Med-Surg Endocrine - Progression Exam

The nurse teaches proper foot care to a client with diabetes mellitus. Which statement by the client indicates that further teaching is needed?

"I will make sure my flip flops are made of leather." Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet due to the chronic complication of peripheral neuropathy. Peripheral neuropathy results from damage to the nerves in the extremities. Clients may be unable to feel injuries if they occur and must take extra measures in caring for their feet. Clients should be taught to wear closed-toed, leather-based shoes to prevent injury. Careful, daily attention to foot care can prevent long-term complications. The following instructions can be used in teaching diabetic foot care: Proper footwear - Wear shoes that are comfortable, supportive, and well-fitting (preferably leather). Avoid high-heeled, open-heeled, and open-toed shoes. Wear clean, absorbent (eg, cotton) socks. Daily hygiene and inspection - Use a mild soap and warm water; dry feet thoroughly, especially between toes. Apply lanolin lotion to prevent drying (but not between toes) (Option 1). Inspect for any break in skin integrity using a mirror or a second person to visualize the bottom of the feet. Trim toenails straight across; file edges along contour of the toes. Injury avoidance - Do not walk barefoot, use hot water or heating pads, wear restrictive shoes or clothing, or cross the legs for extended periods (Options 3 and 4). Report problems - Do not self-treat corns, calluses, or ingrown toenails. Cleanse cuts or abrasions with mild soap and water; report non-healing or infected injuries to the health care provider immediately. Educational objective: Careful, daily attention to foot care can prevent long-term complications. Clients with diabetes should be taught to wear closed-toed, leather-based shoes to prevent injury. Clients should also receive instruction regarding daily hygiene and inspection, injury avoidance, and prompt reporting of problems.

The nurse cares for a client with type 2 diabetes mellitus and hemoglobin A1C results of 8% at an outpatient health clinic. Which statement by the nurse will best address these results?

"Let's review your diet, exercise, and medication regimen over the past 2-3 months" Explanation: Hemoglobin A1C is a diagnostic test used to measure the percentage of glycosylated hemoglobin in the blood. A normal hemoglobin A1C is 4%-6% in clients without diabetes; the goal is to keep the level <7% in clients with diabetes. The A1C test measures blood glucose control over a period of 2-3 months; higher measurements indicate higher glycemic levels. High levels may indicate poor adherence to the recommended diet and exercise plan or ineffective antihyperglycemic medication regimen. It is important for the nurse to review the diet, exercise, and medication plan with the client who has a high hemoglobin A1C. (Option 1) Although it is important to review signs and symptoms of hypoglycemia with all clients with diabetes, this statement does not address the elevated hemoglobin A1C. (Option 3) A diet recall of the last 24-48 hours will not give the nurse adequate information on possible causes of an elevated hemoglobin A1C as this test measures glycemic control over 2-3 months. (Option 4) A hemoglobin A1C may be tested when the client is not fasting. Educational objective: Hemoglobin A1C is a diagnostic test used to measure the percentage of glycosylated hemoglobin in the blood over a period of 2-3 months. A normal hemoglobin A1C is 4%-6% in clients without diabetes; the goal is to keep the level <7% in clients with diabetes.

A client diagnosed with septic shock has an upward-trending glucose level (180-225 mg/dL [10.0-12.5 mmol/L]) requiring control with insulin. The client's spouse asks why insulin is needed as the client is not a diabetic. What is the most appropriate response by the nurse?

"The increase in glucose is a normal response to stress by the body. We give insulin to keep the level at 140 - 180 mg/dL." Stress-induced hyperglycemia (gluconeogenesis) can occur in hospitalized clients in relation to surgery, trauma, acute illness, and infection. Hyperglycemia (glucose level >140 mg/dL [7.8 mmol/L]) affects both diabetic and non-diabetic hospitalized clients, especially those who are critically ill. Approximately 80% of clients in the intensive care unit who develop hyperglycemia have no history of diabetes before admission. Hyperglycemia is associated with increased risk of complications (eg, health care-associated infection, increased length of stay, acute kidney injury). To minimize complications and avoid hypoglycemia, the recommended glucose target range for critically ill clients is 140-180 mg/dL [7.8-10.0 mmol/L]. For non-critically ill clients, <140 mg/dL [7.8 mmol/L] fasting and <180 mg/dL [10.0 mmol/L] random blood glucose are recommended. (Option 1) Hospital hyperglycemia is not a direct cause of type II diabetes mellitus. In the non-diabetic client, the glucose level usually returns to normal after resolution of the disease process and/or discontinuation of steroid medications. A target glucose range of <140 mg/dL [7.8 mmol/L) is not recommended for this client. (Option 2) The prevalence of diabetes in hospitalized clients is high (about 1 in 4) and may be an undiagnosed pre-existing condition. A normal-range glucose level (70-110 mg/dL [3.9-6.1 mmol/L]) is not the recommended target range in this client due to the risk of hypoglycemia (with aggressive control) and worse outcomes. (Option 4) Although hyperglycemia does affect the ability to fight infection, 70-110 mg/dL [3.9-6.1 mmol/L] is not the recommended target range for this client. Educational objective: Stress-induced hyperglycemia causes complications in the hospitalized client. To minimize complications, the recommended target glucose range for critically ill clients is 140-180 mg/dL [7.8-10.0 mmol/L]. For non-critically ill clients, <140 mg/dL (7.8 mmol/L) fasting and <180 mg/dL (10.0 mmol/L) random blood glucose are recommended.

The nurse reviews prescriptions for assigned adult clients. Which prescription should the nurse question?

0.45% sodium chloride (NaCl) solution prescribed for a client with SIADH secretion who has a sodium level of 120 mEq/L Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is associated with increased water reabsorption and excessive intra- and extracellular fluid, which result in hypervolemia from fluid retention and dilutional hyponatremia. In the setting of SIADH, the nurse should question a prescription for a hypotonic solution (eg, 0.45% NaCl; or dextrose water) as it would worsen the fluid and electrolyte imbalance. A prescription for fluid restriction and a hypertonic IV solution (eg, 3% NaCl) administered in small quantities would be appropriate to shift fluid back into the vascular compartment and correct hyponatremia. (Option 2) Isotonic fluids (eg, normal saline) are appropriate for clients with volume deficit such as those with gastrointestinal bleeding. (Option 3) Septic shock involves an inflammatory response to pathogens that leads to massive vasodilation and increased capillary permeability, resulting in intravascular hypovolemia and severe hypotension. An isotonic solution (eg, 0.9% NaCl) bolus is prescribed to expand intravascular volume and increase blood pressure. (Option 4) A burn injury causes tissue damage and increased capillary permeability; this leads to fluid and electrolyte losses related to evaporation and intravascular fluid shifts into the interstitial tissue, which result in hypovolemia, hemoconcentration (eg, hematocrit >53% [0.53]), and hypotension. An isotonic solution (eg, lactated Ringer's) is prescribed to replace fluid and electrolyte losses. Educational objective: Syndrome of inappropriate antidiuretic hormone secretion is associated with hypervolemia and dilutional hyponatremia. Fluid restriction and hypertonic IV solutions (eg, 3% saline) are prescribed to correct hyponatremia.

The nurse assesses a client with Cushing syndrome. Which clinical manifestations should the nurse expect? Select all that apply.

1. Hyperglycemia 2. Hypertension 4. Truncal obesity Cushing syndrome is the result of prolonged exposure to excess corticosteroids, especially glucocorticoid steroids. The most common cause is the administration of corticosteroids, such as prednisone or hydrocortisone, for other conditions. However, pituitary adenomas can secrete adrenocorticotropic hormone (ACTH), which in turn causes the adrenal glands to produce too much cortisol. Clinical manifestations include: Androgen excess from adrenal gland stimulation can result in acne, hirsutism, and menstrual irregularities (eg, oligomenorrhea). Metabolic complications include truncal obesity (subsequently causing peripheral insulin resistance), hypertension, and hyperglycemia (ie, excess cortisol stimulating gluconeogenesis). Fat accumulation in the face (ie, moon face) and the back of neck (ie, buffalo hump) is common (Options 1, 2, and 4). Dermatological changes are possible and include easy bruising, purple striae, and skin atrophy; these result from loss of collagen. Proximal muscle weakness and bone loss (ie, osteoporosis) due to steroid catabolism on muscles and bone can develop in untreated clients. (Options 3 and 5) Hyponatremia and weight loss are associated with adrenocortical insufficiency, or Addison disease. Educational objective: Clinical manifestations of Cushing syndrome include weight gain, truncal obesity, moon face, skin atrophy, easy bruising, purple striae on the abdomen, muscle weakness, hypertension, and hyperglycemia. Associated androgen excess can result in acne, hirsutism, and menstrual irregularities.

The nurse educates a 30-year-old female client who is being evaluated for hyperthyroidism with a radioactive iodine uptake (RAIU) test. Which instruction(s) should the nurse include in the teaching plan? Select all that apply.

1."A pregnancy test must be obtained prior to RAIU test administration." 2."All jewelry or metal around the neck area should be removed before the RAIU test." 3."Antithyroid medications should be held for 5-7 days before the RAIU test." Explanation: A RAIU test involves administering a low dose of radioactive iodine, in contrast to radioactive iodine treatment for some types of thyroid cancer, which uses a high dose to destroy all thyroid tissue. The thyroid gland is the only tissue that uses iodine, which is a key component of thyroid hormones. A scan is performed at 2, 6, and 24 hours to assess the areas actively absorbing iodine, which can narrow the diagnosis to hyperfunctioning thyroid disorders (eg, Graves' disease). Important nursing considerations: Notify the primary health care provider (PHCP) if computerized tomography scan or other recent x-ray using iodine contrast has been performed; the iodine may alter the test results. Antithyroid or thyroid hormone medication should be held for 5-7 days before undergoing a RAIU test as these can also alter results. All premenopausal women must take a pregnancy test before the procedure, as radioactive iodine could adversely affect the development of the fetal thyroid gland. Important aspects of client education: Maintain nothing by mouth (NPO) status for 2-4 hours prior to the procedure (Option 5). Eating may resume 1-2 hours after swallowing the iodine; a normal diet can be restarted when the test ends. Remove dentures and jewelry/metal around the neck to allow clear visualization during the scan. Drink plenty of fluids after the procedure to clear RAI from the system. Notify the PHCP if you are allergic to any medications (eg, iodine). However, a RAIU test is generally safe (even in the presence of an iodine allergy) due to the diminutive amount of iodine used. You will be awake during the procedure but there should be no discomfort (Option 4). Do not breastfeed immediately after this procedure, and ask your PHCP when breastfeeding may resume. Educational objective: RAIU measures the metabolic activity in the thyroid gland in order to differentiate between the many types of thyroid disorders. For an accurate measurement, medications affecting the thyroid should be held 7 days prior to the test date and clients are NPO for 4 hours prior to iodine administration. Premenopausal women must take a pregnancy test. Dentures, metal, and jewelry should be removed.

