Unit of 3: Endocrine & Metabolic Disorders

Which client will the community health nurse visit first?

the client with type 1 diabetes mellitus with acute visual changes The highest priority client is the one with acute vision problems. The other clients need to be seen but are not emergent.

The nurse is caring for a client with type 2 diabetes who has been admitted with hyperglycemia. What is the most important consideration when developing a teaching plan for this client?

Assess what the client already knows, then identify learning needs. It is most important to assess the client's teaching learning needs. The client needs to share what is already known about diabetes and how it has been managed. Then it is important to identify the client's level of motivation and what information is still needed. All the listed information related to diabetes is important. However, to individualize the teaching the nurse will need to assess what the client already knows and direct the teaching to what is not understood.

A client with diabetes has been diagnosed with hypertension, and the health care provider has prescribed atenolol, a beta-blocker. When teaching the client about the drug, what should the nurse tell the client about how it may interact with the client's diabetes? Atenol may cause:

an increase in the hypoglycemic effects of insulin. There is a direct interaction between the effects of insulin and those of beta blockers. The nurse must be aware that there is a potential for increased hypoglycemic effects of insulin when a beta blocker is added to the client's medication regimen. The client's blood sugar should be monitored. Ketoacidosis occurs in hyperglycemia. Although a decrease in the incidence of ketoacidosis could occur when a beta blocker is added, the direct result is an increase in the hypoglycemic effect of insulin.

When educating the client with type 1 diabetes, the nurse knows that more education is needed when the client says:

"I will be able to switch to insulin pills when my sugar is under control." Oral antidiabetic agents are effective only in adult clients with type 2 diabetes. Oral antidiabetic agents aren't effective in type 1 diabetes. The need to eliminate sugar, give insulin, and receive proper foot care are all items that indicate the client understands the teaching.

A nurse is caring for a client in addisonian crisis. Which medication order should the nurse question?

potassium chloride The nurse should question an order for potassium chloride because addisonian crisis results in hyperkalemia. Administering potassium chloride is contraindicated. Because the client is hyponatremic, an order for normal saline solution is appropriate. Hydrocortisone and fludrocortisone are used to replace deficient adrenal cortex hormones.

A nurse is caring for a client in acute addisonian crisis. Which test result does the nurse expect to see?

serum potassium level of 6.8 mEq/L (6.8 mmol/L) A serum potassium level of 6.8 mEq/L indicates hyperkalemia, which can occur in adrenal insufficiency as a result of reduced aldosterone secretion. A BUN level of 2.3 mg/dl is lower than normal. A client in addisonian crisis is likely to have an increased BUN level because the glomerular filtration rate is reduced. A serum sodium level of 156 mEq/L indicates hypernatremia. Hyponatremia is more likely in this client because of reduced aldosterone secretion. A serum glucose level of 236 mg/dl indicates hyperglycemia. This client is likely to have hypoglycemia caused by reduced cortisol secretion, which impairs glyconeogenesis.

The client with type 1 diabetes mellitus says, "If I could just avoid what you call carbohydrates in my diet, I guess I would be okay." What is the best response by the nurse?

"A person with diabetes should monitor their eating of proteins, fats, and carbohydrates." Diabetes mellitus is a multifactorial, systemic disease associated with problems in the metabolism of all food types. The client's diet should contain appropriate amounts of all three nutrients, plus adequate minerals and vitamins. Limiting carbohydrate intake is just part of a comprehensive diabetic diet plan. A client with type 1 diabetes will need lifelong insulin therapy. Carbohydrates from fruit and vegetable sources will still need to be factored into carbohydrate intake. Telling a client "all we ask you to do" is a value-judgement and is not therapeutic communication.

When obtaining a health history from a client newly admitted to the hospital, which statement indicates the client's needs for further follow-up?

"No matter how much I drink, I'm still thirsty all the time." Polydipsia, or increased thirst, is a classic clinical manifestation of diabetes. The excessive loss of fluids is the result of the osmotic diuresis that occurs with glycosuria. Other clinical manifestations include hunger, fatigue, blurred vision, slow-healing wounds, and hyperglycemia. The report of shortness of breath is not an acute issue and can be followed up upon later. In addition, painful joints and having trouble urinating are a concern to the client and should be addressed after the acute health concern is addressed.

The client with Addison's disease is taking glucocorticoids at home. Which statement indicates that the client understands how to take the medication?

"Various circumstances increase the need for glucocorticoids, so I will need to adjust the dosage." The need for glucocorticoids changes with circumstances. The basal dose is established when the client is discharged, but this dose covers only normal daily needs and does not provide for additional stressors. As the manager of the medication schedule, the client needs to know signs and symptoms of excessive and insufficient dosages. Glucocorticoid needs fluctuate. Glucocorticoids are not cumulative and must be taken daily. They must never be discontinued suddenly; in the absence of endogenous production, Addisonian crisis could result. Two-thirds of the daily dose should be taken at about 0800 and the remainder at about 1600. This schedule approximates the diurnal pattern of normal secretion, with highest levels between 0400 and 0600 and lowest levels in the evening.

A nurse is caring for a client who is prescribed 1 unit of regular insulin for every 6 g of carbohydrates consumed at mealtime and 1 unit of regular insulin for every 30 mg/dL increase of blood sugar above 130 mg/dL. For lunch, the client ate a hamburger bun (20 g carbohydrates), a 3-oz burger (10 g carbohydrates), and a 12-oz diet soda (0 g carbohydrates). The client's blood sugar is now 190 mg/dL. How much total insulin will the nurse administer? Record your answer using a whole number.

7 According to the guidelines, 30 g carbohydrates/6 = 5 units regular insulin; blood sugar 190-130 = 60 mg above 1 unit for each 30 mg/dl elevation = 2; 5 + 2 = 7 units of regular insulin. It is important to calculate the required insulin to be given as a corrective dose with each meal.

A nurse obtained a client's fasting blood sugar (FBS) at 0700, which was 144 mg/dL (8 mmol/L). The client has an order for regular insulin 8 units every morning. What should the nurse do next?

Administer the insulin as ordered. The nurse knows that a normal fasting blood sugar is between 72 and 108 mg/dL (4 and 6 mmol/L). The result of 144 mg/dL indicates that the client requires insulin to lower the blood glucose level. The nurse would not hold the insulin dose. Because there is alreadt a prescription for insulin, it is not necessary to contact the healthcare provider at this time. Based on the FBS result, the nurse would administer insulin before offering the client food.

The physician has prescribed sodium chloride for a hospitalized 51-year-old client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply.

Document presenting signs and symptoms. Maintain intake and output records. Compare ABG findings with previous results. Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate or decreased hydrogen ion concentrations. The result is retention of sodium bicarbonate and increased base bicarbonate. Nursing management includes documenting all presenting signs and symptoms to provide accurate baseline data, monitoring laboratory values, comparing ABG findings with previous results (if any), maintaining accurate intake and output records to monitor fluid status, and implementing prescribed medical therapy.

