Medsurg- endocrine
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." 4. "Conscious sedation will be used to help with relaxation during the RAIU test." 5. "It is important to refrain from eating or drinking for at least 12 hours before the RAIU test."
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.
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. 1. Acanthosis nigricans 2. Hirsutism 3. Hyperpigmented skin 4. Truncal obesity 5. 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.
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 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.
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? 1. Insert an indwelling urinary catheter for accurate output calculation(0%) 2. Obtain serum potassium level results and report to the primary health care provider(8%) 3. Prepare an insulin drip for intravenous (IV) infusion as prescribed(24%) 4. Start an IV line and infuse normal saline as prescribed(66%)
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 pHand 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 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? 1. Deficient fluid volume related to osmotic diuresis(35%) 2. Imbalanced nutrition, less than body requirements related to inability to metabolize glucose(3%) 3. Ineffective breathing pattern related to the presence of metabolic acidosis(55%) 4. Ineffective health maintenance related to the inability to manage DM during illness(5%)
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.
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? 1. Check serum BUN and creatinine levels every hour(43%) 2. Discontinue insulin infusion when blood glucose is <350 mg/dL (19.4 mmol/L)(31%) 3. Increase insulin infusion rate when blood glucose level decreases(4%) 4. Initiate potassium IV when serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L)(20%)
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.
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. 1. Administer artificial tears to moisten the conjunctiva 2. If eyelids don't close during sleep, lightly tape them shut 3. Recommend the use of dark glasses to prevent irritation 4. Teach about the importance of smoking cessation 5. Teach avoidance of eye movement to prevent further damage
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.
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? 1. Administer both insulins as prescribed(63%) 2. Hold both glargine and lispro insulin(2%) 3. Hold the glargine insulin(10%) 4. Hold the lispro insulin(23%)
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).
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. 1. Abdominal pain 2. Blood glucose level >600 mg/dL (33.3 mmol/L) 3. History of type 2 diabetes 4. Kussmaul respirations 5. 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).
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. 1. Emphasize the importance of a low-carbohydrate diet 2. Encourage the client to increase high-fiber foods in the diet 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
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.
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? 1. 29-year-old with new onset of influenza(14%) 2. 40-year-old experienced cyclist who rides an extra 10 miles (16 km)(58%) 3. 65-year-old with cellulitis of the right leg(7%) 4. 72-year-old with emphysema who is taking prednisone(20%)
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).
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. 1. Diaphoresis 2. Flushing 3. Pallor 4. Polyuria 5. 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.
The nurse cares for a client with type 1 diabetes mellitus who is obtunded and responding to only painful stimuli. A STAT blood sample reveals a blood glucose level of 38 mg/dL (2.11 mmol/L). Which initial action by the nurse is best? 1. Administer 50% dextrose in water IV push(73%) 2. Assist the client to drink 4 oz (120 mL) of orange juice(21%) 3. Measure the client's heart rate and blood pressure(2%) 4. Observe for sweating, shakiness, and pallor(1%)
Hypoglycemia, a potentially life-threatening complication of diabetes mellitus, is identified by blood glucose <70 mg/dL (<3.9 mmol/L) and often occurs as a result of illness or inappropriate use of antidiabetic medications. When blood glucose levels (BGLs) are low, the body activates the autonomic nervous system, causing shakiness, palpitations, and sweating. Without intervention, hypoglycemia may cause altered mental status (eg, difficulty speaking, confusion), which may progress to seizures, coma, and death. Nurses caring for clients with hypoglycemia and altered mental status or dysphagia should immediately administer IV glucose replacement (eg, 50% dextrose in water) to quickly restore BGLs and prevent potentially lethal neurological changes (Option 1). Afterward, the nurse should retest the BGL every 15 minutes, repeating treatment if it remains low. (Option 2) Clients with altered mental status (eg, obtunded, responsive only to painful stimuli) are at high risk for aspiration and are not appropriate candidates for oral glucose replacement. (Options 3 and 4) Obtundation, a sign of severe hypoglycemia, and a confirmed BGL of 38 mg/dL (2.11 mmol/L) are sufficient indicators for implementing emergency intervention. Assessment of additional signs of hypoglycemia, heart rate, and blood pressure should not delay implementation of lifesaving treatment.
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. 1. Female with a low-density lipoprotein (LDL) level of 96 mg/dL (2.5 mmol/L) 2. Female with a waist circumference of 38 inches (96.5 cm) 3. Female with blood pressure of 148/90 mm Hg 4. Male with a fasting blood glucose of 99 mg/dL (5.5 mmol/L) 5. 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.
The nurse is teaching a group of clients diagnosed with diabetes mellitus. Which lesson regarding foot care should be included? Select all that apply. 1. Cut toenails straight across and file along the curves of the toes 2. Rub feet vigorously with a towel after bathing to ensure dryness 3. Use a mild foot powder on perspiring feet 4. Use cotton or lamb's wool to separate overlapping toes 5. Use an over-the-counter corn removal kit to remove corns or calluses
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: 1. 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. 2. Inspect for abrasions, cuts, or sores. Have others inspect the feet if eyesight is poor. 3. 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). 4. Avoid using over-the-counter products (eg, iodine, alcohol, strong adhesives) on cuts or abrasions (Option 5). 5. To improve circulation, do not sit with legs crossed or for extended periods, avoid tight-fitting garments, and perform daily exercise. 6. Report other types of problems such as infections or athlete's foot immediately.
