, low sodium c. Low protein, low calcium d. High carbohydrate, low potassium

ANS: B The client with Cushing's disease has weight gain, muscle loss, hyperglycemia, and sodium retention. Dietary modifications need to include reduction of total calories and carbohydrates to prevent or reduce the degree of hyperglycemia. Sodium retention causes water retention and hypertension. Clients are encouraged to restrict their sodium intake moderately. Clients often have bone density loss and need more calcium.

26. The nurse has been reviewing options for insulin therapy with several clients. For which client does the nurse choose to recommend the pen-type injector insulin delivery system? a. Older adult client who lives at home alone but has periods of confusion b. Client on an intensive regimen with frequent, small insulin doses c. Client from the low-vision clinic who has trouble seeing the syringe d. "Brittle" client who has frequent episodes of hypoglycemia

ANS: B The pen-type injector allows greater accuracy with small doses, especially doses lower than 5 units. It is not recommended for those who have visual or neurologic impairments. The client with frequent hypoglycemia would not derive special benefit from using the pen.

9. A client has been diagnosed with hypothyroidism. Which medication is the nurse prepared to administer to treat the client's bradycardia? a. Atropine sulfate b. Levothyroxine sodium (Synthroid) c. Propranolol (Inderal) d. Epinephrine (Adrenalin)

ANS: B The treatment for bradycardia from hypothyroidism is to treat the hypothyroidism using levothyroxine sodium. If the heart rate were so slow that it became an emergency, then atropine or epinephrine might be an option for short-term management. Inderal is a beta blocker and would be contraindicated for a client with bradycardia.

56. A client has been taught about lifestyle changes to help manage newly diagnosed diabetes mellitus type 2. Which statement by the client indicates good understanding? a. "Weight gain may lead to type 1 diabetes and I would need insulin." b. "I may not need to take medications if my weight is maintained." c. "I do not have to check my blood glucose if my weight is in the proper range." d. "My vision and foot pain may go away if I lose some weight."

ANS: B Type 2 diabetes can be prevented or delayed by weight loss and increased physical activity. Encourage all clients to maintain weight within an appropriate range for height and body build. Once diagnosed with type 2 diabetes, blood glucose monitoring is indicated, regardless of whether the client is taking oral antidiabetic medications. Vision and neurologic changes will not go away with weight control.

31. The nurse determines that which arterial blood gas values are consistent with ketoacidosis in the client with diabetes? a. pH 7.38, HCO3- 22 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg b. pH 7.28, HCO3- 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg c. pH 7.48, HCO3- 28 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg d. pH 7.28, HCO3- 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg

ANS: B When the lungs can no longer offset acidosis, the pH decreases to below normal. The arterial blood gases show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels.

11. A client with suspected syndrome of inappropriate antidiuretic hormone (SIADH) has a serum sodium of 114 mEq/L. Which action by the nurse is best? a. Consult with the registered dietitian about increased dietary sodium. b. Restrict the client's fluid intake to 900 mL/24 hr. c. Handle the client gently by using turn sheets for repositioning. d. Instruct the nursing assistants to measure intake and output.

ANS: B With SIADH, clients often have dilutional hyponatremia. The client needs a fluid restriction, sometimes to as little as 500 to 600 mL/24 hr. The client should be on intake and output (I&O); however, this will monitor only the client's intake, so it is not the best answer. Reducing intake will help increase the client's sodium. Adding sodium to the client's diet will not help if he or she is retaining fluid and diluting the sodium. The client is not at increased risk for fracture, so gentle handling is not an issue.

1. A client has been admitted with hypoparathyroidism. The client's serum laboratory values are as follows: calcium, 7.2 mg/dL; sodium, 144 mEq/L; magnesium, 1.2 mEq/L; potassium, 5.7 mEq/L. Which medications does the nurse anticipate administering? (Select all that apply.) a. Potassium chloride orally b. Calcium chloride IV c. 3% NS IV solution d. 50% magnesium sulfate e. Calcitriol (Rocaltrol) orally

ANS: B, D The client has hypocalcemia (treated with calcium chloride) and hypomagnesemia (treated with magnesium sulfate). The potassium level is high, so replacement is not needed. The client's sodium level is normal, so hypertonic IV solution is not needed. No information about a vitamin D deficiency is available, so calcitriol is not needed.

20. A client being treated for hypothyroidism has been admitted for pneumonia. Which activity does the nurse include as a priority in this client's care plan? a. Monitor the client's IV site every shift. b. Administer acetaminophen (Tylenol) for fever. c. Ensure that working suction equipment is in the room. d. Assess vital signs every 4 hours.

ANS: C A client with hypothyroidism who develops another illness is at risk for myxedema coma. In this emergency situation, maintaining an airway is a priority. The nurse should ensure that suction is available in the client's room because it may be needed if myxedema coma develops. The other interventions are necessary for any client with pneumonia, but having suction available is a safety feature for this client.