A client who has been diagnosed with type 1 diabetes has an insulin drip to aid in lowering the serum blood glucose level of 600 mg/dL (33.3 mmol/L). The client is also receiving ciprofloxacin IV. The health care provider (HCP) prescribes discontinuation of the insulin drip. What should the nurse do next?

Inform the HCP that the client has not received any subcutaneous insulin yet. ecause subcutaneous administration of insulin has a slower rate of absorption than IV insulin, there must be an adequate level of insulin in the bloodstream before discontinuing the insulin drip; otherwise, the glucose level will rise. Adding an IV antibiotic has no influence on the insulin drip; it should not be piggy-backed into the insulin drip. Glargine cannot be administered IV and should not be mixed with other insulins or solutions.

A client with syndrome of inappropriate antidiuretic hormone (SIADH) is experiencing lethargy, weakness, headache, and muscle aches. Which intervention is the nurse's priority?

Initiate seizure precautions. SIADH causes the release of excessive ADH resulting in fluid retention and dilutional hyponatremia. The client is exhibiting symptoms of hyponatremia, which can lead to seizures. Thus the priority is to place client on seizure precautions. Although administering declomycin, increasing salt intake, and monitoring serum osmolarity are appropriate interventions, they are not the priority.

A nurse explains to a client that the nurse will administer the client's first insulin dose in the client's abdomen. How does absorption at the abdominal site compare with absorption at other sites?

Insulin is absorbed more rapidly at abdominal injection sites than at other sites. Subcutaneous insulin is absorbed most rapidly at abdominal injection sites, more slowly at sites on the arms, and slowest at sites on the anterior thigh. Absorption after injection in the buttocks is less predictable.

The nurse is providing dietary teaching for a client with diabetes. Which statement about the diet would be accurate?

It is planned around a wide variety of commonly available foods. Each client should be given an individually devised diet selecting commonly used foods from the Diabetic Association exchange diet. Family members should be included in the diet teaching. Nutritional requirements are not the same for all clients. Flexibility is needed based on activity, not rigid control. Seasoning and processed food should be managed.

The client has chronic pancreatitis. What should the nurse teach the client to do to monitor the effectiveness of pancreatic enzyme replacement?

Observe stools for steatorrhea. If the dosage and administration of pancreatic enzymes are adequate, the client's stool will be relatively normal. Any increase in odor or fat content would indicate the need for dosage adjustment. Stable body weight would be another indirect indicator. Fluid intake does not affect enzyme replacement therapy. If diabetes has developed, the client will need to monitor glucose levels. However, glucose and ketone levels are not affected by pancreatic enzyme therapy and would not indicate effectiveness of the therapy.

The nurse is teaching a client scheduled for thyroid lobectomy. What information will the nurse include?

daily neck exercises Surgical clients should be taught specific and general postoperative care. Following thyroid surgery, clients should perform neck exercises to maintain range of motion. Clients will be placed in semi-Fowler's position postoperatively to ease the work of breathing. All surgical clients should be taught to observe for common surgical complications, such as bleeding or infection, and to provide postoperative wound care. After partial thyroidectomy for an early-stage cancer, the client will not need a tracheostomy. If a calcium imbalance develops, it will be hypocalcemia resulting from removal or damage to the parathyroid glands.

A client has had a bilateral adrenalectomy. For which potential complication should the nurse assess the client?

delayed wound healing Persistent cortisol excess undermines the collagen matrix of the skin, impairing wound healing. It also carries an increased risk of infection and of bleeding. The wound should be observed and documentation performed regarding the status of healing. Confusion and emboli are not expected complications after adrenalectomy. Malnutrition also is not an expected complication after adrenalectomy. Nutritional status should be regained postoperatively.

The nurse teaches the client with type 1 diabetes mellitus about the importance of maintaining stable blood glucose levels. The nurse should suggest the client include which type of food to minimize the rise in blood glucose level after meals?

dietary fiber Foods high in dietary fiber tend to blunt the rise in blood glucose levels after meals. Dietary fiber is the part of food not broken down and absorbed during digestion. Most fibers come from plants; good sources include whole grains, legumes, vegetables, fruits, and nuts. The other foods do not minimize this rise in blood sugar after meals. Dairy products are poor sources of fiber. Foods fortified with vitamins are satisfactory if they also contain fiber. However, many foods fortified with vitamins contain either no dietary fiber (such as fortified milk) or little fiber (such as products fortified with vitamins but made with refined grains). Meats are poor sources of fiber.

A client is diagnosed with a goiter after traveling in a foreign country for 3 months. During the trip, the client could not tolerate food. Which signs and symptoms would the nurse expect to see in this client? Select all that apply.

dizziness when raising the arms above the head dysphagia respiratory distres A goiter can result from inadequate dietary intake associated with changes in diet or malnutrition. It is caused by insufficient thyroid gland production and depletion of glandular iodine. Signs and symptoms of a goiter include enlargement of the thyroid gland, dizziness when raising the arms above the head, dysphagia, and respiratory distress. Cardiomegaly and oliguria are not associated with a goiter.

When caring for a client with diabetes insipidus, the nurse expects to administer

vasopressin. Because diabetes insipidus results from decreased antidiuretic hormone (vasopressin) production, the nurse should expect to administer synthetic vasopressin for hormone replacement therapy. Furosemide, a diuretic, is contraindicated because a client with diabetes insipidus experiences polyuria. Insulin and dextrose are used to treat diabetes mellitus and its complications, not diabetes insipidus.

A physician has referred a client newly diagnosed with diabetes mellitus to the diabetes nurse-educator. When the nurse brings up the subject, the client states, "I'd rather work with you than with a stranger." What is the nurse's best response?

"I'll set up a meeting for today. Then you and I can meet to talk about how things went." he client may feel overwhelmed and anxious about this diagnosis. The client's made a therapeutic connection with the nurse at a vulnerable time in their life when the client must address many new issues. Offering to follow up with the client encourages them to move forward and gives them an opportunity to meet with a safe and trusted person afterward. Telling the client that the nurse-educator is more knowledgeable about the subject doesn't help address the client's feelings. Telling the client not to worry or that they'll get over these feelings minimizes the client's feelings and may impair the nurse-client relationship.

A client's 1200 blood glucose was inaccurately documented as 310 mg/dL (17.2 mmol/L) instead of 130 mg/dL (7.2 mmol/L). This error was not noticed until 1300. The nurse administered the sliding scale insulin for a blood glucose of 310 mg/dL (17.2 mmol/L). What should the nurse do first?

Assess the client for hypoglycemia. The nurse should first assess the client because a hypoglycemic reaction is likely to occur. At this time, the nurse also should give the client a fast-acting simple carbohydrate. Then the nurse should notify the HCP for prescriptions to prevent or treat severe hypoglycemia. The nurse could consult the clinical pharmacist until able to contact the HCP, but the first action is to assess the client in order to have accurate information to report. When the situation has been resolved, the nurse should document the incident and report the incident to the charge nurse.