A client is suspected of having Graves' disease (hyperthyroidism). Which signs and/or symptoms are expected to be present in this client? Select all that apply.

1.Anxiety 4.Heart palpitations 5.Protrusion of the eyeballs Hyperthyroidism refers to a sustained hyperfunctioning of the thyroid gland due to an increase in thyroid hormones (T3 and T4). Elevated thyroid hormones suppress serum TSH levels. The symptoms are a result of the hypermetabolic rate caused by the increase in thyroid hormones. These include weight loss, heart palpitations, heat intolerance, excessive sweating, anxiety, hand tremors, diarrhea, and insomnia. Hyperthyroidism can also cause retro-orbital tissue expansion and weakness of the muscle fibers in the eye. Exophthalmos is an irreversible protrusion of the eyeballs. Eyelid lag (ie, Graefe's sign) is a delayed movement in the eyelid when the eye looks downward. (Options 2, 3, and 6) Bradycardia, dry skin, constipation, and weight gain are commonly associated with hypothyroidism, a disorder caused by a thyroid hormone deficiency (low T3 and T4, high TSH), which causes a slowing of the metabolic rate. Educational objective: Hyperthyroidism refers to a sustained hyperfunctioning of the thyroid gland due to an increase in thyroid hormones (T3 and T4). It causes symptoms associated with a high metabolic rate, including weight loss, heart palpitations, heat intolerance, anxiety, hand tremors, and insomnia.

A client with type I diabetes mellitus is brought to the emergency department by his wife. The client has fruity breath with rapid, deep respirations at 36 breaths per minute, reports abdominal pain, and appears weak. The nurse should anticipate implementation of which prescription(s)? Select all that apply.

3. Perform a fingerstick and serum blood glucose test 4. Prepare to administer an IV infusion of regular insulin 5. Start an IV line and administer a bolus of normal saline Explanation: The client is exhibiting the cardinal signs and symptoms of diabetic ketoacidosis (DKA). DKA is an acute life-threatening complication, typically of type I diabetes, characterized by hyperglycemia, ketosis, and acidosis. It is caused by an intense deficit of insulin. Glucose cannot be used properly for energy when this deficit occurs and the body begins to break down fat stores, producing ketones, a byproduct of fat metabolism, resulting in metabolic acidosis. The lack of insulin also results in increased production of glucose in the liver, further exacerbating hyperglycemia. Because some of the symptoms of hypoglycemia and DKA overlap, a blood glucose level should be checked to ensure that hyperglycemia is present. Hyperglycemia can cause osmotic diuresis, leading to dehydration. In addition, ketones are excreted in the urine as the body tries to restore its pH balance. Vital electrolytes such as sodium, potassium, chloride, phosphate, and magnesium become depleted during the process. Cardinal signs of dehydration such as poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension, weakness, and lethargy can occur. The nurse should start an IV and bolus the client with normal saline or 1/2 normal saline to reverse dehydration. This should occur prior to treating the hyperglycemia with regular insulin IV infusion. Because insulin promotes water, potassium, and glucose entrance into the cell, it can exacerbate vascular dehydration and imbalance of electrolytes, particularly potassium. A potassium level (along with other electrolytes) should also be assessed prior to beginning the prescribed insulin therapy. Other signs associated with DKA include Kussmaul respirations, deep, rapid respirations that have a fruity/acetone smell as the carbon dioxide is exhaled. This compensatory mechanism results in a lowered PaC02 in an attempt to restore the body's normal pH level and should not be reversed (Option 2). (Option 1) IV dextrose is administered during acute hypoglycemic episodes and would worsen DKA. Educational objective: DKA is an acute life-threatening complication, typically of type I diabetes, characterized by hyperglycemia, ketosis, and acidosis. It is caused by an intense deficit of insulin and should be treated first with rehydration (normal saline) and then insulin administration

The nurse practicing in an out-patient clinic cares for a client recently diagnosed with hyperthyroidism. Which diet-related teaching should the nurse add to the client's plan of care? Select all that apply.

3.Include meals and snacks high in protein content 4.Teach avoidance of caffeine-containing liquids 5.Teach the client about consumption of a high-calorie diet of 4000-5000 calories/day Explanation: Hyperthyroidism refers to sustained hyperfunctioning of the thyroid gland due to excessive secretion thyroid hormones (T3, T4); this leads to an increased metabolic rate. In clients with hyperthyroidism, teaching and learning objectives to satisfy hunger and prevent weight loss and tissue wasting include: Adherence to a high calorie diet (4000-5000 calories per day). Consumption of approximately 6 full meals and snacks per day. These should be packed with protein (1-2 g/kg of ideal body weight), carbohydrates, and be full of vitamins and minerals (Option 1). Avoidance of high-fiber foods due to the constant hyperstimulation of the gastrointestinal (GI) tract. High-fiber foods may increase GI symptoms (eg, diarrhea) (Option 2). However, high-fiber diets are recommended if the client with hyperthyroidism has constipation. Avoidance of stimulating substances (eg, caffeinated drinks: coffee, tea, soft drinks). Avoidance of spicy foods as these can also increase GI stimulation. Educational objective: Hyperthyroidism leads to a high metabolic rate. It is important for the nurse to teach the client nutritional measures, including consumption of a diet high in calories (high in protein, carbohydrates, vitamins, and minerals) to satisfy hunger and prevent weight loss and tissue wasting.

When no changes are made to the diet or prescribed insulin, which client with type 1 diabetes mellitus does the nurse anticipate having the highest risk of developing hypoglycemia?

40-year-old experienced cyclist who rides an extra 10 miles Explanation: Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) is an acute and sometimes life-threatening complication of diabetes mellitus. It occurs when the proportion of insulin exceeds the glucose in the blood. Counterregulatory hormones (eg, epinephrine) are then released and the autonomic nervous system is activated, causing symptoms of hypoglycemia such as sweating, tremor, and hunger. Aerobic exercise typically lowers blood glucose levels. As muscles use up glucose, the liver is unable to produce enough glucose to keep up with the demand. Even an experienced exerciser should check blood glucose levels before, during, and after exercise, and also carry a carbohydrate drink or snack in case of a hypoglycemic episode (Option 2). Clients with an acute illness (eg, influenza, cellulitis) are more likely to experience hyperglycemia. Increased glucose levels occur due to the physiological stress response caused by infection (Options 1 and 3). Hyperglycemia is also a side effect of prednisone (Option 4). Educational objective: Aerobic exercise typically lowers blood glucose levels as glucose production in the liver fails to keep up with elevated glucose uptake by the muscles at work.

The nurse is conducting a health-screening clinic at an industrial work site. The nurse should be most concerned about which client's risk for metabolic syndrome?

55-year-old woman with waist circumference of 37 inches, triglycerides of 190 mg/dL, and fasting blood glucose of 120 mg/dL. Metabolic syndrome is the presence of ≥3 metabolic health factors that increase a client's risk for stroke, diabetes mellitus, and cardiovascular disease. Criteria include: Abdominal obesity: Waist circumference (≥40 inches [102 cm] in men, ≥35 inches [89 cm] in women) High serum triglycerides >150 mg/dL (1.7 mmol/L) or hypertriglyceridemia drug treatment Low levels of high-density lipoprotein (HDL) cholesterol (<40 mg/dL [1.0 mmol/L] in men, <50 mg/dL [1.3 mmol] in women) Hypertension ≥130/85 mm Hg or hypertension drug treatment Fasting blood glucose ≥100 mg/dL (5.6 mmol/L) or hyperglycemia drug treatment The 55-year-old woman (waist circumference 37 inches [94 cm], triglycerides 190 mg/dL [2.2 mmol/L], fasting blood glucose 120 mg/dL [6.7 mmol/L]) is at highest risk for metabolic syndrome with 3 of 5 criteria (obesity, high triglycerides, hyperglycemia) (Option 3). (Option 1) The 27-year-old woman (triglycerides 210 mg/dL [2.4 mmol/L]) has only 1 metabolic syndrome-associated condition (hypertriglyceridemia). (Option 2) The 45-year-old man (fasting blood glucose 118 mg/dL [6.6 mmol/L]) has only 1 metabolic syndrome-associated condition (hyperglycemia). (Option 4) The 82-year-old man (blood pressure 148/88 mm Hg, fasting blood glucose 104 mg/dL [5.8 mmol/L]) has only 2 metabolic syndrome-associated conditions (hypertension, hyperglycemia). His HDL is within normal limits. Educational objective: Clients with metabolic syndrome are at increased risk for stroke, diabetes mellitus, and cardiovascular disease. Criteria for metabolic syndrome include at least 3 of 5 conditions: abdominal obesity, hyperglycemia, low levels of high-density lipoprotein, high serum triglycerides, and hypertension.

The nurse cares for a client who is experiencing exophthalmos as a complication of Graves' disease. Which nursing action(s) should be included in the client's plan of care? Select all that apply.

Administer artificial tears to moisten the conjunctiva If eyelids don't close during sleep, lightly tape them shut Recommend the use of dark glasses to prevent irritation Teach about the importance of smoking cessation Exophthalmos is a complication of hyperthyroidism (hypermetabolic state due to thyroid hormone overproduction) from Graves' disease. It is defined as a protrusion of the eyeballs caused by increased orbital tissue (connective, adipose, muscular) expansion and can be irreversible. The exposed cornea is at risk for dryness, injury, and infection. Nursing care for a client with exophthalmos includes: Maintaining the head of the bed in a raised position to facilitate fluid drainage from the periorbital area Using artificial tears or other similar products to moisten the eyes to prevent corneal drying (causes abrasions/ulcers) Taping the client's eyelids shut during sleep if they do not close on their own Teaching the client the following: Regular visits to the ophthalmologist are necessary to measure eyeball protrusion and evaluate condition. If recommended, anti-thyroid drugs should be taken to prevent further exacerbation of exophthalmos. Smoking cessation is necessary as smoking increases the risk of Graves' disease and associated eye problems. Restrict salt intake to decrease periorbital edema. Use dark glasses to decrease glare and prevent external irritants and infection. Perform intraocular muscle exercises (turning the eyes using complete range of motion) to maintain flexibility. Educational objective: Exophthalmos is a complication of hyperthyroidism from Graves' disease leading to increased orbital tissue (connective, adipose, muscular) expansion that can be irreversible. Nursing care to keep eyes moist and protected is needed to prevent corneal ulcers and infection.