1. A client has a hormone deficiency. Which deficiency is the highest priority? a. Growth hormone b. Luteinizing hormone c. Thyroid-stimulating hormone d. Follicle-stimulating hormone

ANS: C A deficiency of thyroid-stimulating hormone (TSH) is the most life-threatening deficiency of the hormones listed in this question. TSH is needed to ensure proper synthesis and secretion of the thyroid hormones, whose functions are essential for life.

23. The nurse is caring for a client who has undergone a hypophysectomy. Which is the nurse's priority postoperative intervention? a. Keep the head of the bed flat and the client supine. b. Instruct the client to cough, turn, and deep breathe hourly. c. Report clear or yellow drainage from the nose or incision site. d. Apply petroleum jelly to the client's lips to avoid mouth dryness.

ANS: C A light yellow drainage or a halo effect on the dressing is indicative of a cerebrospinal leak. The client should have the head of the bed elevated after surgery. Although deep breathing is important postoperatively, coughing should be avoided to prevent cerebrospinal leakage. Although application of petroleum jelly to the lips will help with mouth dryness, this instruction is not as important as reporting the yellowish drainage.

52. A client is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted? a. Serum potassium level has increased from 2.8 to 3.2 mEq/L. b. Blood osmolarity has decreased from 350 to 330 mOsm. c. Score on the Glasgow Coma Scale is unchanged from 3 hours ago. d. Urine has remained negative for ketone bodies for the past 3 hours.

ANS: C A slow but steady improvement in central nervous system (CNS) functioning is the best indicator of therapy effectiveness for HHS. Lack of improvement in level of consciousness may indicate inadequate rates of fluid replacement. The other assessment findings do not indicate adequacy of treatment.

8. A client just diagnosed with acromegaly is scheduled for a hypophysectomy. Which statement made by the client indicates a need for clarification regarding this treatment? a. "I will drink whenever I feel thirsty after surgery." b. "I'm glad no visible incision will result from this surgery." c. "I hope I can go back to wearing size 8 shoes instead of size 12." d. "I will wear slip-on shoes after surgery so I don't have to bend over."

ANS: C Although removal of the tissue that is oversecreting hormones can relieve many symptoms of hyperpituitarism, skeletal changes and organ enlargement are not reversible. It will be appropriate for the client to drink as needed postoperatively and avoid bending over, reassured that the incision will not be visible.

37. Two months after a simultaneous pancreas-kidney (SPK) transplantation, a client is diagnosed as being in acute rejection. The client states, "I was doing so well with my new organs, and the thought of having to go back to living on hemodialysis and taking insulin is so depressing." Which is the nurse's best response? a. "You should have followed your drug regimen better." b. "You should be glad that at least dialysis treatment is an option for you." c. "One acute rejection episode does not mean that you will lose the new organs." d. "Our center is high on the list for obtaining organs from the national registry."

ANS: C An episode of acute rejection does not automatically mean that the client will lose the transplant. Pharmacologic manipulation of host immune responses at this time can limit damage to the organ and allow the graft to be maintained. The other statements either belittle the client or downplay his or her concerns.

46. Which statement made by a diabetic client who has a urinary tract infection indicates that teaching was effective regarding antibiotic therapy? a. "If my temperature is normal for 3 days in a row, I can stop taking my medicine." b. "If my temperature goes above 100° F (37.8° C), I should double the dose." c. "Even if I feel completely well, I should take the medication until it is gone." d. "When my urine no longer burns, I will no longer need to take the antibiotics."

ANS: C Antibiotic therapy is most effective when the client takes the prescribed medication for the entire course, not just when symptoms are present. The other statements are inaccurate.

24. A client has been newly diagnosed with diabetes mellitus. Which statement made by the client indicates a need for further teaching regarding nutrition therapy? a. "I should be sure to eat moderate to high amounts of fiber." b. "Saturated fats should make up no more than 7% of my total calorie intake." c. "I should try to keep my diet free from carbohydrates." d. "My intake of plain water each day is not restricted."

ANS: C Carbohydrates are an extremely important source of energy. They should compose at least 45% to 65% of the diabetic person's total caloric intake. The client needs to eat at least 130 g of carbohydrates a day. The other statements show good understanding.

7. A client has documented acromegaly. During a physical assessment before surgery for a knee replacement, the nurse discovers that she has a moderately enlarged liver. Which is the nurse's best action? a. Counsel the client on the health risks of alcoholism. b. Assess for jaundice of the skin and eyes. c. Document the finding and monitor the client. d. Draw blood for liver function studies.

ANS: C Clients with acromegaly or gigantism commonly have organomegaly of the heart and liver. Other than documenting the finding and monitoring the client, these actions would be inappropriate because the finding is commonly associated with acromegaly.

12. Which safety measure is most important for the nurse to institute for a client who has Cushing's disease? a. Pad the siderails of the client's bed. b. Assist the client to change positions slowly. c. Use a lift sheet to change the client's position. d. Keep suctioning equipment at the client's bedside.