A nurse is teaching a client with diabetes mellitus about self-management. Which statement would be correct about the administration of lispro insulin?

Take the insulin at around the same time each day at a meal. The nurse should instruct the client to administer the insulin around a meal because the onset of rapid acting insulin is immediate. The use of alcohol may cause hyperglycemia or hypoglycemia. The client should be instructed to monitor glucose level closely and should be discouraged from concurrent use. Long-acting insulin is often taken in the evening once per day because the insulin mimics the basal insulin secretion for a full day. Lispro insulin can only be mixed with NPH insulin.

A nurse is caring for a client with hypothyroidism. The client is extremely upset about altered physical appearance. The client doesn't want to take the medication because "it isn't doing any good." What should the nurse do?

Tell the client that as the medication corrects the hormone deficiency improvement in looks can be expected soon. Stating that the client will soon experience improvement is supportive and encouraging and offers direction in a way that motivates continued medication compliance. Stating that the client should ask the physician about the medication dosage might cause the client alter the dosage, and also is putting the client off instead of addressing the concerns. Stating that the client looks fine discounts the client's feelings. Advising the client to practice self-acceptance is parental and direct at a time when the client needs support and understanding.

Which information should the nurse include in the teaching plan of a female client with bilateral adrenalectomy?

The client will need steroid replacement for the rest of her life. Bilateral adrenalectomy requires lifelong adrenal hormone replacement therapy. If unilateral surgery is performed, most clients gradually reestablish a normal secretion pattern. The client and family will require extensive teaching and support to maintain self-care management at home. Information on dosing, adverse effects, what to do if a dose is missed, and follow-up examinations is needed in the teaching plan. Although steroids are tapered when given for an intermittent or one-time problem, they are not discontinued when given to clients who have undergone bilateral adrenalectomy because the clients will not regain the ability to manufacture steroids. Steroids must be taken on a daily basis, not just during periods of physical or emotional stress

The nurse is teaching the client to self-administer insulin. Which approach to establishing learning goals will likely be most effective? When the goals are established by the:

client, nurse, pharmacist, and health care provider so the client can participate in planning care with the entire team. Learning goals are most likely to be attained when they are established mutually by the client and members of the health care team, including the nurse, pharmacist, and health care provider.Learning is motivated by perceived problems or goals arising from unmet needs. The perception of the unmet needs must be the client's; however, the nurse, pharmacist, and health care provider help the client arrive at his or her own perception of the need or reason to learn.

A client has been admitted to the hospital for the treatment of diabetic ketoacidosis, a problem that was accompanied by a random blood glucose reading of 31.9 mmol/L (575 mg/dL), vomiting, and shortness of breath. This client has experienced which of the following phenomena?

exacerbation This client has experienced a significant exacerbation of a chronic disease (diabetes mellitus), which has manifested as an acute threat to the client's health. Morbidity is an epidemiological statistic of the frequency of a disease. The client's problem does not have an infectious etiology and while risk factors underlie the present condition, they are not the essence of the current state.

A nurse is teaching a client with type 1 diabetes how to treat adverse reactions to insulin. To reverse hypoglycemia, the client ideally should ingest an oral carbohydrate. However, this treatment isn't always possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand?

glucagon During a hypoglycemic reaction, a layperson may administer glucagon, an antihypoglycemic agent, to raise the blood glucose level quickly in a client who can't ingest an oral carbohydrate. Epinephrine isn't a treatment for hypoglycemia. Although 50% dextrose is used to treat hypoglycemia, it must be administered I.V. by a skilled healthcare professional. Hydrocortisone takes a relatively long time to raise the blood glucose level and therefore isn't effective in reversing hypoglycemia.

A client with cirrhosis begins to develop ascites. Spironolactone is prescribed to treat the ascites. The nurse should monitor the client closely for which drug-related adverse effect?

hyperkalemia Spironolactone is a potassium-sparing diuretic; therefore, clients should be monitored closely for hyperkalemia. Other common adverse effects include abdominal cramping, diarrhea, dizziness, headache, and rash. Constipation and dysuria are not common adverse effects of spironolactone. An irregular pulse is not an adverse effect of spironolactone but could develop if serum potassium levels are not closely monitored.

The nurse is caring for a client on the urinary unit. When providing report to the next shift, it is noted that the client has osteopenia and history of renal calculi. Which disorder would the nurse suspect?

hyperparathyroidism Hyperparathyroidism is characterized by osteopenia and renal calculi secondary to overproduction of parathyroid hormone. The hallmark symptom of hypoparathyroidism is tetany from hypocalcemia. Hypopituitarism presents with extreme weight loss and atrophy of all endocrine glands. Symptoms of hypothyroidism include hair loss, weight gain, and cold intolerance.

The nurse is caring for a client with multiple organ failure who is in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?

lungs and kidneys The lungs and kidneys facilitate the ratio of bicarbonate to carbonic acid. Carbon dioxide is one of the components of carbonic acid. The lungs regulate carbonic acid levels by releasing or conserving CO2 by increasing or decreasing the respiratory rate. The kidneys assist in acid-base balance by retaining or excreting bicarbonate ions.

Which statement indicates that the client with diabetes insipidus understands how to manage care? The client will:

maintain normal fluid and electrolyte balance. Because diabetes insipidus involves excretion of large amounts of fluid, maintaining normal fluid and electrolyte balance is a priority for this client. Special dietary programs or restrictions are not indicated in treatment of diabetes insipidus. Serum glucose levels are priorities in diabetes mellitus but not in diabetes insipidus.

The nurse is caring for a client who is scheduled for an adrenalectomy. Which drug may be included in the preoperative prescriptions to prevent Addison's crisis following surgery?

methylprednisolone sodium succinate intravenously A glucocorticoid preparation will be administered intravenously or intramuscularly in the immediate preoperative period to a client scheduled for an adrenalectomy. Methylprednisolone sodium succinate protects the client from developing acute adrenal insufficiency (Addison's crisis) that occurs as a result of the adrenalectomy. Spironolactone is a potassium-sparing diuretic. Prednisone is an oral corticosteroid. Fludrocortisones is a mineral corticoid.

The nurse should teach the diabetic client that which is most indicative of hypoglycemia?

nervousness The four most commonly reported signs and symptoms of hypoglycemia are nervousness, weakness, perspiration, and confusion. Other signs and symptoms include hunger, incoherent speech, tachycardia, and blurred vision. Anorexia and Kussmaul's respirations are clinical manifestations of hyperglycemia or ketoacidosis. Bradycardia is not associated with hypoglycemia; tachycardia is.