The nurse in the intensive care unit cares for a client with primary adrenocortical insufficiency (Addison's disease). The client reports nausea and abdominal pain. The blood pressure suddenly drops from 120/74 mm Hg to 88/48 mm Hg, heart rate increases from 80 to 100/min, and the client appears confused. Which action should the nurse take first?

Administer as needed dose of hydrocortisone IV push Addison's disease is adrenocortical insufficiency or hypofunction of the adrenal cortex. Addisonian crisis or acute adrenocortical insufficiency is a potentially life-threatening complication. Clients report nausea, vomiting, and abdominal pain. Signs of addisonian crisis include hypotension, tachycardia, dehydration, hyperkalemia, hyponatremia, hypoglycemia, fever, weakness, and confusion. Priority emergency management of addisonian crisis includes shock management, with fluid resuscitation using 0.9% normal saline and 5% dextrose; and administration of high-dose hydrocortisone replacement IV push. (Options 2, 3, and 4) Assessment and documentation are important components of the nursing process, but emergency treatment of an addisonian crisis is the priority action. Educational objective: Addisonian crisis is a potentially life-threatening complication of Addison's disease and commonly presents with abdominal pain, hypotension, and hypoglycemia. Emergency management includes shock management with fluid resuscitation using 0.9% normal saline and 5% dextrose, and administration of high-dose hydrocortisone replacement IV push.

The nurse in the intensive care unit cares for a client with primary adrenocortical insufficiency (Addison's disease). The client reports nausea and abdominal pain. The blood pressure suddenly drops from 120/74 mm Hg to 88/48 mm Hg, heart rate increases from 80 to 100/min, and the client appears confused. Which action should the nurse take first?

Administer as-needed dose of hydrocortisone IV push Explanation: Addison's disease is adrenocortical insufficiency or hypofunction of the adrenal cortex. Addisonian crisis or acute adrenocortical insufficiency is a potentially life-threatening complication. Clients report nausea, vomiting, and abdominal pain. Signs of addisonian crisis include hypotension, tachycardia, dehydration, hyperkalemia, hyponatremia, hypoglycemia, fever, weakness, and confusion. Priority emergency management of addisonian crisis includes shock management, with fluid resuscitation using 0.9% normal saline and 5% dextrose; and administration of high-dose hydrocortisone replacement IV push. (Options 2, 3, and 4) Assessment and documentation are important components of the nursing process, but emergency treatment of an addisonian crisis is the priority action. Educational objective: Addisonian crisis is a potentially life-threatening complication of Addison's disease and commonly presents with abdominal pain, hypotension, and hypoglycemia. Emergency management includes shock management with fluid resuscitation using 0.9% normal saline and 5% dextrose, and administration of high-dose hydrocortisone replacement IV push.

A client's diabetes is controlled with a morning dose of glargine and a scheduled, fixed dose of lispro with meals. Before breakfast, the client's fingerstick glucose is 105 mg/dL (5.8 mmol/L). The tray is in the room, and the client is eager to eat. What action should the nurse take?

Administer both insulins as prescribed Glargine (Lantus) is a long-acting (basal) insulin given to prevent hyperglycemia for 24 hours. The drug has no peak, and so timing of administration is not dependent on food intake. However, if the client is NPO for more than 12 hours, the provider may hold it. Lispro (Humalog) is a rapid-acting insulin with a peak of 30 minutes to 3 hours and should be given only if it is certain the client will eat within 15 minutes. Lispro is prescribed in two ways: Scheduled prandial (ie, fixed dosage) given to prevent hyperglycemia with consumption of food. Typically, this would not be held unless the blood sugar is below normal (70 mg/dL [3.9 mmol/L]) or according to facility guidelines. Correctional (ie, sliding-scale dosage) given to correct hyperglycemia. Typically, this would be held when blood glucose is below 150 mg/dL (8.3 mmol/L). Both glargine and lispro would be given according to schedule, as the client is not NPO and plans to eat immediately, and glucose is above 70 mg/dL [3.9 mmol/L] (Option 1). (Options 2, 3, and 4) Holding glargine will increase the blood sugar level over 24 hours. Holding lispro will cause blood glucose to rise uncontrollably due to the consumption of food. Educational objective: Rapid-acting insulin (eg, scheduled prandial fixed dosing, correctional sliding-scale dosing) is given if a client plans to eat within 15 minutes. Scheduled prandial insulin prevents hyperglycemia after meals and is held when blood glucose is below normal (70 mg/dL [3.9 mmol/L]). Correctional insulin corrects existing hyperglycemia.

In the intensive care unit, the nurse cares for a client who develops diabetes insipidus (DI) 2 days after pituitary adenoma removal via hypophysectomy. Which intervention should the nurse implement?

Administer desmopressin Explanation: Diabetes insipidus (DI) is a condition that occurs due to insufficient production/suppression of antidiuretic hormone (ADH). Neurogenic DI is a type of DI that results from impaired ADH secretion, transport, or synthesis. It sometimes occurs after manipulation of the pituitary or other parts of the brain during surgery, brain tumors, head injury, or central nervous system infections. DI is characterized by polydipsia (increased thirst) and polyuria (increased urine output) with low urine specific gravity (dilute urine). As a result, fluids should be replaced orally/intravenously to prevent dehydration (Option 3). ADH release is impaired in neurogenic DI. As a result, ADH replacement with vasopressin (Pitressin) can be used to treat DI. However, it also has vasoconstrictive properties. Therefore, desmopressin (DDAVP), an analog without vasopressor activity, is the preferred therapy. Clients on this treatment should be monitored for urine output, urine specific gravity, and serum sodium (to avoid hyponatremia due to excess DDAVP). (Option 2) DI is not associated with low/high blood glucose and should not be confused with diabetes mellitus (DM) as both DI and DM involve symptoms of excessive urination (polyuria). (Option 4) The Trendelenburg position (body laid flat and supine with feet higher than the head by at least 15-30 degrees) is contraindicated in most neurological conditions. Educational objective: DI occurs when there is insufficient production/suppression of ADH. It is characterized by polydipsia and polyuria with diluted urine. Oral and/or intravenous fluid replacement is imperative to prevent dehydration. DI is treated with ADH replacement drugs (eg, desmopressin acetate [DDAVP]). Clients should be monitored for urine output, urine specific gravity, and serum sodium.

A hospitalized client with acute pancreatitis has nausea, vomiting, epigastric pain, and tachycardia. Laboratory results show elevated serum lipase levels. Which interventions would the nurse anticipate being prescribed for the client? Select all that apply.

Administer hydromorphone IV PRN for pain Administer intravenous fluids Insert a nasogastric tube for nasogastric suction Supportive care for symptom relief and prevention of complications are the major goals in clients with acute pancreatitis. These strategies include: NPO status - The client is maintained on NPO status as any ingestion of food will stimulate the excretion of pancreatic enzymes. A nasogastric tube is used to suction out gastric secretions; this will reduce nausea and lessen stimulation of the pancreas as these juices will move to the duodenum. Pain management - Intravenous opioids (eg, hydromorphone, fentanyl) are frequently utilized for pain management. Morphine can also be used; worsening pancreatitis due to increase in sphincter of Oddi pressure has not been proven in studies. IV fluids - Aggressive fluid replacement to prevent hypovolemic shock is critical. Inflammation of the pancreas releases chemical mediators that increase capillary permeability and cause third spacing (fluid going into empty spaces). (Option 4) The client should maintain positions that flex the trunk and draw the knees up to the abdomen (semi-Fowler's) to decrease tension on the abdomen. A side-lying position with the head elevated to 45 degrees will help relieve the pain even better. (Option 5) NPO status is maintained to inhibit stimulation of pancreatic enzymes. Educational objective: The major goals in acute pancreatitis are symptom management (eg, opioids, NPO status, nasogastric suction) and monitoring and prevention of complications (eg, IV fluids), giving the pancreas time to heal.

The nurse is caring for an adolescent client diagnosed with type 1 diabetes. The client exhibits hot, dry skin and a glucose level of 350 mg/dL (19.4 mmol/L). Arterial blood gases show a pH of 7.27. STAT serum chemistry labs have been drawn. Cardiac monitoring shows a sinus rhythm with peaked T waves, and the client has minimal urine output. What is the nurse's next priority action?

Administer normal saline infusion Explanation: This client has diabetic ketoacidosis (DKA). All clients with DKA experience dehydration due to osmotic diuresis. Prompt and adequate fluid therapy restores tissue perfusion and suppresses the elevated levels of stress hormones. The initial hydrating solution is 0.9% saline infusion. (Option 1) Insulin therapy should be started after the initial rehydration bolus as serum glucose levels fall rapidly after volume expansion. (Option 3) Urinalysis is important but not a priority. (Option 4) Potassium should never be given until the serum potassium level is known to be normal or low and urinary voiding is observed. Peaked T waves indicate hyperkalemia in this client. Clients with insulin deficiency frequently have increased serum potassium levels due to the extracellular shift despite having total body potassium deficit from urinary losses. Once insulin is given, serum potassium levels drop rapidly, often requiring potassium replacement. Potassium is never given as a rapid IV bolus, as cardiac arrest may result. Educational objective: Clients with diabetic ketoacidosis and hyperosmolar hyperglycemic state require IV normal saline as a priority due to severe dehydration. Once fluids are given as a bolus, insulin is initiated. The serum potassium levels can be elevated in the initial stages despite a low total body potassium. Potassium repletion is started once the serum potassium levels are normalized or trending low (from elevated levels).

The nurse is caring for a client with suspected Graves disease. Which assessment finding requires priority intervention?