ANS: C Cushing's syndrome or disease greatly increases the serum levels of cortisol, which contributes to excessive bone demineralization and increases the risk for pathologic bone fracture. The client should not require suctioning. Padding the siderails and assisting the client to change position may be effective, but these measures will not protect him or her as much as using a lift sheet.

55. A client was admitted with diabetic ketoacidosis (DKA). Which manifestations does the nurse monitor the client most closely for? a. Shallow slow respirations and respiratory alkalosis b. Decreased urine output and hyperkalemia c. Tachycardia and orthostatic hypotension d. Peripheral edema and dependent pulmonary crackles

ANS: C DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually clients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur.

15. A client has received vasopressin (DDAVP) for diabetes insipidus. Which assessment finding indicates a therapeutic response to this therapy? a. Urine output is increased; specific gravity is increased. b. Urine output is increased; specific gravity is decreased. c. Urine output is decreased; specific gravity is increased. d. Urine output is decreased; specific gravity is decreased.

ANS: C Diabetes insipidus causes urine output to be greatly increased, with a low urine osmolarity, as evidenced by a low specific gravity. Effective treatment results in decreased urine output that is more concentrated, as evidenced by an increased specific gravity.

1. In preparing a staff in-service presentation about diabetes mellitus, the nurse includes which information? a. Diabetes increases the risk for development of epilepsy. b. The cure for diabetes is the administration of insulin. c. Diabetes increases the risk for development of cardiovascular disease. d. Carbohydrate metabolism is altered in diabetes, but protein metabolism is normal.

ANS: C Diabetes mellitus is a major risk factor for morbidity and mortality caused by coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Insulin is a lifelong treatment for some diabetic clients. Because insulin regulates the metabolism of carbohydrates, fats, and protein, abnormalities in insulin production or use alter their metabolism.

7. During assessment of a client with a 15-year history of diabetes, the nurse notes that the client has decreased tactile sensation in both feet. Which action does the nurse take first? a. Document the finding in the client's chart. b. Test sensory perception in the client's hands. c. Examine the client's feet for signs of injury. d. Notify the health care provider.

ANS: C Diabetic neuropathy is common when the disease is of long duration. The client is at great risk for injury in any area with decreased sensation because he or she is less able to feel injurious events. Feet are common locations for neuropathy and injury, so the nurse should inspect them for any signs of injury. After assessing, the nurse should document findings in the client's chart. Testing sensory perception in the hands may or may not be needed. The health care provider can be notified after assessment and documentation have been completed.

12. A client with hypothyroidism as a result of Hashimoto's thyroiditis asks the nurse how long she will have to take thyroid medication. Which is the nurse's best response? a. "You will need to take the thyroid medication until the goiter is completely gone." b. "Thyroiditis is cured with antibiotics. Then you won't need thyroid medication." c. "You'll need thyroid pills for life because your thyroid won't start working again." d. "When blood tests indicate normal thyroid function, you can stop the medication."

ANS: C Hashimoto's thyroiditis results in a permanent loss of thyroid function. The client will need lifelong thyroid replacement therapy. The other answers are incorrect.

10. A client has hypothyroidism. Which problem does the nurse address as a priority for this client? a. Heat intolerance b. Body image problems c. Depression and withdrawal d. Obesity

ANS: C Hypothyroidism causes many problems in psychosocial functioning. Depression is the most common reason for seeking medical attention. Memory and attention span may be impaired. The client's family may have great difficulty accepting and dealing with these changes. The client is often unmotivated to participate in self-care. Lapses in memory and attention require the nurse to ensure that the client's environment is safe. Heat intolerance is seen in hyperthyroidism. Body image problems and weight issues do not take priority over mental status and safety.

3. Which safety measure does the nurse use for the adult client who has growth hormone deficiency? a. Avoid intramuscular medications. b. Place the client in protective isolation. c. Use a lift sheet to reposition the client. d. Assist the client to change positions slowly.

ANS: C In adults, growth hormone is necessary to maintain bone density and strength. Adults with growth hormone deficiency have thin, fragile bones. Avoiding IM medications, using protective isolation, and assisting the client as he or she moves from sitting to standing will not serve as safety measures when the client is deficient in growth hormone.

54. The nurse has been teaching a client about a new diagnosis of diabetes mellitus. Which statement by the client indicates a good understanding of self-management? a. "After bathing each day, I will inspect my feet and rub lotion between my toes and on my heels." b. "I can store 3 months' worth of insulin at room temperature as long as the bottles are not open." c. "My medical alert bracelet is important to identify me as having diabetes if I am unconscious." d. "If I travel eastward to see my family, I should plan on using more insulin on the day I travel."

ANS: C It is important to encourage clients with diabetes mellitus to wear a medical alert bracelet. This bracelet is helpful if the client becomes hypoglycemic and is unable to provide self-care. Lotion should not be applied between the toes. Insulin in active use can be stored at room temperature for 28 days; otherwise insulin is stored in the refrigerator. Eastbound travel will require a reduction in insulin.