A client with a large goiter is scheduled for a subtotal thyroidectomy to treat thyrotoxicosis. Saturated solution of potassium iodide (SSKI) is prescribed preoperatively for the client. What should the nurse explain to the client about the expected outcome of using this drug? The drug helps:

reduce the vascularity of the thyroid gland. SSKI is frequently administered before a thyroidectomy because it helps decrease the vascularity of the thyroid gland. A highly vascular thyroid gland is very friable, a condition that presents a hazard during surgery. Preparation of the client for surgery includes depleting the gland of thyroid hormone and decreasing vascularity. SSKI does not decrease the progression of exophthalmos, and it does not decrease the body's ability to store thyroxine or increase the body's ability to excrete thyroxine.

A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia?

sweating, tremors, and tachycardia Sweating, tremors, and tachycardia, thirst, and anxiety are early signs of hypoglycemia. Dry skin, bradycardia, and somnolence are signs and symptoms associated with hypothyroidism. Polyuria, polydipsia, and polyphagia are signs and symptoms of diabetes mellitus.

The nurse is completing a health assessment of a 42-year-old female with suspected Graves' disease. When conducting a focused assessment, what should the nurse should assess the client for?

tachycardia Graves' disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is a common feature of hyperthyroidism. Cold skin is associated with hypothyroidism.

A client with hypothyroidism (myxedema) is receiving levothyroxine, 25 mcg P.O. daily. Which finding should the nurse recognize as an adverse reaction to the drug?

tachycardia Levothyroxine, a synthetic thyroid hormone, is given to a client with hypothyroidism to simulate the effects of thyroxine. Adverse reactions to this agent include tachycardia. Dysuria, leg cramps, and blurred vision aren't associated with levothyroxine.

When a nurse attempts to make sure the physician obtained informed consent for a thyroidectomy, the nurse realizes the client doesn't fully understand the surgery. The nurse approaches the physician, who curtly says, "I've told this client all about it. Just get the consent." The nurse should

tell the physician the client isn't comfortable consenting to surgery at this point. The nurse has evaluated the client's knowledge concerning the surgery and determined that the client doesn't have enough information to give informed consent. Even though the physician might want to move ahead, the nurse should advocate for the client by telling the physician the client isn't ready for the surgery. Telling the physician that the client hasn't been given enough information would be rude. The nurse shouldn't ask the charge nurse to talk with the physician unless the physician refuses to accept the nurse's professional opinion. Explaining surgery for the purpose of obtaining consent is beyond the nurse's scope of practice.

The nurse is instructing the client with hypothyroidism who takes levothyroxine 100 mcg, digoxin, and simvastatin. The nurse judges that the teaching regarding the use of these medications is effective if the client will take:

the levothyroxine before breakfast and the other medications 4 hours later. Levothyroxine) must be given at the same time each day on an empty stomach, preferably ½ to 1 hour before breakfast. Other medications may impair the action of levothyroxine absorption; the client should separate doses of other medications by 4 to 5 hours.

Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer?

using sterile technique during the dressing change The nurse should perform the dressing changes using sterile technique to prevent infection. Applying heat should be avoided in a client with diabetes mellitus because of the risk of injury. Cleaning the wound with povidone-iodine solution and debriding the wound with each dressing change prevents the development of granulation tissue, which is essential in the wound healing process.

A client with newly diagnosed type 1 diabetes is scheduled to receive regular insulin 10 units and NPH insulin 20 units every morning. When should the nurse schedule the administration of these medications?

both insulins 0.5 hours before breakfast Regular and NPH insulins are scheduled together one-half hour before breakfast. They do not need to be given separately or in different syringes.

A client recently diagnosed with hyperparathyroidism demands to see what the healthcare provider has written in the chart. What is the nurse's best response?

"I'll get the chart and set up a time for you to review it with your healthcare provider." Every client has a right to access information that the hospital has collected about the client. However, it is in the client's best interests to have a knowledgeable professional present to explain complicated information and unfamiliar terminology that the chart might include. Having the client sign a release of medical information may be necessary, but that does not assist the client to schedule a review with the healthcare provider. Suggesting the client review the chart with the healthcare provider does not facilitate the review. Contacting medical records to set up a time for the client to review does not ensure that a knowledgable professional is available to assist the client during the review.

The nurse is caring for a client in the medical unit. The nurse receives a health care provider's order for hydrocortisone 100 mg intravenously at a rate of 10 cc/hour for a client in acute adrenal crisis. The nurse understands that this treatment is common in clients with which disease process?

Addison's disease Intravenous hydrocortisone for clients in acute adrenal crisis is the proper treatment for individuals with Addison's disease. Cushing's syndrome is associated with excessive amounts of glucocorticoids. Hyperthyroidism and hypoparathyroidism are not treated with hydrocortisone.

Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"?

"Test your blood glucose every 4 hours." The nurse should instruct a client with diabetes mellitus to check their blood glucose levels every 3 to 4 hours and take insulin or an oral antidiabetic agent as usual, even when the client is sick. If the client's blood glucose level rises above 300 mg/dl, the client should call their physician immediately. If the client is unable to follow the regular meal plan because of nausea, the client should substitute soft foods, such as gelatin, soup, and custard.

An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, (2.3 mmol/L) and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting

15 g of a simple carbohydrate. To reverse hypoglycemia, the American Diabetes Association (Canadian Diabetes Association) guidelines recommend ingesting 15 g of a simple carbohydrate, such as 15 g of glucose tablets, 3 teaspoons (15 mL) or 3 packets of table sugar dissolved in water, 3/4 cup (175 mL) of juice or regular soft drink, 6 LifeSavers (1 = 2.5 g carbohydrate), or a 1 tablespoon (5 mL) of honey. Then the client should check their blood glucose after 15 minutes. If necessary, this treatment may be repeated in 15 minutes. Ingesting only 2 to 5 g of a simple carbohydrate may not raise the blood glucose level sufficiently. Ingesting more than 15 g may raise it above normal, causing hyperglycemia.

While reviewing the day's charts, a nurse who's been under a great deal of personal stress realizes that the nurse forgot to administer insulin to client with diabetes mellitus. The nurse has made numerous errors in the past few weeks and is now afraid this job is in jeopardy. What is the bestcourse of action?

Report the error, complete the proper paperwork, and meet with the unit manager. Making an error can be very stressful and a nurse may feel great pressure to hide the mistake or not follow protocol. Discussing the problem with the unit coordinator may help the nurse address some of the underlying stress that led up to making the error. Nonetheless, the nurse must still report the error and complete the proper paperwork. The nurse should contact the physician and follow their instructions, but shouldn't bypass proper protocol.

The client who has undergone a bilateral adrenalectomy is concerned about persistent body changes and unpredictable moods. What should the nurse teach the client about these changes?

The body and mood will gradually return to normal. As the body readjusts to normal cortisol levels, mood and physical changes will gradually return to a normal state. The body changes are not permanent, and the mood swings should level off.