Agitation and confusion Thyroid storm is a serious and potentially life-threatening emergency for clients with Graves disease. This condition occurs when the thyroid gland releases large amounts of thyroid hormone in response to stress (eg, trauma, surgery, infection). Characteristic features include tachycardia, hypertension, cardiac arrhythmias (eg, atrial fibrillation), and fever up to 104-106 F (40-41 C). Other findings include severe nausea, vomiting, anxiety, altered mentation, and seizures. (Option 2) Heat intolerance is an expected symptom in hyperthyroidism, including Graves disease. (Option 3) Tachycardia and arrhythmias (eg, atrial fibrillation) are commonly seen with hyperthyroidism of any cause, including Graves disease. These alone cannot differentiate whether the client has simple hyperthyroidism or life-threatening thyroid storm. (Option 4) Exophthalmos (protruding eyeball) is commonly seen in Graves disease. The eyelids do not close over the eyeballs properly, leading to excessive dryness and resultant corneal damage (exposure keratitis). Although it is important to treat exophthalmos, it is not immediately life-threatening. Educational objective: Thyroid storm is a life-threatening complication of Graves disease. Fever, altered mentation, and excess autonomic activity (eg, severe hypertension, tachycardia) are common. Early recognition and treatment are crucial.

The nurse is planning care for a client immediately following a thyroidectomy. Which of the following nursing actions are appropriate to include in the plan of care? Select all that apply.

Assess frequently for facial or extremity numbness or tingling Ensuring that a tracheostomy insertion kit is at the bedside at all times Maintaining the HOB 30 - 45 degrees Monitor client's voice strength and quality. Thyroidectomy is a surgery involving partial or complete removal of the thyroid, often to treat hyperthyroidism or thyroid cancer. Clients undergoing a thyroidectomy require close monitoring as they are at increased risk for airway compromise due to potential neck swelling, hypocalcemia, and nerve damage. Nurses planning care following a thyroidectomy promote client recovery and monitor for and prevent complications by: Assessing for and immediately reporting signs of hypocalcemia (eg, facial or extremity numbness or tingling, stridor, Trousseau and Chvostek signs), which may occur from parathyroid gland trauma during surgery (Option 1) Assessing for stridor and new or worsening changes in voice strength and quality (eg, hoarseness, whispering), which may indicate laryngeal nerve damage that can result in respiratory arrest (Option 5) Keeping emergency airway equipment (eg, tracheostomy kit, suction, oxygen) at the bedside in case respiratory distress develops (Option 3) Maintaining the client in semi-Fowler position, which promotes drainage of surgical site edema around the neck and reduces the risk of respiratory distress (Option 4) (Option 2) Postoperatively, the client should avoid excessive neck flexion and extension, which may strain and cause disruption of the incision site, leading to hemorrhage. Encourage the client to maintain neutral head and neck alignment. Educational objective: Following a thyroidectomy, place the client in semi-Fowler position with a neutral head and neck position. Keep a tracheostomy kit, suction, and oxygen at the bedside in case airway compromise develops. Monitor frequently for signs of hypocalcemia and changes in voice strength and quality.

A client with type 1 diabetes mellitus is on intensive insulin therapy. The client is of the Islamic faith and insists on fasting during Ramadan. What is the most important nursing action?

Assess the client's clinical stability and glycemic control Diabetic clients whose religious practices require them to change their current diet (eg, fasting) and glycemic management regimen should be assessed for clinical stability (eg, comorbidities) and glycemic control, including: History of hyperglycemia, hypoglycemia, and ketoacidosis Dosage and timing of medications Knowledge of meal planning Ability to perform blood glucose monitoring during the fast Fasting during Ramadan is one of the Five Pillars of Islam. Observance of Ramadan and daytime fasting occurs throughout the ninth month of the lunar calendar. During this time, Muslim clients are required to refrain from food and drink from dawn to sunset. Clients who are sick, children, pregnant women, and the elderly are exempt from fasting; however, some clients who fall into these categories may insist on fasting, creating challenges for their health care team. (Option 1) Clients with diabetes who are at lower risk for adverse events while fasting based on risk assessment need to receive instruction on adjusting their meal planning, physical exercise, and insulin therapy. Those at high risk for complications should be discouraged from fasting.

An elderly client with type 2 diabetes is admitted to the medical unit due to urosepsis. The client is wearing an insulin pump for continuous subcutaneous insulin infusion therapy. The client's significant other reports that the client self-manages the insulin pump extremely well and keeps blood glucose in the specified target range. What is the admitting nurse's priority action?

Assess the client's level of orientation Explanation: Change in mental status and confusion is a common presenting symptom of sepsis in the elderly. The nurse should assess the client's cognitive status and level of orientation and consciousness. Diminished mental acuity, side effects of medication, and impairment related to a medical condition during hospitalization affect the client's ability to manage the insulin pump safely. Mental status is the key to safe insulin pump use, so if the client is not competent to operate the pump, the nurse should notify the health care provider (HCP) and document the findings in the client's electronic medical record. The HCP will determine if continuing the use of the pump during hospitalization is appropriate. (Option 2) Assessing the infusion pump site for signs of infection and intactness of the infusion set is important, but it is not the priority action. (Option 3) The HCP prescribes the basal insulin along with the parameters for bolus and correction doses while the client is hospitalized. The nurse should check and document the make and model, pump settings, type of insulin, and the date that the infusion site and set were changed. However, this is not the priority action. (Option 4) Consulting with the diabetic resource nurse or educator to determine the client's competency and ability to manage a specific type of pump and provide ongoing client education is an appropriate action. However, this is not the priority. Educational objective: When caring for a hospitalized client wearing an insulin pump, the priority nursing action is to assess the client's mental capacity to determine the ability to self-manage the pump safely.

A nurse is teaching a nutrition class for clients with newly diagnosed type 2 diabetes. Which meal represents the best adherence to the principles of and recommendations for diabetic meal planning?

Black bean chili with brown rice, mixed green salad Black bean chili with brown rice is a low-fat, low glycemic index, high-fiber meal. The other meals do contain some acceptable items but none are the best option due to low-fiber content and high glycemic index. The American Diabetic Association recommends a simple "Create My Plate" method for meal planning. Specific dietary recommendations include: Monitor carbohydrate intake Manage caloric intake if weight loss is desired High-fiber foods (30-35 g of fiber per day), including whole grains, legumes, fruits, vegetables, and low-fat dairy products Use monounsaturated fats, limit use of saturated fat, and eliminate trans fatty acids Choose foods with a low glycemic index Consume total cholesterol of <300 mg per day Reduce sodium intake Limit intake of foods containing sucrose Limit intake of alcoholic beverages (Option 1) Although tilapia is a good selection of lean protein, the white rice has minimal fiber and a high glycemic index. (Option 3) Although grilled chicken is a good selection of lean protein, the baked French fries have minimal fiber and a high glycemic index and are high in sodium. (Option 4) The hamburger contains saturated fat. The bun, lettuce, and tomato have minimal fiber. Educational objective: Clients with diabetes should eat foods with a low glycemic index and high fiber content. Saturated fats and sodium should be restricted.

The emergency department nurse cares for a client admitted with a diagnosis of hyperosmolar hyperglycemic state. The nurse understands which characteristics are commonly associated with this complication? Select all that apply.

Blood glucose level >600 mg/dL (33.3 mmol/L) History of type 2 diabetes Neurological manifestations Hyperosmolar hyperglycemic state is a serious complication usually associated with type 2 diabetes. With this condition, clients are able to produce enough insulin to prevent diabetic ketoacidosis but not enough to prevent extreme hyperglycemia, osmotic diuresis, and extracellular fluid deficit. Because some insulin is produced, blood glucose rises slowly and symptoms may not be recognized until hyperglycemia is extreme, often >600 mg/dL (33.3 mmol/L). This eventually causes neurological manifestations such as blurry vision, lethargy, obtundation, and progression to coma. Because some insulin is present, symptoms associated with ketones and acidosis, such as Kussmaul respirations (hyperventilation) and abdominal pain, are typically absent (Options 1 and 4). Educational objective: Hyperosmolar hyperglycemic state differs from diabetic ketoacidosis in that it is typically associated with type 2 diabetes mellitus. Because these clients produce some insulin, severe hyperglycemia happens more slowly and is often not noted until neurological manifestations occur.

The nurse cares for a client with Addison's disease who was involved in a motor vehicle accident and hospitalized for a fracture of the right femur. Which client information is most important to report to the primary health care provider (PHCP)?

Blood pressure change from 128/80 mm Hg to 90/50 mm Hg Addison's disease is adrenocortical insufficiency or hypofunction of the adrenal cortex. A deficiency in all 3 classes of adrenal corticosteroids, including glucocorticoids, mineralocorticoids, and androgens, is present in Addison's disease. Addisonian crisis, or acute adrenocortical insufficiency, is a potentially life-threatening complication of Addison's disease. It can lead to shock and should be reported immediately to the PHCP. Addisonian crisis is triggered by stress, and its manifestations include the following: Hypotension and tachycardia Dehydration Hyperkalemia and hyponatremia Hypoglycemia Fever Weakness and confusion (Option 2) Although any new ECG changes should be assessed and investigated, this finding is typically non-consequential and is not life-threatening. (Option 3) Although pain should be assessed carefully and managed, it is expected with a fractured femur and is not life-threatening. (Option 4) Vesicular breath sounds auscultated over the lung tissue are a normal and expected finding. Educational objective: Addison's disease is adrenocortical insufficiency or hypofunction of the adrenal cortex. A potential life-threatening complication is Addisonian crisis. Signs and symptoms include hypotension, tachycardia, hyperkalemia, hyponatremia, hypoglycemia, fever, weakness, and confusion; these should be reported to the PHCP immediately.

The nurse assesses a female client with a diagnosis of primary adrenal insufficiency (Addison disease). The nurse recognizes which finding associated with the disease?

Bronze pigmentation of skin Addison disease, or primary adrenocortical insufficiency, is also described as hypofunction of the adrenal cortex. The adrenal gland is responsible for secretion of glucocorticoids, androgens, and mineralocorticoids. Bronze hyperpigmentation of the skin in sun-exposed areas is caused by an increase in adrenocorticotropic hormone (ACTH) by the pituitary in response to low cortisol (ie, glucocorticoid) levels (Option 1). Clients with Addison disease may also have vitiligo, or patchy/blotchy skin, which is usually present when the etiology of the disease is an autoimmune problem. The immune cells are thought to destroy melanocytes which produce melanin (or brown pigment), resulting in a patchy appearance. Other common manifestations of Addison disease include the following: Slow, progressive onset of weakness and fatigue Anorexia and weight loss Orthostatic hypotension Hyponatremia and hyperkalemia Salt cravings Nausea and vomiting Depression and irritability (Options 2, 3, and 4) Purple striae, hirsutism (increased facial and body hair), and a supraclavicular fat pad (ie, buffalo hump) are characteristics of Cushing syndrome, a condition associated with excess corticosteroid production. In contrast, Addison disease is a condition of hyposecretion of glucocorticoids.