4. A client with untreated diabetes mellitus has polyuria, is lethargic, and has a blood glucose of 560 mg/dL. The nurse correlates the polyuria with which finding? a. Serum sodium, 163 mEq/L b. Serum creatinine, 1.6 mg/dL c. Presence of urine ketone bodies d. Serum osmolarity, 375 mOsm/kg

ANS: D Hyperglycemia causes hyperosmolarity of extracellular fluid. This leads to polyuria from an osmotic diuresis. The client's serum osmolarity is high. The client's sodium would be expected to be high owing to dehydration. Urine ketone bodies and serum creatinine are not related to the polyuria.

51. The nurse is teaching a client with type 2 diabetes about acute complications. Which teaching point by the nurse is most accurate? a. Ketosis is less prevalent among obese adults owing to the protective effects of fat. b. People with type 2 diabetes have normal lipid metabolism, so ketones are not made. c. Insulin produced in type 2 diabetes prevents fat catabolism but not hyperglycemia. d. Oral antidiabetic agents do not promote the breakdown of fat for fuel (lipolysis).

ANS: C Ketosis occurs as a result of fat catabolism when intracellular glucose is unavailable for energy production. The client with type 1 diabetes becomes ketotic because he or she produces no insulin, and blood glucose cannot enter the cells. In type 2 diabetes, natural insulin production continues, although at a greatly reduced level. This level is not sufficient to keep blood glucose levels in the normal range but permits just enough glucose to enter cells for energy production, so that fats are not catabolized for this purpose. The other rationales are incorrect.

9. A client who had a trans-sphenoidal hypophysectomy 2 days ago now has nuchal rigidity. Which is the nurse's priority action? a. Have the client do active range-of-motion exercises for the neck. b. Document the finding and monitor the client. c. Take the client's temperature and other vital signs. d. Assess using a pain scale and administer pain medication.

ANS: C Nuchal rigidity is a major manifestation of meningitis, a potential postoperative complication associated with this surgery. Meningitis is an infection; usually the client will also have a fever and tachycardia. Range-of-motion exercises are inappropriate because meningitis is a possibility. Although pain medication may be a palliative measure, it is not the most appropriate initial action. Documentation should be done after all assessments are completed and should not be the only action.

7. On the second postoperative day after a subtotal thyroidectomy, the client tells the nurse that he feels numbness and tingling around his mouth. Which is the nurse's priority intervention? a. Offer mouth care. b. Loosen the dressing. c. Assess Chvostek's sign. d. Assess the client hourly.

ANS: C Numbness and tingling around the mouth or in the fingers and toes are manifestations of hypocalcemia, which could progress to cause tetany and seizure activity. The nurse should assess the client further by testing for Chvostek's sign and Trousseau's sign. Then the nurse should notify the provider. The other choices do not address the emergency situation.

3. Which dietary modification does the nurse provide for a client with hyperthyroidism? a. Decreased calories and proteins and increased carbohydrates b. Elimination of carbohydrates and increased proteins and fats c. Increased calories, proteins, and carbohydrates d. Supplemental vitamins and reduction of calories

ANS: C The client is hypermetabolic and has an increased need for calories, carbohydrates, and proteins. Proteins are especially important because the client is at risk for a negative nitrogen balance. The other modifications are inappropriate for a client with hyperthyroidism.

18. A client on medication after a bilateral adrenalectomy calls the clinic asking to be seen for "stomach flu" with nausea and vomiting. Which response by the nurse is best? a. "I will call in a prescription for an antiemetic medication for you." b. "Try to drink extra fluids until you can come in for an appointment." c. "You need to go to the nearest emergency department today." d. "Double the dose of your medication today and tomorrow."

ANS: C The client with bilateral adrenalectomy is on lifelong cortisol replacement therapy. The client cannot skip any doses of his or her medication. If the client has nausea and vomiting for longer than 24 hours and cannot give himself or herself an injection of hydrocortisone, the client must go to the nearest emergency department to get it. The other answers are inappropriate.

1. A client presents with elevations in triiodothyronine (T3) and thyroxine (T4) and with normal thyroid-stimulating hormone (TSH) levels. Which is the nurse's priority intervention? a. Administer levothyroxine (Synthroid). b. Administer propranolol (Inderal). c. Monitor the apical pulse. d. Assess for Trousseau's sign.

ANS: C The client's laboratory findings suggest that the client is experiencing hyperthyroidism. The increased metabolic rate can cause an increase in the client's heart rate, and the client should be monitored for the development of dysrhythmias. Placing the client on a telemetry monitor might also be a precaution. Synthroid is given for hypothyroidism. Propranolol is a beta blocker often used to lower sympathetic nervous system activity in hyperthyroidism. Trousseau's sign is a test for hypocalcemia.