A client with diabetic ketoacidosis (DKA) has asked the unlicensed nursing assistant for another pitcher of water. It is the third such request over the past 4 hours. The nurse would recognize this request as which manifestation?

an occurrence of the excess loss of fluid associated with osmotic diuresis Due to the DKA and fluid shift, the client would present with the 3 Ps: polyuria, polyphagia, and polydipsia. Fatigue and weakness may be caused by muscle wasting from the catabolic state of insulin deficiency. The other choices are part of the problem but not the main manifestation of the disease process.

A client undergoing a bilateral adrenalectomy has postoperative prescriptions for hydromorphone hydrochloride 2 mg to be administered subcutaneously every 4 hours as needed for pain. Why should the nurse administer hydromorphone in small doses? A small dose is:

as potent as morphine in larger doses. Hydromorphone hydrochloride is about five times more potent than morphine sulfate, from which it is prepared. Therefore, it is administered only in small doses. Hydromorphone hydrochloride can cause dependency in any dose; however, fear of dependency developing in the postoperative period is unwarranted. The dose is determined by the client's need for pain relief. Hydromorphone hydrochloride is not irritating to subcutaneous tissues. As with opioid analgesics, excretion depends on normal liver function.

After a 3-month trial of dietary therapy, a client with type 2 diabetes still has blood glucose levels above 180 mg/dl (9.99mmol/L). The physician adds glyburide, 2.5 mg P.O. daily, to the treatment regimen. The nurse should instruct the client to take the glyburide:

at breakfast. Like other oral antidiabetic agents ordered in a single daily dose, glyburide should be taken with breakfast. If the client takes glyburide later, such as in mid-morning, after dinner, or at bedtime, the drug won't provide adequate coverage for all meals consumed during the day.

An adult with type 2 diabetes mellitus has been NPO since 2200 in preparation for having a nephrectomy the next day. At 0600 on the day of surgery, the nurse reviews the client's medical record and laboratory results. Which finding should the nurse report to the health care provider (HCP)?

blood glucose of 140 mg/dL (7.8 mmol/L) The client's blood glucose level is elevated, beyond levels accepted for fasting; normal blood glucose range is 70 to 120 mg/dL (3.9 to 6.7 mmol/L). The specific gravity is within normal range (1.001 to 1.030). Urine output should be 30 to 50 mL/h; thus, 350 mL is a normal urinary output over 8 hours. The potassium level is normal.

Which assessment finding requires immediate action in a client diagnosed with Addison's disease?

blood pressure that has decreased from baseline A decreasing blood pressure may indicate that the client is experiencing an Addisonian crisis. Tachycardia and tachypnea are also manifestations of an Addisonian crisis. Fever can be an indication of Addisonian crisis, but the temperature has only increased one degree.

A client with Addison's disease has fluid and electrolyte loss due to inadequate fluid intake and to fluid loss secondary to inadequate adrenal hormone secretion. As the client's oral intake increases, which fluids would be most appropriate?

chicken broth and juice Electrolyte imbalances associated with Addison's disease include hypoglycemia, hyponatremia, and hyperkalemia. Regular salted (not low salt) chicken or beef broth and fruit juices provide glucose and sodium to replenish these deficits. Diet soda does not contain sugar. Water could cause further sodium dilution. Coffee's diuretic effect would aggravate the fluid deficit. Milk contains potassium and sodium.

A client with diabetes insipidus is receiving vasopressin. Which sign indicates that the drug is having the intended effect?

concentration of urine The major characteristic of diabetes insipidus is decreased tubular reabsorption of water due to insufficient amounts of antidiuretic hormone (ADH). Vasopressin is administered to the client with diabetes insipidus because it has pressor and ADH activities. Vasopressin works to increase the concentration of the urine by increasing tubular reabsorption, thus preserving up to 90% water. Vasopressin is administered to the client with diabetes insipidus because it is a synthetic ADH. The administration of vasopressin results in increased tubular reabsorption of water, and it is effective for emergency treatment or daily maintenance of mild diabetes insipidus. Vasopressin does not decrease blood pressure or affect insulin production or glucose metabolism, nor is insulin production a factor in diabetes insipidus.

A client is going to receive an insulin pump prior to discharge and the nurse has done extensive teaching. Which statement indicates that the client has a good understanding about the pump?

"I will need to monitor blood glucose levels multiple times a day while on the insulin pump." Based on the infusion of rapid-acting insulin, regular blood glucose monitoring is needed based on nutritional consumption and level of activity. Only rapid-acting insulin is used in pumps. Clients are taught to bolus based on nutrition and consumption of diet. The pump increases flexibility, not decreases.

During preoperative teaching for a client who will undergo subtotal thyroidectomy, the nurse should include which statement?

"You must avoid hyperextending your neck after surgery." To prevent undue pressure on the surgical incision after subtotal thyroidectomy, the nurse should advise the client to avoid hyperextending the neck. The client may elevate the head of the bed as desired and should perform deep breathing and coughing to help prevent pneumonia. Subtotal thyroidectomy doesn't affect swallowing.

The nurse should institute which measure to prevent transmission of the hepatitis C virus to health care personnel?

decreasing contact with blood and blood-contaminated fluids Hepatitis C is usually transmitted through blood exposure or needlesticks. A hepatitis C vaccine is currently under development, but it is not available for use. The first line of defense against hepatitis B is the hepatitis B vaccine. Hepatitis C is not transmitted through feces or urine. Wearing a gown and mask will not prevent transmission of the hepatitis C virus if the caregiver comes in contact with infected blood or needles.

The nurse should monitor the client with Cushing's disease for which finding?

hypokalemia Sodium retention is typically accompanied by potassium depletion. Hypertension, hypokalemia, edema, and heart failure may result from the hypersecretion of aldosterone. The client with Cushing's disease exhibits postprandial or persistent hyperglycemia. Clients with Cushing's disease have hypernatremia, not hyponatremia. Bone resorption of calcium increases the urine calcium level.

A client with type 1 diabetes takes 15 units of insulin isophane before breakfast and 8 units before dinner. During a follow-up visit, the nurse reevaluates the client's knowledge about insulin therapy and self-administration skills. The nurse realizes the client requires additional teaching when the nurse discovers the client takes which over-the-counter preparations?

salicylate-containing preparations The client requires additional teaching if they take salicylates with insulin. Salicylates may interact with insulin causing hypoglycemia. Antacids, vitamins with iron, and acetaminophen aren't known to interact with insulin.

A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which statement indicates that the client understands the condition and how to control it?

"I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual." Stating the need to remain hydrated and pay attention to eating, drinking, and voiding needs indicates that the client understands HHNS. Inadequate fluid intake during hyperglycemic episodes commonly leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. Drinking a glass of nondiet soda would be appropriate for hypoglycemia. Limiting fluids will exacerbate the development of HHNS; limiting food might be acceptable, but it may lead to ketosis. A high-carbohydrate diet would exacerbate the client's condition, particularly if fluid intake is low.

A client is diagnosed with Addison's disease. Which statement by the client to the nurse would require further instruction?