During a screening clinic, the nurse performs a health assessment on several adult clients. Which finding by the nurse is most important to report to the primary health care provider?

Brownish skin thickening on the neck Acanthosis nigricans is a skin disorder characterized by the presence of symmetric, hyperpigmented velvety plaques located in flexural and intertriginous regions of skin (axilla, neck). Skin tags (acrochordons) are commonly present on regions affected by acanthosis nigricans. Both indicate insulin resistance (diabetic dermopathy). The client should be referred to the primary health care provider for evaluation of undiagnosed diabetes mellitus and/or metabolic syndrome. (Option 1) A BMI of 18.5 to 24.9 kg/m2 indicates a normal weight. (Option 3) A fasting total cholesterol <200 mg/dL (5.2 mmol/L) is normal. (Option 4) Although any change or growth of a mole should be reported, a pale or brown round mole <5 mm is typically a normal finding. Educational objective: Acanthosis nigricans is a velvety light brownish to black skin thickening seen in the axillae, neck, or flexures and is indicative of insulin resistance (diabetic dermopathy). Skin tags (acrochordons) are commonly present on regions affected by acanthosis nigricans.

The nurse in the endocrinology clinic is reviewing phone messages from clients. Which client would be the priority to call first?

Client with hyperthyroidism who has a new temperature reading of 101.5 F (38.6C) Hyperthyroidism results from excessive secretion of thyroid hormones. Affected clients are at risk for developing thyroid storm, a life-threatening form of hyperthyroidism. Symptoms of thyroid storm include fever, tachycardia, cardiac dysrhythmias (eg, atrial fibrillation), nausea, vomiting, diarrhea, and altered mental status. Client management includes reducing fever, maintaining hydration, and preventing cardiac compromise (eg, heart failure). (Option 1) The post-thyroidectomy client who needs a refill of the thyroid replacement medication should be contacted third. Without thyroid replacement therapy, this client would experience signs and symptoms of hypothyroidism (eg, extreme fatigue, bradycardia). (Option 2) Clients on corticosteroids may report moods swings and irritability; these are common side effects. (Option 3) The client with diabetes who is asymptomatic but has elevated blood sugars should be contacted second as prolonged hyperglycemia may lead to dehydration and acidosis. Educational objective: Clients with hyperthyroidism are at risk for developing thyroid storm, a life-threatening condition. Symptoms include fever, tachycardia, cardiac dysrhythmias, nausea, vomiting, diarrhea, and altered mental status. Client management includes reducing fever, maintaining hydration, and preventing cardiac compromise.

The nurse in an outpatient clinic receives a blood test report of moderately elevated thyroid-stimulating hormone (TSH) and markedly decreased T3 and T4 levels. Which signs and/or symptoms should be expected in the client's evaluation? Select all that apply

Cold intolerance Constipation Forgetfulness Hair loss Hypothyroidism is a thyroid disorder characterized by thyroid hormone deficit (low T3 and T4). TSH is elevated due to compensatory increase from pituitary. Hypothyroidism affects almost every body system and is predominately associated with a slow metabolic rate. Some common manifestations include the following: Decreased gut motility leading to constipation Cool and pale skin due to decreased blood flow; hyperkeratosis results in dry and rough skin Brittle nails and hair; hair loss due to poor blood supply Bradycardia from low metabolic state Joint pains and muscle aches are common Clients can develop dementia and depression due to mental slowing Cold intolerance characteristic Modest weight gain (Options 5 and 6) Weight loss; heat intolerance; shakiness; diarrhea; and warm, moist skin are symptoms associated with hyperthyroidism or an increased metabolic rate. Educational objective: Signs and symptoms of hypothyroidism (a thyroid hormone deficit) are associated with a low metabolic rate. Weight gain, constipation, dry skin, hair loss, cold intolerance, bradycardia, mental slowing (dementia and depression), and anemia are some of the most common manifestations.

The clinic nurse is taking vital signs on a client who reports being fatigued every day and gaining weight lately despite not eating much. The nurse should also ask about which symptoms? Select all that apply.

Cold intolerance Constipation Menstrual irregularity Fatigue and weight gain are classic manifestations of hypothyroidism. Features of hypothyroidism typically result from decreased metabolic rate and include cold intolerance, constipation, dry skin, irregular or prolonged menstrual periods, and mental slowing or difficulty concentrating. (Options 3, 5, and 6) Fever, tachycardia, and sweating are signs of hyperthyroidism, which is a hypermetabolic state, with signs and symptoms that are usually the opposite of those seen in hypothyroidism. The presenting symptoms of a hyperthyroid client would likely include weight loss despite an increased appetite and difficulty sleeping. Educational objective: Hypothyroidism is associated with symptoms of a low metabolic rate; hyperthyroidism causes symptoms of a high metabolic rate.

The nurse teaches disease management to a group of clients with type I diabetes mellitus. Which of the following should the nurse teach as signs or symptoms associated with hypoglycemia? Select all that apply.

Diaphoresis Pallor Trembling Hypoglycemia (low blood glucose <70 mg/dL [3.9 mmol/L]) is an acute and potentially serious complication that occurs when levels of insulin exceed the proportion of glucose. Epinephrine is one of the major hormones released during a hypoglycemic reaction and may cause early symptoms such as trembling, palpitations, anxiety/arousal, and restlessness. Diaphoresis and pallor are present on examination. When the brain is deprived of glucose due to prolonged and severe hypoglycemia, neuroglycopenic symptoms (confusion, seizures, coma) develop. (Option 2) Flushing (red skin) is commonly seen with fever, carcinoid syndrome, polycythemia vera, and sexual intercourse. Flushing is not seen with hypoglycemia. (Option 4) Polyuria and weight loss are usually associated with hyperglycemia, not hypoglycemia. Educational objective: Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) is an acute and potentially serious complication. Signs and symptoms include shakiness, palpitations, anxiety/arousal, restlessness, diaphoresis, and pallor.

The nurse is teaching a group of clients diagnosed with diabetes mellitus. Which lesson regarding foot care should be included? Select all that apply.

Cut toenails straight across and file along the curves of the toes Use a mild foot powder on perspiring feet Use cotton or lamb's wool to separate overlapping toes Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet. This is due to the chronic complication of peripheral neuropathy, which results from nerve damage in the extremities. Instructions for diabetic foot care include: Wash feet daily with warm water and mild soap; test water temperature with thermometer beforehand. Gently pat feet dry, particularly between the toes (Option 2). Use lanolin to prevent dry and cracked skin, but do not apply between the toes. Inspect for abrasions, cuts, or sores. Have others inspect the feet if eyesight is poor. To prevent injury, use cotton or lamb's wool to separate overlapping toes. Cut toenails straight across and use a nail file to file along the curves of the toes. Avoid going barefoot and wear sturdy leather shoes. Use mild foot powder to absorb perspiration and wear clean, absorbent socks with seams aligned (Options 1, 3, and 4). Avoid using over-the-counter products (eg, iodine, alcohol, strong adhesives) on cuts or abrasions (Option 5). To improve circulation, do not sit with legs crossed or for extended periods, avoid tight-fitting garments, and perform daily exercise. Report other types of problems such as infections or athlete's foot immediately. Educational objective: Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet due to the chronic complication of peripheral neuropathy. Clients should keep feet clean, dry, and free from irritation.

In the intensive care unit, the nurse cares for a client admitted with a head injury who develops syndrome of inappropriate antidiuretic hormone. Which data should the nurse expect with the onset of this condition? Select all that apply.

Decreased serum osmolality High urine specific gravity Low serum sodium Explanation: Syndrome of inappropriate antidiuretic hormone (SIADH) is potential complication of head injury. In SIADH, the extra ADH leads to excessive water absorption by the kidneys. Low serum osmolality and low serum sodium are the result of increased total body water (dilution). As ADH is secreted and water is retained, urine output is decreased and concentrated, resulting in a high specific gravity. (Options 2 and 4) Increased urine output is associated with diabetes insipidus (DI). In DI, ADH is suppressed, causing polyuria, severe dehydration, and high serum osmolality if the client is unable to drink enough to maintain a fluid balance. Educational objective: Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition that results in increased ADH. Too much ADH causes increased total body water, resulting in a low serum osmolality and low serum sodium. As ADH is secreted and water is retained, urine output is decreased and concentrated, resulting in a high specific gravity.

A client is diagnosed with diabetic ketoacidosis (DKA). The client reports frequent urination, thirst, and weakness. The nurse assesses a temperature of 102.4 F (39.1 C), fruity breath, deep labored respirations with a rate of 30/min, and dry mucous membranes. What is the priority nursing diagnosis (ND) at this time?

Deficient fluid volume related to osmotic diuresis DKA is a life-threatening emergency caused by a relative or absolute insulin deficiency. The condition is characterized by hyperglycemia, ketosis, metabolic acidosis, and dehydration. The most likely contributing factors in this client include stress associated with illness and infection (elevated temperature) and inadequate insulin dosage and self-management. Deficient fluid volume related to osmotic diuresis secondary to hyperglycemia as evidenced by dry mucous membranes and client report of frequent urination, thirst, and weakness is the priority ND. Hyperglycemia leads to osmotic diuresis, dehydration, electrolyte imbalance, and possible hypovolemic shock and renal failure. Therefore, this condition requires rapid correction through the infusion of isotonic intravenous fluids and poses the greatest risk to the client's survival (Option 1). (Option 2) When the supply of insulin is insufficient and glucose cannot be metabolized for energy, the body breaks down fat stores leading to ketosis (fruity breath) and metabolic acidosis. However, it does not pose the greatest risk to survival and is not the priority ND. (Option 3) Tachypnea and deep labored respirations (ie, Kussmaul) are the body's attempt to eliminate excess acid (pCO2) through hyperventilation and normalize the pH. However, it does not pose the greatest risk to survival and is not the priority ND. (Option 4) Ineffective health maintenance related to inability to manage a condition during illness (evidenced by DKA development in this client) is an appropriate ND. However, it does not pose the greatest risk to survival at this time and is not the priority ND. Educational objective: Hyperglycemia associated with DKA leads to osmotic diuresis, dehydration, electrolyte imbalance, and possible hypovolemic shock and renal failure. Deficient fluid volume related to osmotic diuresis is an appropriate ND for a client with DKA.