2. Which is the best instruction for the nurse to give a client scheduled for a thyroid scan? a. "You will have external beam radiation." b. "No radiation is used for this scan." c. "No special radiation precautions are needed." d. "Your thyroid will be radioactive for weeks."

ANS: C The radioactive iodine used in thyroid scans is of low intensity and has such a short half-life that the client is not considered to be a radiation hazard. Thus, no radiation precautions are necessary. The other statements are inaccurate.

40. Three hours after surgery, the nurse notes that the breath of the client with type 1 diabetes has a "fruity" odor. Which is the nurse's best first action? a. Document the finding in the client's chart. b. Increase the IV fluid flow rate. c. Test the serum for ketone bodies. d. Perform pulmonary hygiene.

ANS: C The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a "fruity" odor to the breath. Documentation should occur after all assessments have been completed. The other options are not needed for this problem.

5. A client with diabetes has a serum creatinine of 1.9 mg/dL. The nurse correlates which urinalysis finding with this client? a. Ketone bodies in the urine during acidosis b. Glucose in the urine during hyperglycemia c. Protein in the urine during a random urinalysis d. White blood cells in the urine during a random urinalysis

ANS: C Urine should not contain protein. The presence of proteinuria in a diabetic client marks the beginning of kidney problems known as diabetic nephropathy, which progresses eventually to end-stage kidney disease. Decline in kidney function is assessed with serum creatinine. This client's creatinine level is high. The other findings would not be correlated with declining kidney function.

42. A diabetic client has numbness and reduced sensation. Which intervention does the nurse teach this client to prevent injury? a. "Examine your feet daily using a mirror." b. "Rotate your insulin injection sites." c. "Wear white socks instead of colored socks." d. "Use a bath thermometer to test the water temperature."

ANS: D Clients with diminished sensory perception can easily experience a burn injury when bath water is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and wearing white socks also will not prevent injury.

8. Which client statement alerts the nurse to the possibility of hypothyroidism? a. "My sister has thyroid problems." b. "I seem to feel the heat more than other people." c. "Food just doesn't taste good without a lot of salt." d. "I am always tired, even with 10 or 12 hours of sleep."

ANS: D Clients with hypothyroidism usually feel tired or weak despite getting many hours of sleep. Thyroid problems are not inherited. Heat intolerance is indicative of hyperthyroidism. Loss of taste is not a manifestation of hyperthyroidism.

27. A client is learning to inject insulin. Which action is important for the nurse to teach the client? a. "Do not use needles more than twice before discarding." b. "Massage the site for 1 full minute after injection." c. "Try to make the injection deep enough to enter muscle." d. "Keep the vial you are using in the pantry or the bedroom drawer."

ANS: D Cold insulin directly from the refrigerator is the most common cause of irritation (not infection) at the insulin injection site. Insulin in active use can be stored at room temperature. However, the bathroom is not the best place to store any medication because of increased heat and humidity. Needles should be used only once. Massage will not prevent or treat irritation from cold insulin. Insulin is given by subcutaneous, not intramuscular, injection.

58. A client recently diagnosed with type 1 diabetes tells the nurse, "I will never be able to stick myself with a needle." Which is the nurse's best response? a. "Try not to worry about it. We will give you your injections here in the hospital." b. "Everyone gets used to giving themselves injections. It really does not hurt." c. "I am not sure how your disease can be managed if you refuse to give yourself the shots." d. "Tell me what it is about the injections that is concerning you."

ANS: D Devote as much teaching time as possible to insulin injection and blood glucose monitoring. Clients with newly diagnosed diabetes are often fearful of giving themselves injections. If the client is worried about giving the injections, it is best to try to find out what specifically is causing the concern, so it can be addressed. Giving the injections for the client does not promote self-care ability. Telling the client that others give themselves injections may cause the client to feel badly. Stating that you don't know another way to manage the disease is dismissive of the client's concerns.

10. Which client is at greatest risk for undiagnosed diabetes mellitus? a. Young, muscular white man b. Young African-American man c. Middle-aged Asian woman d. Middle-aged American Indian woman

ANS: D Diabetes is a particular problem among African Americans, Hispanics, and American Indians. The incidence of diabetes increases in all races and ethnic groups with age. Being both an American Indian and middle-aged places a person at highest risk.

6. A young adult client newly diagnosed with type 1 diabetes mellitus has been taught about self-care. Which statement by the client indicates a good understanding of needed eye examinations? a. "At my age, I should continue seeing the ophthalmologist as I usually do." b. "I will see the eye doctor whenever I have a vision problem and yearly after age 40." c. "My vision will change quickly now. I should see the ophthalmologist twice a year." d. "Diabetes can cause blindness, so I should see the ophthalmologist yearly."

ANS: D Diabetic retinopathy is a leading cause of blindness in North America. All clients with diabetes, regardless of age, should be examined by an ophthalmologist (rather than an optometrist or optician) at diagnosis and at least yearly thereafter.