"I will use salt substitute to flavor my foods." The Addison's client will have high potassium, low sodium, and low calcium and exhibit hyperpigmentation due to the deficit of corticosteroids. Using a salt substitute requires further instruction, as salt substitutes contain potassium. The client with Addison's disease has high levels of potassium. Steroids tend to cause stomach distress, so it is appropriate to take with food to decrease these symptoms. Increasing calcium is encouraged, and sunscreen is appropriate due to the hyperpigmentation of the skin.

A nurse is caring for a client with poorly managed diabetes mellitus who has a serious foot ulcer. When the nurse informs the client that the physician has ordered a wound care nurse to examine the wound, the client asks why should anyone other than the staff nurse care for the wound. The client states, "It's no big deal. I'll keep it covered and put antibiotic ointment on it." Which responses made by the nurse would be appropriate? Select all that apply.

"The wound nurse is specially trained to care for diabetic wounds." "You could possibly lose your foot without proper care." "We're very concerned about your foot and we want to provide the best possible care for you." Since diabetics are at an increased risk for loss of lower extremities due to vascular problems, foot care specialists are warranted. Foot care nurses are specially trained to care for diabetic wounds.

The nurse has been assigned to a client who has had diabetes for 10 years. The nurse gives the client's usual dose of regular insulin at 7 a.m. At 10:30 a.m., the client has light-headedness and sweating. The nurse should contact the physician, report the situation, background, and assessment, and recommend intervention for:

Hypoglycemia. The peak action of regular insulin is approximately 2 to 3 hours after administration. The client is having typical hypoglycemic symptoms. Acidosis results from uncontrolled diabetes mellitus, with hyperpnea (Kussmaul respirations) as the outstanding symptom. The hallmark symptoms of hyperglycemia are increased thirst, fruity breath, and glycosuria. The signs and symptoms of diabetic ketoacidosis include Kussmaul respirations, fruity breath, tachycardia, abdominal pain, nausea, vomiting, headache, thirst, dry skin, and dehydration.

A client with hypothyroidism is afraid of needles and doesn't want to have their blood drawn. What should the nurse say to help alleviate the client's concerns?

I'll stay here with you while the technician draws your blood." The nurse should tell the client that they will stay with them as the blood is drawn. This response provides the client with the reassuring presence of the nurse and enhances the therapeutic alliance, possibly providing a greater opportunity to educate the client. Although telling the client that blood won't need to be drawn as often when thyroid levels are stable provides the client with a rationale for needing blood work, it's more appropriate for the nurse to stay with the client. Saying that the procedure will be over quickly or that the physician has ordered the blood draw ignores the client's stated fear.

The nurse is caring for a client following a motor vehicle incident with head trauma suspected of diabetes insipidus. Which nursing intervention is appropriate?

Measure and record urinary output. Diabetes insipidus is characterized by polyuria (up to 8 L/day), constant thirst, and an unusually high oral intake of fluids. Treatment with the appropriate drug should decrease both oral fluid intake and urine output. A urine output of 200 ml/hour indicates continuing polyuria. Blood sugar has nothing to do with diabetes insipidus.

The nurse is caring for a client with type 1 diabetes. The nurse finds the client unconscious and administers glucagon, 1 mg intramuscularly. What is the next action by the nurse when the client regains consciousness?

Offer orange juice and crackers. A client with type 1 diabetes who requires glucagon should be given a complex carbohydrate snack as soon as possible to restore the liver glycogen and prevent secondary hypoglycemia. Orange juice and crackers work well in treating hypoglycemia. Carbohydrates that contain fat, such as ice cream, are not recommended. The healthcare provider should be alerted to the hypoglycemic event, but not until the client's blood sugar has stabilized. To prevent further hypoglycemia, the nurse would not administer the ordered rapid-acting insulin until after the client's blood sugar has normalized and the client is able to eat a meal.

A nurse is assigned to a client who is using an insulin pump. The nurse has never cared for a client with an insulin pump and isn't sure what to do. What should the nurse do first?

Request information about nursing responsibilities in caring for a client with a pump. Taking the initiative to gain new information relevant to client care as well as expressing a desire to support the unit's needs is an appropriate and professional nursing response. Refusing the assignment is inappropriate because the nurse isn't taking any initiative to learn about the pump. Refusing to care for the client until the nurse receives training is inappropriate; the nurse should gather information and evaluate the client before refusing to provide care. Accepting the assignment doesn't address the issue of lack of knowledge and may put the nurse or the client in jeopardy.

A client is prescribed exenatide. What should the nurse instruct the client to do? Select all that apply.

Review the one-time set-up for each new pen. Inject in the thigh, abdomen, or upper arm. Administer the drug within 60 minutes before morning and evening meals. Client teaching includes reviewing proper use and storage of the exenatide dosage pen, particularly the one-time set-up for each new pen. The nurse should instruct the client to inject the drug in the thigh, abdomen, or upper arm. The drug should be administered within 60 minutes of the morning and evening meals; the client should not inject the drug after a meal. The nurse should review steps for managing hypoglycemia, especially if the client also takes a sulfonylurea or insulin. If a dose is missed, the client should resume treatment as prescribed, with the next scheduled dose.

A client visiting the clinic is scheduled for an outpatient thyroid scan in 2 weeks. Which instructions should the nurse include to ensure that this client is prepared for the test? Select all that apply.

Stop using iodized salt or iodized salt substitutes 1 week before the scan. Stop eating seafood 1 week before the scan. Do not take any prescribed thyroid medication on the day of the scan. A thyroid scan visualizes the distribution of radioactive dye in the thyroid gland. Interventions before the scan include stopping the ingestion of iodine, which is found in iodized salt, salt substitutes, and seafood. The client should also be instructed not to take thyroid medication because it may interfere with the scan. The client does not have to refrain from consuming food or fluids after midnight if the scan is done on an outpatient basis. The radioactive dye is administered intravenously. Routinely prescribed medications can be taken after the scan. Bed rest is maintained with a thyroid biopsy, not a scan.

A staff member says she is really busy and asks the charge nurse to double-check a dose of insulin which she has drawn up. The nurse holds up a bottle of Lente insulin, but the charge nurse notices a bottle of Lantus insulin on the medication cart. This nurse has made multiple medication errors and the charge nurse is concerned that she isn't safe. What should the charge nurse do?

Tell the nurse that she'd like to start at the beginning to be on the safe side. The charge nurse should observe the process from the beginning and determine whether the nurse is following the five rights of drug administration. Only then should she cosign that the dose is correct. Saying that she can't check the dose unless she sees the nurse draw it up, asking the nurse which bottle of insulin she used, and asking to see the original order provide too much opportunity for error.

The nurse is assigned to care for the following clients. Which client should the nurse see first?

a client diagnosed with hypothyroidism and a heart rate of 48 beats per minute A heart rate of 48 beats per minute may have significant implications for cardiac output and hemodynamic stability. Clients with Graves disease usually have a rapid heart rate, but 94 beats per minute is a normal finding. The diabetic client may need sliding-scale coverage, which is not urgent. Clients with Cushing disease frequently have dependent edema.