The nurse is assessing a group of clients in the community health clinic for metabolic syndrome. Which clients exhibit features of the syndrome? Select all that apply.

Female with a waist circumference of 38 inches (96.5 cm) Female with blood pressure of 148/90 mm Hg Male with a triglyceride level of 201 mg/dL (2.3 mmol/L) Individuals with metabolic syndrome (insulin resistance syndrome) have an increased risk of diabetes and coronary artery disease. The presence of abdominal obesity causes increased insulin production (hyperinsulinemia); this excess insulin leads to insulin resistance, the primary feature of metabolic syndrome. Metabolic syndrome is characterized by the presence of 3 or more of the following criteria: Increased waist circumference: ≥40 in (102 cm) in men, ≥35 in (89 cm) in women (Option 2) Blood pressure: ≥130 mm Hg systolic or ≥85 mm Hg diastolic or drug treatment for hypertension (Option 3) Triglyceride level: >150 mg/dL (1.7 mmol/L) or drug treatment for elevated triglycerides (Option 5) High-density lipoprotein (HDL) levels: <40 mg/dL (1.04 mmol/L) in men and <50 mg/dL (1.3 mmol/L) in women or drug treatment for low HDL-C Fasting glucose levels: ≥100 mg/dL (5.6 mmol/L) or drug treatment for elevated blood glucose (Option 4) The mnemonic for metabolic syndrome is "We Better Think High Glucose" (Waist circumference, Blood pressure, Triglyceride, HDL, Glucose). (Option 1) The normal LDL level is <100 mg/dL (2.6 mmol/L); therefore, this client's LDL level is within normal limits. LDL level is not a criterion for diagnosing metabolic syndrome, although a normal level is important for cardiovascular health. Educational objective: Features of metabolic syndrome include increased waist circumference, elevated blood pressure, increased triglycerides, decreased HDL, and increased fasting blood glucose. The mnemonic is "We Better Think High Glucose" (Waist circumference, Blood pressure, Triglyceride, HDL, Glucose).

The nurse cares for a client admitted to the hospital due to confusion. The client has a nonmetastatic lung mass and a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). Which action(s) should the nurse expect to implement? Select all that apply.

Fluid restriction Seizure precautions Strict record of fluid intake and output SIADH is an endocrine condition in which antidiuretic hormone overproduction leads to water retention, increased total body water, and dilutional hyponatremia (low serum sodium). Hyponatremia can cause confusion, seizures, or other neurologic complications. It is important for the nurse to anticipate these problems and institute seizure precautions. SIADH treatment includes: Fluid restriction to <1000 mL/day Oral salt tablets to increase serum sodium (Option 3) Hypertonic saline (3%) during the first few hours for clients with markedly decreased serum sodium and severe neurologic manifestations Vasopressin receptor antagonists (eg, conivaptan) The nurse should also maintain a strict fluid intake and output chart and daily weights and carefully monitor neurologic status to evaluate for improvement or deterioration. (Option 1) Normal saline fluid bolus would worsen the hyponatremia as the client already has excess fluid volume. Symptoms are caused by a low sodium level. If the sodium level must be raised, the client will need hypertonic (3%) saline or salt tablets as these contain mainly sodium and little free fluid. Educational objective: SIADH can occur due to lung cancer and is characterized by water retention, increased total body water, and dilutional hyponatremia. Hyponatremia may cause neurologic complications (eg, confusion, seizures). SIADH treatment includes fluid restriction, oral salt tablets, and administration of 3% saline IV and/or vasopressin receptor antagonists.

The nurse cares for a client with type 2 diabetes mellitus. The client is alert and oriented but also shaky, pale, and diaphoretic. The client's fingerstick blood glucose is 50 mg/dL (2.8 mmol/L). Which of the following is the best next step the nurse can take?

Give client 6 oz of orange juice or low-fat milk Explanation: This client is exhibiting signs and symptoms of a hypoglycemic reaction (evidenced by low blood glucose <70 mg/dL [3.9 mmol/L]). The client who is alert enough to ingest food/liquids orally should be given 15 grams of a simple carbohydrate such as orange juice or low-fat milk (Option 2). The fat in whole milk slows the absorption process and will not treat hypoglycemia quickly enough. For this reason, low-fat milk is recommended. Fingerstick blood glucose should be checked 10-15 minutes after this (Option 4). If the client shows no improvement, the simple carbohydrate can be readministered orally. (Options 1 and 3) Dextrose (D50 IV push), a highly concentrated sugar, and glucagon (intramuscular, subcutaneous, intravenous/gel), a hormone that stimulates glycogenolysis (conversion of glycogen to glucose), are administered to hypoglycemic clients who are unable to ingest a simple oral carbohydrate. These can cause rebound hypoglycemia by stimulating additional insulin release from the body in response to increased serum glucose levels. Educational objective: A client who experiences a hypoglycemic reaction (evidenced by low blood glucose <70 mg/dL [3.9 mmol/L]) and is alert enough to ingest food/liquids orally should be given a simple carbohydrate (eg, orange juice, low-fat milk).

A client is admitted to the intensive care unit with diagnoses of a brain tumor complicated by transient diabetes insipidus. Which client data related to this complication should the nurse expect? Select all that apply.

High serum osmolality Low urine specific gravity Reports of excessive thirst Explanation: Diabetes insipidus (DI) is a condition in which antidiuretic hormone (ADH) is insufficiently produced or suppressed. Neurogenic DI results from manipulation or interference with ADH release, transport, or synthesis. It sometimes occurs after manipulation of the pituitary or other parts of the brain during surgery, brain tumors, head injury, or central nervous system infections. It is characterized by polydipsia (increased thirst) and polyuria (increased urine output) and can lead to dehydration resulting in weight loss (Option 4), hypernatremia, and a high serum osmolality (>295 mOsm/kg [295 mmol/kg]). Urine is dilute and copious (2-20 L/day) (Option 1) with a low specific gravity (<1.003). Educational objective: Diabetes insipidus is a condition in which antidiuretic hormone is insufficiently produced or suppressed, resulting in polydipsia and polyuria (up to 20 L/day). Urine is copious and dilute with a low specific gravity (<1.003). Fluid volume deficit can lead to dehydration, hypernatremia, high serum osmolality, and weight loss.

The nurse is performing an initial assessment on a client diagnosed with Addison's disease. Which assessment findings should the nurse anticipate? Select all that apply.

Hyperpigmented skin Weight loss Addison's disease, or chronic adrenal insufficiency, occurs when the adrenal glands do not produce adequate amounts of steroid hormones (mineralocorticoids, glucocorticoids, androgens). Symptoms include weight loss, muscle weakness, low blood pressure, hypoglycemia, and hyperpigmented skin (skin folds, buccal area, palmar crease). Hyperpigmented skin is a characteristic universal finding; this results from increased adrenocorticotropic hormone which is due to a decrease in cortisol negative feedback. Treatment consists of replacement therapy with oral mineralocorticoids and corticosteroids (Options 3 and 5). (Option 1) Acanthosis nigricans is a skin condition that occurs with obesity and diabetes and appears as velvet-like patches of darkened, thick skin. These areas typically occur around the back of the neck and in the groin and armpits. (Option 2) Hirsutism is a condition in women that consists of male-pattern hair growth on the face, lower abdomen, chest, and back. Common causes are polycystic ovary syndrome and Cushing's syndrome. Loss of libido and decreased axillary and pubic hair are common in Addison's disease due to lower levels of androgens. (Option 4) Clients with Cushing's syndrome, an overproduction of steroid hormones, have truncal obesity or large deposits of abdominal fat. Educational objective: Addison's disease (chronic adrenal insufficiency) leads to hyperpigmented skin, low blood pressure, weight loss, and muscle weakness.

In the intensive care unit, the nurse cares for a client who has been admitted with diabetic ketoacidosis. The client is on a continuous infusion of regular insulin at 5 units/hr via IV pump. Which action should the nurse expect to implement?

Initiate potassium IV when serum potassium is 3.5- 5.0 mEq/L (3.5 - 5.0 mmol/L) Diabetic ketoacidosis (DKA) is an acute, serious complication generally due to lack of insulin in clients with type 1 diabetes. DKA is characterized by hyperglycemia, ketosis, and acidosis. Hyperglycemia causes osmotic diuresis, resulting in profound dehydration. Clients with DKA may initially develop hyperkalemia as a compensatory response to acidosis despite having a total body potassium deficit from urinary loss. Management of DKA includes fluid resuscitation, IV insulin, and hourly blood glucose monitoring. When serum glucose is <250 mg/dL (13.9 mmol/L), D5W is administered to prevent hypoglycemia until ketoacidosis is resolved. Hypokalemia often occurs with resolution of acidosis and administration of IV insulin, which shifts potassium from the intravascular to the intracellular space. Therefore, potassium is administered even when the client is normokalemic (3.5-5.0 mEq/L [3.5-5.0 mmol/L]) to prevent hypokalemia and subsequent life-threatening arrhythmias (Option 4). (Option 1) Serum potassium, glucose, and anion gap or bicarbonate levels are regularly monitored in DKA to monitor treatment effectiveness. Although serum creatinine and BUN levels may be elevated due to dehydration and may be monitored, hourly monitoring is not indicated. (Option 2) IV insulin infusion may be discontinued on resolution of acidosis and ketosis, which generally occurs with a blood glucose level of <200 mg/dL (11.1 mmol/L). (Option 3) As blood glucose is reduced, the insulin infusion rate is decreased to prevent a hypoglycemic event. Educational objective: Hypokalemia often occurs with resolution of diabetic ketoacidosis and administration of IV insulin, which shifts potassium from the intravascular to the intracellular space. Potassium is administered even when the client is normokalemic (3.5-5.0 mEq/L [3.5-5.0 mmol/L]) to prevent life-threatening arrhythmias.

The nurse is assigned to care for a client who had a thyroidectomy 24 hours ago. On initial assessment, which finding requires the most immediate action by the nurse?