29. A client with diabetes has proliferative retinopathy, nephropathy, and peripheral neuropathy. Which statement by the client indicates a good understanding of the disease and exercise? a. "Because I have so many complications, I guess exercise is not a good idea." b. "I have so many complications that I better exercise hard to keep from getting worse." c. "I love to walk outside, but I probably better avoid doing that now." d. "I should look into swimming or water aerobics to get my exercise."

ANS: D Exercise is not contraindicated for this client, although modifications based on existing pathology are necessary to prevent further injury. Swimming or water aerobics will give the client exercise without the worry of having the correct shoes or developing a foot injury. The client can walk outside if this is the exercise that he or she prefers. The client should not exercise too vigorously.

3. The nurse is monitoring a client with hypoglycemia. Glucagon provides which function? a. It enhances the activity of insulin, restoring blood glucose levels to normal more quickly after a high-calorie meal. b. It is a storage form of glucose and can be broken down for energy when blood glucose levels are low. c. It converts excess glucose into glycogen, lowering blood glucose levels in times of excess. d. It prevents hypoglycemia by promoting release of glucose from liver storage sites.

ANS: D Glycogen is a counterregulatory hormone secreted by the alpha cells of the pancreas when blood glucose levels are low. The actions of glycogen that raise blood glucose levels include stimulating the liver to break down glycogen (glycogenolysis) and forming new glucose from protein breakdown (gluconeogenesis). The other statements are not accurate descriptions of the actions of glucagon.

23. A client has a new insulin pump. Which is the nurse's priority instruction in teaching the client? a. "Test your urine daily for ketones." b. "Use only buffered insulin." c. "Keep the insulin frozen until you need it." d. "Change the needle every 3 days."

ANS: D Having the same needle remain in place through the skin for longer than 3 days drastically increases the risk for infection in or through the delivery system. Having an insulin pump does not require the client to test for ketones in the urine. Insulin should not be frozen. Insulin is not buffered.

44. A client has long-standing diabetes mellitus. Which finding alerts the nurse to decreased kidney function in this client? a. Urine specific gravity of 1.033 b. Presence of glucose in the urine c. Presence of ketone bodies in the urine d. Sustained elevation in blood pressure

ANS: D Hypertension is both a cause of renal dysfunction and a result of renal dysfunction. Renal dysfunction often occurs in the client with diabetes. Glucose and ketones in the urine are consistent with diabetes mellitus but are not specific to renal function. Specific gravity is elevated with dehydration.

15. When taking the blood pressure of a client after a parathyroidectomy, the nurse notes that the client's hand has gone into flexion contractions. Which laboratory result does the nurse correlate with this condition? a. Serum potassium, 2.9 mEq/L b. Serum potassium, 5.8 mEq/L c. Serum sodium, 122 mEq/L d. Serum calcium, 6.9 mg/dL

ANS: D Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. This effect of hypocalcemia is enhanced in the presence of tissue hypoxia. The flexion contractions (Trousseau's sign) that occur during blood pressure measurement are indicative of hypocalcemia, not the other electrolyte imbalances, which include hypokalemia, hyperkalemia, and hyponatremia.

11. A client has hypothyroidism and has been started on levothyroxine (Synthroid). Which assessment finding leads the nurse to conclude that the treatment is effective? a. Thirst is recognized and the client drinks fluids appropriately. b. Weight has been the same for 3 weeks. c. Total white blood cell count is 6000 cells/mm3. d. Heart rate is 70 beats/min and regular.

ANS: D Hypothyroidism decreases body functioning and can result in effects such as bradycardia, confusion, and constipation. If a client's heart rate is bradycardic while on thyroid hormone replacement, this is an indicator that the replacement may not be adequate. Conversely, a heart rate above 100 beats/min may indicate that the client is receiving too much of the thyroid hormone. The other assessment findings do not give any indication as to whether treatment is successful.

49. A client is receiving IV insulin for hyperglycemia. Which laboratory value requires immediate intervention by the nurse? a. Serum chloride level of 98 mmol/L b. Serum calcium level of 8.8 mg/dL c. Serum sodium level of 132 mmol/L d. Serum potassium level of 2.5 mmol/L

ANS: D Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The chloride level is normal. The calcium and sodium levels are slightly low, but this would not be related to hyperglycemia and insulin administration.

5. A client scheduled for a partial thyroidectomy asks the nurse why she is being given an iodine preparation before surgery. Which is the nurse's best response? a. "Iodine will help make the internal surgical environment sterile." b. "It is given to stimulate the storage of excess thyroid hormones." c. "This will replace the hormones you will lose after your operation." d. "It will prevent excessive bleeding during surgery."

ANS: D Iodine preparations decrease the size and vascularity of the thyroid gland, reducing the risk for hemorrhage and the potential for thyroid storm during surgery. The other answers are not accurate.