The nurse is caring for a client with a metabolic acidosis (pH 7.25). Which value is most useful to the nurse in determining whether the cause of the acidosis is due to acid gain or to bicarbonate loss?

anion gap Metabolic acidosis is a common clinical disturbance characterized by a low pH (increased H+concentration) and a low plasma bicarbonate concentration. It can be produced by a gain of hydrogen ion or a loss of bicarbonate. It can be divided clinically into two forms, according to the values of the serum anion gap: high anion gap acidosis and normal anion gap acidosis. A patient diagnosed with metabolic acidosis is determined to have normal anion gap metabolic acidosis if the anion gap is within this normal range. An anion gap greater than 16 mEq (16 mmol/L) (the normal value for an anion gap is 8-12 mEq/L (8-12 mmol/L) without potassium in the equation. If potassium is included in the equation, the normal value for the anion gap is 12-16 mEq/L (12-16 mmol/L) and suggests an excessive accumulation of unmeasured anions and would indicate high anion gap metabolic acidosis as the type. An anion gap occurs because not all electrolytes are measured. More anions are left unmeasured than cations. A low or negative anion gap may be attributed to hypoproteinemia. Disorders that cause a decreased or negative anion gap are less common compared to those related to an increased or high anion gap.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise?

cerebral edema Noncompliance with treatment for SIADH may lead to water intoxication from fluid retention caused by excessive antidiuretic hormone. This, in turn, limits water excretion and increases the risk for cerebral edema. Hypovolemic shock results from, severe deficient fluid volume; in contrast, SIADH causes excess fluid volume. The major electrolyte disturbance in SIADH is dilutional hyponatremia, not hyperkalemia. Because SIADH doesn't alter renal function, potassium excretion remains normal; therefore, severe hyperkalemia doesn't occur. Tetany results from hypocalcemia, an electrolyte disturbance not associated with SIADH.

A nurse is managing the care of a client 10 days after a liver transplant. What assessments may indicate organ rejection? Select all that apply.

fever tachycardia elevated liver enzymes Transplant rejection is a Type IV hypersensitivity cell-mediated immune response. Elevated temperature, tachycardia, and elevated liver enzymes are signs of liver transplant rejection. Because the rejected liver is not processing bilirubin, the urine will be tea colored and stool will be clay colored with rejection.

When teaching a client with Cushing's syndrome about dietary changes, the nurse should instruct the client to increase intake of

fresh fruits. Cushing's syndrome causes sodium retention, which increases urinary potassium loss. Therefore, the nurse should advise the client to increase intake of potassium-rich foods, such as fresh fruit. The client should restrict consumption of dairy products, processed meats, cereals, and grains because they contain significant amounts of sodium.

A client tells the nurse that they have been working hard for the past 3 months to control the client's type 2 diabetes with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check

glycosylated hemoglobin level. Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day life span of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months. Fasting blood glucose and urine glucose levels give information only about glucose levels at the point in time when they were obtained. Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks.

A client with a history of Addison's disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. The client's spounse reports that the client acted confused and was extremely weak upon waking that morning. The client's blood pressure is 90/58 mm Hg, pulse is 116 beats/minute, and temperature is 101° F (38.3° C). A diagnosis of acute adrenal insufficiency is made. What should the nurse expect to administer by I.V. infusion?

hydrocortisone Emergency treatment for acute adrenal insufficiency (addisonian crisis) is I.V. infusion of hydrocortisone and saline solution. The client is usually given a dose containing hydrocortisone 100 mg I.V. in normal saline every 6 hours until blood pressure returns to normal. Insulin isn't indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia. Potassium isn't indicated because these clients are usually hyperkalemic. The client needs normal — not hypotonic — saline solution.

The nurse is assessing a client with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). What findings does the nurse attribute to complications of this condition?

jugular vein distention and confusion SIADH results in antidiuretic hormone (ADH) overproduction, which leads to fluid retention and dilutional hyponatremia. Severe SIADH can cause such complications as vascular fluid overload, signaled by jugular vein distention. Hyponatremia results in osmotic fluid shifts in the brain that lead to neurological changes such as irritability and confusion. Tetany and laryngeal spasms are associated with hypocalcemia. Thirst is associated with hypernatremia. Weight gain would be expected with fluid retention. Cardiac arrhythmia would be seen with abnormal potassium levels. Polyuria would be associated with diabetes insipidus, a lack of ADH.

A client receiving thyroid replacement therapy develops influenza and forgets to take the prescribed thyroid replacement medicine. The nurse understands that skipping this medication puts the client at risk for developing what life-threatening complication?

myxedema coma Myxedema coma (severe hypothyroidism) is a life-threatening condition that may develop if thyroid replacement medication isn't taken. Although thyroid storm is life-threatening, it is caused by severe hyperthyroidism. Systolic hypertension is associated with thyroid storm. A cerebrovascular accident is not typically associated with hypothyroidism.

A nursing coordinator calls the intensive care unit (ICU) to inform the department that a client with a suspected pheochromocytoma will be admitted from the emergency department. The ICU nurse should prepare to administer which drug to the client?

nitroprusside Excess catecholamine release occurs with pheochromocytoma and causes hypertension. The nurse should prepare to administer nitroprusside to control the hypertension until the client undergoes adrenalectomy to remove the tumor. Dopamine is used to treat hypotension, which is not associated with pheochromocytoma. Pheochromocytoma does not affect blood glucose levels, so insulin is not indicated in this client unless there is an underlying diagnosis of diabetes mellitus. Lidocaine is sometimes used to treat ventricular arrhythmias, which are not associated with pheochromocytoma.

Which of the following arterial blood gas (ABG) results would the nurse anticipate for a client with a 3-day history of vomiting?

pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 The client's ABG would likely demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+. A common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis where only gastric fluid is lost. The other results do not represent metabolic alkalosis.

A client has had an adrenalectomy. What is the priority goal for this client in the first 24 hours after surgery?

preventing adrenal crisis The priority in the first 24 hours after adrenalectomy is to identify and prevent adrenal crisis. Monitoring of vital signs is the most important evaluation measure. Hypotension, tachycardia, orthostatic hypotension, and arrhythmias can be indicators of pending vascular collapse and hypovolemic shock that can occur with adrenal crisis. Beginning oral nutrition is important, but not necessarily in the first 24 hours after surgery, and it is not more important than preventing adrenal crisis. Promoting self-care activities is not as important as preventing adrenal crisis. Ambulating in the hallway is not a priority in the first 24 hours after adrenalectomy.

Which goal is the priority for a client in Addisonian crisis?

preventing irreversible shock Addison's disease is caused by a deficiency of adrenal corticosteroids and can result in severe hypotension and shock because of uncontrolled loss of sodium in the urine and impaired mineralocorticoid function. This results in loss of extracellular fluid and dangerously low blood volume. Glucocorticoids must be administered to reverse hypotension. Preventing infection is not an appropriate goal of care in this life-threatening situation. Relieving anxiety is appropriate when the client's condition is stabilized, but the calm, competent demeanor of the emergency department staff will be initially reassuring.