Laryngeal stridor Explanation: Stridor is a high-pitched, vibratory, harsh sound during inspiration or expiration that indicates partial airway obstruction. When stridor occurs after a thyroidectomy, a delicate surgery involving a highly vascularized area, the most immediate concern is airway compromise secondary to hemorrhage or laryngeal edema. This is a life-threatening complication requiring immediate intervention. The nurse should ensure that suctioning devices, oxygen, and a tracheostomy tray are readily available in the recovery room as immediate tracheostomy may be necessary. Respiratory stridor, also observed in epiglottitis, is very different from the minor laryngeal edema that commonly occurs after intubation and results in transient hoarseness in the postoperative period. Persistent hoarseness and the inability to raise one's voice more than 24 hours postoperatively may indicate damage to the laryngeal nerve, a frequent complication of thyroid surgery. (Option 1) This calcium level is normal (8.6-10.2 mg/dL [2.15-2.55 mmol/L]). However, hypocalcemia is a potential complication of a thyroidectomy as the parathyroid glands that regulate calcium levels in the blood are often inadvertently removed or damaged during surgery. The nurse should ensure that calcium gluconate is available. (Options 2 and 4) Although the pain and tachycardia warrant action by the nurse, these are not as high a priority as the life-threatening complication of airway obstruction. Educational objective: Stridor indicates airway obstruction, and abrupt onset is a medical emergency. Stridor after thyroidectomy requires immediate action by the nurse to maintain airway patency. Suctioning devices, oxygen, and a tracheostomy tray should be available for rapid surgical intervention.

The nurse is giving report to a licensed practical nurse (LPN) who will be helping to monitor a client who just had a total thyroidectomy. What will the nurse emphasize as most important to report immediately?

Noisy breathing Respiratory distress is a life-threatening complication of thyroid surgery that occurs when swelling in the surgical area at the base of the neck compresses the airway. Stridor and/or difficulty breathing in the client who has had thyroid surgery should be reported immediately to the registered nurse, and a rapid response should be activated. (Option 1) Although elevated blood pressure is important to monitor, it is a less serious symptom than stridor. (Option 2) An irregular heart rate is a less serious symptom than stridor, and it may be a baseline finding in the client with hyperthyroidism. (Option 3) Although low oxygen saturation is a sign of impending airway compromise, it is also commonly seen in all types of postoperative clients, making it a less specific sign of airway obstruction than noisy breathing in the thyroidectomy client. Educational objective: Airway swelling is a life-threatening complication of thyroid surgery. Signs of respiratory distress such as stridor and dyspnea require rapid intervention.

The nurse assesses a client who had a thyroidectomy 8 hours ago. The nurse finds the client anxious, with tingling around the mouth and muscle twitching in the right arm. Which action is most important for the nurse to implement first?

Obtain a serum calcium level Normal serum calcium is 8.6-10.2 mg /dL (2.15-2.55 mmol/L). Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of thyroidectomy because the parathyroids that regulate calcium levels in the blood are accidentally removed during this surgical procedure. The nurse should monitor the client closely for signs of hypocalcemia, which include tetany (overactive neurological responses such as tingling in the hands, feet, and around the mouth; spasms or cramps that can occur even in the larynx; positive Trousseau or Chvostek sign). A serum calcium level should be drawn, and the nurse should ensure that calcium gluconate is readily available in case this complication occurs. (Option 1) Monitoring for bleeding is an important assessment. However, when bleeding occurs post thyroidectomy, blood typically trickles and pools behind the client's neck. This client's symptoms are more consistent with hypocalcemia. (Option 2) It is important to document findings in the electronic medical record, but the nurse should do this after taking action to help the client. (Option 3) If laryngeal spasm occurs as a result of hypocalcemia, hypoxia may be evident in arterial blood gases. However, the client will also exhibit signs of hypoxemia (eg, stridor, respiratory distress, low pulse oximetry reading). Checking the calcium level so that effective treatment can begin is the highest priority. Educational objective: Normal serum calcium is 8.6-10.2 mg /dL (2.15-2.55 mmol/L). Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of thyroidectomy. The nurse should monitor for signs and symptoms of tetany (tingling of hands, toes, and circumoral region; positive Trousseau or Chvostek sign), confirm with serum calcium results, and administer calcium gluconate as prescribed. Untreated clients can develop life-threatening laryngeal spasm.

The nurse assesses a client with hyperparathyroidism who had a parathyroidectomy 4 hours ago. Which assessment technique should the nurse use to check for complications in this client?

Place blood pressure cuff on arm, inflate to pressure > than systolic BP, and hold in place for 3 minutes Normal serum calcium is 8.6-10.2 mg /dL (2.15-2.55 mmol/L). Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of parathyroidectomy because the parathyroids regulate calcium levels in the blood. When one or more parathyroids are removed, it may take some time for others that have been dormant during hyperparathyroidism (which causes an increase in serum calcium) to begin regulating serum calcium. Trousseau's sign may indicate hypocalcemia before other signs and symptoms of hypocalcemia, such as tetany, occur. Trousseau's sign can be elicited by placing the BP cuff on the arm, inflating to a pressure > than systolic BP, and holding in place for 3 minutes. This will occlude the brachial artery and induce a spasm of the muscles of the hand and forearm when hypocalcemia is present. Chevostek's sign another early indicator of hypocalcemia, should also be assessed. It may be elicited by tapping the face at the angle of the jaw and observing for contraction on the same side of the face. (Option 1) Phalen's maneuver is used to diagnose carpal tunnel syndrome. (Option 2) The heel-to-shin test is another means of assessing cerebellar function. An abnormal examination is evident when the client is unable to keep the foot on the shin. (Option 3) The Romberg test is a component of a neurological examination to assess vestibular function (perception of head position in space), proprioception (perception of the body in space), and vision. Educational objective: Normal serum calcium is 8.6-10.2 mg/dL (2.15-2.55 mmol/L). Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of parathyroidectomy. The nurse should check for Trousseau's and Chevostek's signs as early indications of hypocalcemia.

An elderly client with hypothyroidism is brought to the emergency department for depressed mental status. The client lives alone but has not taken medications for several months or seen a health care provider. Which action should the nurse take first? Click on the exhibit button for additional information. Vital signs Temperature 95 F (35 C) Blood pressure 90/50 mm Hg Heart rate 50/min Respirations 37/min O2 saturation 83%

Prepare for endotracheal intubation Myxedema coma is a complication associated with progression of symptoms of hypothyroidism from lethargy and mental sluggishness to a coma state. This client has hypothermia, bradycardia, hypotension, and depressed mental status. Hypothyroidism can also cause hypoventilation due to central depression of respiratory drive, respiratory muscle fatigue, and mechanical obstruction by a large tongue. This client exhibits signs of acute respiratory distress (increased respirations, very low oxygen saturation). Therefore, life-saving measures to facilitate respiratory support, such as mechanical ventilation, must be implemented first. Other treatments include thyroid hormone replacement with levothyroxine (Synthroid) IV push (Option 1), heating warming the client with a warming blanket (Option 3), and frequent diagnostics of the thyroid, including a serum thyroid panel (Option 2). Educational objective: Myxedema coma is a complication associated with progression of hypothyroidism symptoms. The highest-priority intervention is respiratory support for the client exhibiting signs of acute respiratory distress.

The nurse assesses a 40-year-old client with acromegaly in an outpatient health clinic. Which new finding is most important to report to the health care provider?

Presence of S3 and S4 heart sound Acromegaly is an uncommon condition caused by an overproduction of growth hormone (GH). It is usually due to pituitary adenoma, and onset in adult clients generally occurs at age 40-45. In an adult, increased GH results in overgrowth of soft tissues of the face, hands, feet, and organs. Additional heart sounds (S3, S4) require further assessment for cardiac conditions (eg, heart failure). (Options 1, 2, and 3) Although joint pain, skin changes, and hyperglycemia (normal fasting glucose 70-99 mg/dL [3.9-5.5 mmol/L]) are associated with acromegaly, these are not as life-threatening as acute heart failure (must be reported immediately to the health care provider). Educational objective: Acromegaly is an uncommon condition caused by growth hormone overproduction leading to overgrowth of soft tissues of the face, hands, feet, and organs. The nurse should monitor the client for signs and symptoms of acute complications (eg, heart failure) and report findings to the health care provider.

The school nurse evaluates a 9-year-old client who is sweating, trembling, and slurring while speaking. The client has type 1 diabetes managed with insulin glargine and NPH. What is the most appropriate action by the nurse?

Provide 4 oz of regular soft drink Clients experiencing hypoglycemia may develop shakiness, palpitations, sweating, and altered mental status (eg, difficulty speaking, confusion). If manifestations of hypoglycemia are present, the nurse should check the client's blood glucose level (BGL) immediately. A BGL <70 mg/dL (3.9 mmol/L) requires treatment; however, if glucose testing is not readily available, the client should be treated based on symptoms. Hypoglycemia treatment in a conscious client is administration of 15 g of a quick-acting carbohydrate (Option 4). After treatment, the nurse should retest BGL every 15 minutes, repeating treatment if BGLs remain low. Quick-acting carbohydrate options include: 4 oz (120 mL) of regular soft drink or fruit juice 8 oz (240 mL) low-fat milk 1 tablespoon (15 mL) of honey or syrup 6 hard candies Commercial dextrose products (Option 1) The nurse should hold the client's scheduled insulin until the client's BGL is normal and the symptoms resolve. (Option 2) An emergency glucagon injection is indicated if the client is somnolent, unconscious, or seizing. (Option 3) After the client's BGL improves, the client should eat a meal. However, if the next meal is more than an hour away, the nurse should give the client a serving of carbohydrate plus protein or fat (eg, peanut butter, cheese) to maintain glucose levels. Educational objective: Clients with diabetes should be monitored for signs of hypoglycemia (eg, shakiness, sweating, alterations in mental status). Conscious clients experiencing hypoglycemia should receive a snack of 15 g quick-acting carbohydrates.

The nurse cares for a client with type 1 diabetes mellitus. Which laboratory result is most important to report to the primary health care provider?

Serum creatinine 2.0 mg/dL The normal serum creatinine for an adult is 0.6-1.3 mg/dL (53-115 µmol/L). It provides an estimation of the glomerular filtration rate and is an indicator of kidney function. A level of 2 mg/dL (177 µmol/L) is clearly abnormal. The client with diabetes mellitus is at risk for diabetic nephropathy, a complication associated with microvascular blood vessel damage in the kidney. Early treatment and tight control of blood glucose levels are indicated to prevent progressive renal injury in a client with diabetic nephropathy. (Option 1) Normal serum fasting blood glucose is 70-99 mg/dL (3.9-5.5 mmol/L). (Option 3) Normal serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). (Option 4) Normal serum sodium is 135-145 mEq/L (135-145 mmol/L). Educational objective: The normal serum creatinine for an adult is 0.6-1.3 mg/dL (53-115 µmol/L). Serum creatinine provides an estimation of the glomerular filtration rate and is an indicator of kidney function.