35. The nurse is teaching a client with diabetes about self-care. Which activity does the nurse teach that can decrease insulin needs? a. Reducing intake of liquids to 2 L/day b. Eating animal organ meats high in insulin c. Limiting carbohydrate intake to 100 g/day d. Walking 1 mile each day

ANS: D Moderate exercise, such as walking, helps regulate blood glucose levels on a daily basis and results in lowered insulin requirements for clients with type 1 diabetes. Restricting fluids and eating organ meats will not reduce insulin needs. People with diabetes need at least 130 grams of carbohydrates each day.

6. A client thought to have a problem with the pituitary gland is given a stimulation test using insulin. A short time later, blood analysis reveals elevated levels of growth hormone (GH) and adrenocorticotropic hormone (ACTH). Which is the nurse's interpretation of this finding? a. Pituitary hypofunction b. Pituitary hyperfunction c. Pituitary-induced diabetes mellitus d. A normal pituitary response to insulin

ANS: D Some tests for pituitary function involve administering agents that are known to stimulate the secretion of specific pituitary hormones and then measuring the response. Such tests are termed stimulation tests. For example, the presence of insulin in those with normal pituitary function causes increased release of GH and ACTH. The stimulation test for GH or ACTH assessment involves injecting the client with regular insulin (0.05 to 1 U/kg of body weight) and checking circulating levels of GH and ACTH.

6. Twelve hours after a total thyroidectomy, the client develops stridor. Which is the nurse's priority intervention? a. Reassure the client that the voice change is temporary. b. Document the finding and assess the client hourly. c. Hyperextend the client's neck and apply oxygen. d. Prepare for emergency tracheostomy and call the health care provider.

ANS: D Stridor on exhalation is a hallmark of respiratory distress, usually caused by obstruction resulting from edema. One emergency measure is to remove the surgical clips to relieve the pressure. This might be a physician function. The nurse should prepare to assist with emergency intubation or tracheostomy while notifying the provider or the Rapid Response Team. The other choices do not address the emergency situation.

19. A client who has used insulin for diabetes control for 20 years has a spongy swelling at the site used most frequently for insulin injection. Which is the nurse's best action? a. Apply ice to this area for 20 minutes. b. Document the finding in the client's chart. c. Assess the client for other signs of cellulitis. d. Instruct the client to use a different site for injection.

ANS: D The client has lipohypertrophy as a result of repeated injections at the same site. Avoiding this site for an extended period of time allows dystrophic changes to regress or at least not to become worse. The other actions are not needed.

21. A client on an intensified insulin regimen consistently has a fasting blood glucose level between 70 and 80 mg/dL, a postprandial blood glucose level below 200 mg/dL, and a hemoglobin A1c level of 5.5%. Which is the nurse's interpretation of these findings? a. Increased risk for developing ketoacidosis b. Increased risk for developing hyperglycemia c. Signs of insulin resistance d. Good control of blood glucose

ANS: D The client is maintaining blood glucose levels within the defined ranges for goals in an intensified regimen. Because the client's glycemic control is good, he or she is not at higher risk for ketoacidosis or hyperglycemia and is not showing signs of insulin resistance.

32. A client has diabetic ketoacidosis and manifests Kussmaul respirations. What action by the nurse takes priority? a. Administration of oxygen by mask or nasal cannula b. Intravenous administration of 10% glucose c. Implementation of seizure precautions d. Administration of intravenous insulin

ANS: D The rapid, deep respiratory efforts of Kussmaul respiration is the body's attempt to reduce the acids produced by using fat rather than glucose for fuel. The client who is in ketoacidosis and who does not also have a respiratory impairment does not need additional oxygen. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. Giving the client glucose would be contraindicated. The client does not require Seizure Precautions.

33. A client with type 1 diabetes asks whether an occasional glass of wine is allowed in the diet. Which is the nurse's best response? a. "Drinking any wine or alcohol will increase your insulin requirements." b. "Because of poor kidney function, people diagnosed with diabetes should avoid alcohol at all times." c. "You shouldn't drink alcohol because it will make you hungry and overeat." d. "One glass of wine is okay with a meal and is counted as two fat exchanges."

ANS: D Under normal circumstances, blood glucose levels will not be affected by moderate use of alcohol when diabetes is well controlled. Because alcohol can induce hypoglycemia, it should be ingested with or shortly after a meal. One alcoholic beverage is substituted for two fat exchanges when caloric intake is calculated. The other statements are incorrect.

50. The nurse is teaching a client about sick day management. Which statement by the nurse is most accurate? a. "Continue your prescribed exercise regimen even if you are sick." b. "Avoid eating or drinking to reduce vomiting and diarrhea." c. "Do not use insulin or take your oral antidiabetic agent if you vomit." d. "Monitor your blood glucose levels at least every 4 hours."

ANS: D When ill, the client should monitor his or her blood glucose at least every 4 hours. The other statements are inaccurate.