The nurse is caring for a 72-year-old client with hypothyroidism admitted to the emergency department for altered mental status. The client lives alone but has not taken medications or seen a health care provider for several months. Which action is the priority? Click on the exhibit button for additional information. 1. Administer IV levothyroxine(20%) 2. Check serum TSH, triiodothyronine, and thyroxine(10%) 3. Place a warming blanket on the client(19%) 4. Prepare for endotracheal intubation(48%) Vital signs Temperature 95 F (35 C) Blood pressure 90/50 mm Hg Heart rate 50/min Respirations1 0/minSaO2
Myxedema coma refers to a state of severe hypothyroidism causing decreased level of consciousness (eg, lethargy, stupor) that may progress to a comatose state. Myxedema coma is characterized by hypothermia, bradycardia, hypotension, and hypoventilation. Hypoventilation may occur as a result of respiratory muscle fatigue and mechanical obstruction by an edematous tongue. Clients with signs of respiratory failure (eg, slow or shallow breathing, low oxygen saturation) require emergency endotracheal intubation and mechanical ventilation. The nurse should provide respiratory support (eg, ventilation with a bag-valve-mask) and prepare to assist with intubation (Option 4). (Option 1) Clients with myxedema coma require thyroid hormone replacement with IV levothyroxine to correct the hypothyroid state but only after respiratory status is secured. Improvement in clinical status may not occur for up to a week after initiation of hormone replacement. (Option 2) A serum thyroid panel (eg, TSH, triiodothyronine, thyroxine) is required to confirm hypothyroidism, and these measurements should be monitored during treatment; however, the nurse should ensure that the client is stable before reviewing laboratory values. (Option 3) A warming blanket should be placed on the client to treat hypothermia; however, respiratory support is the priority.
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. 1. Fluid bolus (normal saline) 2. Fluid restriction 3. Salt restriction in the diet 4. Seizure precautions 5. 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.
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. 1. Decreased serum osmolality 2. High serum osmolality 3. High urine specific gravity 4. Increased urine output 5. Low serum sodium
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.
The nurse reviews prescriptions for assigned adult clients. Which prescription should the nurse question? 1. 0.45% sodium chloride (NaCl) solution prescribed for a client with syndrome of inappropriate antidiuretic hormone secretion who has a sodium level of 120 mEq/L (120 mmol/L)(62%) 2. 0.9% NaCl solution prescribed for a client with gastrointestinal bleeding who has a hemoglobin level of 8.9 g/dL (89 g/L)(11%) 3. 1,000 mL bolus of 0.9% NaCl solution prescribed for a client with septic shock who has a white blood cell count of 18,000/mm3 (18.0 × 109/L)(13%) 4. Lactated Ringer's solution prescribed for a male client with hypovolemic shock and a thermal burn who has a hematocrit level of 56% (0.56)(12%)
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 hypertonicIV 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.
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? 1. Administer IV regular insulin(43%) 2. Administer normal saline infusion(42%) 3. Obtain urine for urinalysis(2%) 4. Request prescription for potassium infusion(11%)
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.
The nurse is caring for a client recovering from a thyroidectomy to treat hyperthyroidism. Which assessment finding would require the nurse to immediately notify the health care provider? 1. 0.4 in2 (2.6 cm2) of bright-red blood on the surgical dressing on the client's neck(23%) 2. Client report of sore throat while talking and burning when swallowing(28%) 3. Pain rated as 8 on a scale of 0-10 at the surgical incision site(2%) 4. Temperature increase to 100 F (37.8 C) from 98.9 F (37.2 C) 30 minutes prior(45%)
Thyrotoxicosis (ie, thyroid storm) is a life-threatening condition characterized by an increase in thyroid hormone levels that results in a hypermetabolic state. Most commonly, thyrotoxicosis occurs as an exacerbation of hyperthyroidism and is treated with antithyroid medications and/or surgical removal of the thyroid (thyroidectomy). However, thyrotoxicosis may also occur due to excess thyroid hormone intake from medications and physical manipulation of the thyroid gland. The nurse caring for a client after thyroidectomy must closely monitor for and immediately report any clinical manifestations of thyrotoxicosis (eg, fever, chills, tachycardia), including small rises in body temperature (Option 4). After surgery, thyroid hormone levels can remain elevated for several days and may even increase from intraoperative thyroid gland manipulation. Without treatment, thyrotoxicosis can rapidly progress to lethal complications (eg, hyperthermia, ventricular tachycardia). (Options 1 and 3) Expected postsurgical findings (eg, pain, small volume incisional bleeding) do not require notification unless the findings are unresolved by interventions (eg, pain medicine) or excessive (eg, continuous or large volume bleeding). (Option 2) Postoperative sore throat is expected due to irritation from the endotracheal tube used during surgery. However, the nurse should monitor for hoarseness or noisy breathing, which may indicate laryngeal stridor and airway compromise.
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? 1. Ask client to place backs of the hands against each other to provide hyperflexion of the wrist while the elbows remain flexed(17%) 2. Instruct client to lie down and run the heel of one foot down the shin of the other leg(7%) 3. Perform Romberg test by asking the client to stand with eyes closed and feet together(8%) 4. Place blood pressure (BP) cuff on arm, inflate to pressure > than systolic BP, and hold in place for 3 minutes(66%)
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 forearmwhen 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.