The nurse cares for a group of clients on a medical surgical floor. The client with which condition is at highest risk for developing syndrome of inappropriate antidiuretic hormone (SIADH)?

Small cell lung cancer SIADH is an endocrine condition in which too much ADH is produced, causing water retention, increased total body water, and dilutional hyponatremia (low serum sodium). Some cancer cells, particularly those of small cell lung cancer, have the ability to produce and secrete ADH, leading to SIADH. Other causes include central nervous system disorders (eg, stroke, trauma, neurosurgery) and some commonly used medications (eg, desmopressin, carbamazepine). (Options 1 and 3) Carpal tunnel syndrome is a result of aggravated tendons in the wrists causing narrow, pinched nerves. Sciatica is numbness, tingling, or pain caused by an irritation of the sciatic nerve. Both are examples of peripheral nerve disorders. SIADH is more common among clients with central nerve disorders (eg, stroke, neurosurgery). (Option 2) Diabetes mellitus is an endocrine disorder characterized by hyperglycemia and is not commonly associated with SIADH. Educational objective: ADH is sometimes produced and secreted by cancer cells, especially lung cancer cells causing SIADH, a condition in which too much ADH causes water retention, increased total water, and dilutional hyponatremia.

A nurse reviews the most current serum laboratory results for assigned clients. Which result is the highest priority to report to the health care provider?

Sodium of 120 mEq/L in a client with small cell lung cancer Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is often caused by the ectopic production of ADH by a malignant lung tumor (eg, lung cancer). Increased ADH leads to increased water reabsorption and intravascular volume, which results in dilutional hyponatremia. Severe neurologic dysfunction (eg, confusion, seizures) can occur when serum sodium drops below 120 mEq/L (120 mmol/L) (normal: 135-145 mEq/L [135-145 mmol/L]). Therefore, hyponatremia is the highest priority to report as it poses the greatest threat to survival. Hyponatremia requires immediate evaluation and treatment (eg, seizure precautions, fluid restriction, intravenous hypertonic saline) by the health care provider. (Option 1) Albumin (normal: 3.5-5.0 g/dL [35-50 g/L]) is a protein formed in the liver. Hepatocytes lose the ability to synthesize albumin when the cells are diseased. Hypoalbuminemia (<3.5 g/dL [<35 g/L]) should be expected in this client. (Option 2) B-type natriuretic peptide (BNP) (normal: <100 pg/mL [100 pmol/L]) is a substance secreted from the cardiac ventricles in response to increases in ventricular pressures and volume. Therefore, BNP is a marker for heart failure and is elevated in clients with both stable and decompensated heart failure. BNP is an expected finding in this client. (Option 3) Clients in alcohol withdrawal usually require magnesium supplements. Hypomagnesemia (<1.5 mEq/L [<0.75 mmol/L]) results from poor dietary intake, malnutrition, and increased renal excretion, and is common in clients with chronic alcoholism. This finding is within normal limits (normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]). Educational objective: Malignant lung tumors are a common cause of syndrome of inappropriate antidiuretic hormone secretion (SIADH). When serum sodium drops below 120 mEq/L (120 mmol/L), immediate intervention is necessary to prevent severe neurologic dysfunction. Fluid restriction is recommended for clients with SIADH

The nurse cares for a client diagnosed with type I diabetes mellitus who came to the emergency department with the acute complication of diabetic ketoacidosis (DKA). After checking the blood glucose, which prescription should the nurse implement first?

Start an IV line and infuse normal saline as prescribed DKA is a life-threatening complication of type I diabetes characterized by hyperglycemia (>250 mg/dL) that results in ketosis, a metabolic acidosis. Glucose cannot be taken out of the bloodstream and used for energy without insulin. The body begins to break down fat stores into ketones, as it does in a state of starvation, causing a metabolic acidosis (low pH and low HCO3). The lack of insulin also results in increased glucose production in the liver, worsening the hyperglycemia. Hyperglycemia causes osmotic diuresis, and clients are severely dehydrated. The cardinal signs of dehydration are poor skin turgor, dry mucosal membranes, tachycardia, orthostatic hypotension, weakness, and lethargy. Despite laboratory values showing hyperkalemia on admission, clients with DKA have a net potassium deficiency and will need careful replacement after fluid resuscitation. (Option 1) Although it is important to insert an indwelling catheter to monitor fluid balance, rehydrating the client is a life-saving measure with higher priority. (Option 2) Although it is important to monitor serum potassium results before and during insulin administration, rehydrating the client is the highest priority. Dilution will also improve the hyperkalemia. (Option 3) The priority intervention in DKA is to start an IV infusion for bolus rehydration therapy with normal saline. This should occur before insulin infusion as insulin will result in water, potassium, and glucose entering the cells, worsening the dehydration and electrolyte imbalances.

A client is admitted to the intensive care unit with suspected pheochromocytoma. The client's vital signs are temperature of 99.6 F (37.5 C), blood pressure (BP) of 200/110 mm Hg, heart rate of 110/min, and respirations of 20/min. The client is sweating profusely and reports a severe headache. Which prescription should the nurse implement first?

Start nitroprusside infusion at 0.5 mcg/kg/min Explanation: Pheochromocytoma is a condition caused by a tumor in the adrenal medulla. This results in excess release of catecholamines such as epinephrine and norepinephrine, leading to paroxysmal hypertensive crisis. Important points to note when caring for these clients include the following: Hypertension is difficult to treat and is often resistant to multiple drugs. The client should avoid activities that can precipitate a hypertensive crisis (eg, bending, lifting, Valsalva maneuver). Abdominal palpation should be avoided as manipulation of the adrenal gland and release of catecholamines can precipitate a hypertensive crisis. Hypertensive crisis puts the client at risk for stroke and so has the highest priority for treatment. Nitroprusside (Nitropress, Nipride) is a vasodilator given via infusion and can be titrated to keep the BP within a desired parameter. (Options 1, 2, and 3) Administration of acetaminophen and use of a fan may help relieve symptoms. Drawing an electrolyte panel is appropriate. However, these are not life-saving interventions and so are not the highest priority. Educational objective: Pheochromocytoma is a condition caused by a tumor in the adrenal medulla that causes release of catecholamines such as epinephrine and norepinephrine, resulting in paroxysmal hypertensive crisis. Hypertensive crisis puts the client at risk for stroke and should be treated promptly with intravenous nitroprusside or another vasodilator (eg, phentolamine, nicardipine). Abdominal palpation should be avoided in these clients.

The nurse cares for a client with type I diabetes mellitus. Which action, by the nurse, best assesses the chronic complication of autonomic neuropathy?

Take the BP sitting and standing Diabetic neuropathy is caused by nerve damage as a result of the metabolic disturbances associated with diabetes mellitus. Autonomic neuropathy is nerve damage to the autonomic nervous system, the system responsible for involuntary body functions such as blood pressure, heart rate, perspiration, sexual function, and digestion. Impairment to the autonomic nervous system caused by neuropathy can cause symptoms such as postural hypotension, tachycardia, painless myocardial infarction, bowel incontinence, diarrhea, urinary retention, and hypoglycemic unawareness. The client with postural hypotension is also at risk for falls and should be taught to get up from a lying or sitting position slowly. (Options 1, 2 & 3) Sensory or peripheral neuropathy affects the peripheral nervous system and may cause problems with the extremities. Educational objective: Impairment to the autonomic nervous system caused by neuropathy can cause symptoms such as postural hypotension and put the client at risk for falls.

The nurse in the emergency department is caring for a client recently diagnosed with Graves' disease who was admitted following a motor vehicle accident. The nurse notes the vital signs shown in the exhibit. The nurse alerts the primary health care provider that the client may be experiencing which condition? Click on the exhibit button for additional information.

Thyroid storm Thyroid storm is a life-threatening condition that can occur in uncontrolled hyperthyroidism or Graves' disease when a stressful incident, such as this client's motor vehicle accident, triggers a sudden surge of thyroid hormone. Manifestations of thyroid storm include a rapid onset of fever, tachycardia, and elevated blood pressure. The client often feels anxious, tremulous, or restless. Confusion and psychosis can occur, as can seizures and coma. Rapid treatment is necessary. (Option 1) Hypertensive crisis alone would not cause fever. (Option 2) Malignant hyperthermia would occur in the perioperative setting in response to anesthesia. This client has no risk factors for malignant hyperthermia. (Option 3) Serotonin syndrome would occur in the client taking more than one or an overdose of antidepressant medication that increases serotonin levels. Educational objective: Thyroid storm is a life-threatening complication of Graves' disease (hyperthyroidism). Assessment findings include a rapid increase in temperature, heart rate, and blood pressure in response to stress.

The breakfast trays arrive on the unit, and a newly admitted client with type 1 diabetes mellitus is hungry and wants to eat. The nurse reviews the vital signs, laboratory results, and medication administration record. Why does the nurse contact the health care provider before administering the client's 0700 medications? Click on the exhibit button for additional information.

To request a prescription for insulin lispro Type 1 diabetes mellitus is an endocrine disorder characterized by the absence of insulin production in the pancreas, causing hyperglycemia and intracellular energy deficits. Clients with type 1 diabetes mellitus require consistent insulin administration, typically of both short- or rapid-acting and intermediate- or long-acting insulins, to prevent hyperglycemia and provide energy to the cells. The nurse should contact the health care provider (HCP) to report the serum glucose (270 mg/dL [14.9 mmol/L]) and request an additional insulin prescription (Option 4). The client requires rapid-acting insulin (eg, lispro, aspart) before eating to correct the hyperglycemia; long-acting insulins are not effective for immediate correction. (Option 1) Detemir is a long-acting (basal) insulin, prescribed once or twice daily. Long-acting insulins are given to prevent, not correct, hyperglycemia. However, if the blood glucose remains elevated, the detemir dose may need to be increased. (Option 2) Spironolactone is a potassium-sparing diuretic that counteracts potassium loss caused by other diuretics. It is often prescribed in combination with thiazide diuretics to treat hypertension and in combination with loop diuretics to treat ascites associated with liver disease. The nurse would question this prescription if the client were hyperkalemic. (Option 3) Serum potassium is within the normal range of 3.5-5.0 mEq/L (3.5-5.0 mmol/L), so it does not need to be reported to the HCP. Educational objective: Rapid-acting insulin preparations are administered to correct hyperglycemia, whereas long-acting insulin preparations prevent hyperglycemia. The nurse should question a spironolactone prescription and notify the health care provider if the client is hyperkalemic.