Hormones of the Adrenal Cortex

Aldosterone (mineralcorticoids) Cortisol (glucocorticoids) sex hormones

A nurse is collecting an admissions history from a female client who has hypothyroidism. Which of the following findings should the nurse expect? (Select all that apply) (a) Diarrhea (b) Menorrhagia (c) Dry skin (d) Increased libido (e) Hoarseness

B,C,E

A nurse is reviewing manifestations of hyperthyroidism with a client. Which of the following findings should the nurse include? (Select all that apply) (a) Anorexia (b) Heat intolerance (c) Constipation (d) Palpitations (e) Weight loss (f) Bradycardia

B,D,E

Which problems does the nurse expect in an older adult as a result of age-related changes in endocrine function? (Select all that apply) (a) Increased BMR (basal metabolic rate) (b) Decreased core body temp (c) Dehydration (d) Diarrhea (e) Hyperglycemia (f) Polyuria

B, C, E, F

A nurse is providing med teaching for a client who has Addison's disease and is taking hydrocortisone. Which of the following instructions should the nurse include? (Select all that apply) (a) Take med on an empty stomach (b) Notify provider of any illness or stress (c) Report any weakness or dizziness (d) Do not discontinue medication suddenly (e) Eat a low sodium diet

B,C,D

A nurse is reinforcing teaching with a client who has a new prescription for levothyroxine to tx hypothyroidism. Which of the following information should the nurse include in the teaching? (Select all that apply) (a) Weight gain is expected with this drug (b) Med should not be discontinued w/o advice of provider (c) F/U serum TSH levels should be drawn (d) Take the med on an empty stomach (e) Use fiber laxatives for constipation

B,C,D

A nurse in an acute care facility is admitting a client who has acute adrenal insufficiency. Which of the following prescriptions should the nurse anticipate? (Select all that apply) (a) IV therapy with 0.45% sodium chloride (b) Regular insulin (c) Hydrocortisone sodium succinate (d) Sodium polystyrene sulfonate (e) Furosemide

B,C,D,E

A nurse is providing discharge teaching for a client who had a transsphenoidal hypophysectomy. Which of the following instructions should the nurse include? (Select all that apply) (a) Brush teeth after every meal/snack (b) Avoid bending at the knees (c) eat a high fiber diet (d) Notify provider of sweet-tasting drainage (e) Notify provider of diminished sense of smell

C,D

A nurse is assessing a client who is 12 hr post-op thyroidectomy. The nurse should identify which of the following findings as indicative of thyroid crisis? (Select all that apply) (a) Bradycardia (b) Hypothermia (c) Dyspnea (d) Abdominal pain (e) Mental confusion

C,D,E

Hormones of the Ovaries

estrogen and progesterone

Hormones of the Pancreas

insulin and glucagon

Endocrine system controls

metabolism Nutrition Elimination Temperature Fluid & Electrolyte Balance Growth Reproduction

Tests that identify SIADH

serum and/or urine electrolyte and osmolality (285-295 mOsm/kg) urine specific gravity (1.002-1.03)

function of posterior pituitary

stores and releases ADH (vasopressin/antidiuretic hormone) and oxytocin

Hormones of the Testes

testosterone

What does ADH do?

Facilitates reabsorption of water in nephron of kidney

Water Deprivation Test

For clients with diabetes insipidus, if kidneys are unable to concentrate urine- positive test

Major endocrine glands

Hypothalamus Pituitary Gland Adrenal Gland Thyroid Gland Islet cells of the pancreas Parathyroid Gland Gonads

Hormones of Parathyroid

PH (Parathyroid Hormone)

Why is Aspirin contraindicated for fever reduction during Thyroid storm/crisis?

Salicylates release thyroxine from protein-binding sites therefore increasing thyroxine levels even more

Best indicator for hyperthyroidism

T3 level elevated

Three cell types of the islets of the pancreas

alpha - secrete glucose beta - secrete insulin delta - secrete somatostatin

1. In mixing regular and NPH insulin, the nurse completes the following actions. Place these actions in the correct order. (Separate letters by a comma and space as follows: a, b, c, d.) a. Inspect bottles for expiration dates. b. Gently roll bottle of NPH in hands. c. Wash your hands. d. Inject air into the regular insulin. e. Withdraw the NPH insulin. f. Withdraw the regular insulin. g. Inject air into the NPH bottle. h. Clean rubber stoppers with an alcohol swab.

c, a, b, h, g, d, f, e After washing hands, it is important to inspect bottles and then to roll NPH to mix the insulin. It is important to inject air into the NPH bottle before placing the needle in a regular insulin bottle to avoid mixing of regular and NPH insulin. The shorter-acting insulin is always drawn up first.

what happens if there is not enough ADH?

causes DI (diabetes insipidus) therefore drink a lot pee a lot diluted urine (low specific gravity = under 1.002) low BP (not enough vasopressin = vasodilation)

what happens if there is too much ADH?

causes SIADH (*S*yndrome of *I*nappropriate *ADH*) therefore fluid retention edema concentrated urine (high specific gravity = over 1.03) high BP (too much vasopressin = vasoconstriction)