A client is admitted to an acute care facility with a tentative diagnosis of hypoparathyroidism. The nurse should monitor the client closely for the related problem of

profound neuromuscular irritability. Hypoparathyroidism may slow bone resorption, reduce the serum calcium level, and cause profound neuromuscular irritability (as evidenced by tetany). Hypoparathyroidism doesn't alter blood pressure or affect the thirst mechanism, which usually is triggered by fluid volume deficit. Gastritis doesn't cause or result from hypoparathyroidism.

A female client is being successfully treated for Cushing's syndrome. The nurse should expect a decline in

serum glucose level. Hyperglycemia, which develops from glucocorticoid excess, is a manifestation of Cushing's syndrome. With successful treatment of the disorder, serum glucose levels decline. Hirsutism, not hair loss, is common in Cushing's syndrome; therefore, with successful treatment, abnormal hair growth declines. Osteoporosis occurs in Cushing's syndrome; therefore, with successful treatment, bone mineralization increases. Amenorrhea develops in Cushing's syndrome. With successful treatment, the client experiences a return of menstrual flow, not a decline in it.

A client is admitted to the health care facility for evaluation for Addison's disease. Which laboratory test result best supports a diagnosis of Addison's disease?

serum potassium level of 5.8 mEq/L (5.8 mmol/L) Addison's disease decreases the production of aldosterone, cortisol, and androgen, causing urinary sodium and fluid losses, an increased serum potassium level, and hypoglycemia. Therefore, an elevated serum potassium level of 5.8 mEq/L best supports a diagnosis of Addison's disease. A BUN level of 12 mg/dl and a blood glucose level of 90 mg/dl are within normal limits. In a client with Addison's disease, the serum sodium level would be much lower than 134 mEq/L, a nearly normal level.

A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of

sodium and potassium abnormalities. In Addison's disease, a form of adrenocortical hypofunction, aldosterone secretion is reduced. Aldosterone promotes sodium conservation and potassium excretion. Therefore, aldosterone deficiency increases sodium excretion, predisposing the client to hyponatremia, and inhibits potassium excretion, predisposing the client to hyperkalemia. Because aldosterone doesn't regulate calcium, phosphorus, chloride, or magnesium, an aldosterone deficiency doesn't affect levels of these electrolytes directly.

Propylthiouracil (PTU) is prescribed for a client with Graves' disease. Which symptom should the nurse teach the client to report?

sore throat The most serious adverse effects of PTU are leukopenia and agranulocytosis, which usually occur within the first 3 months of treatment. The client should be taught to promptly report to the health care provider (HCP) signs and symptoms of infection, such as a sore throat and fever. Clients having a sore throat and fever should have an immediate white blood cell count and differential performed, and the drug must be withheld until the results are obtained. Painful menstruation, constipation, and increased urine output are not associated with PTU therapy.

A nurse is assigned to care for a postoperative client with diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about the effect on his marriage. In planning this client's care, the most appropriate intervention would be to

suggest referral to a sex counselor or other appropriate professional. The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client's care. The nurse doesn't normally provide sex counseling.

A client diagnosed with Cushing's syndrome is admitted to the hospital and scheduled for a dexamethasone suppression test. What should the nurse do during this test?

Administer 1 mg of dexamethasone orally at night and obtain serum cortisol levels the next morning. When Cushing's syndrome is suspected, a 24-hour urine collection for free cortisol is performed. Levels of 50 to 100 mcg/day (1,379 to 2,756 nmol/L) in adults indicate Cushing's syndrome. If these results are borderline a high-dose dexamethasone suppression test is done. The dexamethasone is given at 2300 to suppress secretion of the corticotrophin-releasing hormone. A plasma cortisol sample is drawn at 0800. Normal cortisol level less than 5 mcg/dL (140 nmol/L) indicates normal adrenal response.

A client with diabetes and peripheral neuropathy is being discharged from the hospital. What instruction should the nurse provide to decrease the risk for skin breakdown? Select all that apply.

Always wear socks, and preferably, shoes to protect the feet. Check the feet daily to look for any injuries to the feet. Use lotion on feet to keep skin from becoming dry and cracked. The client with peripheral neuropathy has a risk for skin breakdown due to decreased sensation in lower legs and, particularly, the feet. The client should wear socks and shoes, check the feet daily, and apply lotion to moisten the dry skin, but lotion should not be applied between the toes because lotion can cause skin maceration. The client should use a nail file instead of clippers to prevent injury and should not use a hot water bottle, as this can cause burns due to the client's decreased sensation.

A client with diabetes mellitus has a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane (NPH) insulin to be taken before breakfast. At about 4:30 p.m. (1630), the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?

The isophane (NPH) insulin is peaking. Headache, sweating, tremor, pallor, and nervousness typically result from hypoglycemia, an insulin reaction in which serum glucose level drops below 70 mg/dl (3.88 mmol/L). Isophane (NPH) insulin typically peaks at 4-12 hours after administration. However, hypoglycemia may occur 4 to 18 hours after administration of isophane (NPH) insulin suspension or insulin zinc suspension, both of which are intermediate-acting insulins. Although hypoglycemia may occur at any time, it usually precedes meals. Hyperglycemia, in which serum glucose level is above 180 mg/dl (10 mmol/L), causes such early manifestations as fatigue, malaise, and drowsiness. Intravenous insulin can cause an acute shift in potassium levels leading to hypokalemia, but these signs and symptoms would include muscle weakness and muscle cramps.

A client with hyperglycemia who weighs 210 lb (95 kg) tells the nurse that their spouse sleeps in another room because the client's snoring keeps the spouse awake. The nurse notices that the client has large hands and a hoarse voice. Which disorder would the nurse suspect as a possible cause of the client's hyperglycemia?

acromegaly Acromegaly, which is caused by a pituitary tumor that releases excessive growth hormone, is associated with hyperglycemia, hypertension, diaphoresis, peripheral neuropathy, and joint pain. Enlarged hands and feet are related to lateral bone growth, which is seen in adults with this disorder. The accompanying soft tissue swelling causes hoarseness and, commonly, sleep apnea. Type 1 diabetes is usually seen in children, and newly diagnosed persons are usually very ill and thin. Hypothyroidism and growth hormone deficiency aren't associated with hyperglycemia.

A nurse should expect a client with hypothyroidism to report

puffiness of the face and hands. Hypothyroidism (myxedema) causes facial puffiness, extremity edema, and weight gain. Signs and symptoms of hyperthyroidism (Graves' disease) include an increased appetite, weight loss, nervousness, tremors, and thyroid gland enlargement (goiter).

A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl (26.1 mmol/L). Which finding is most likely to accompany this blood glucose level?

rapid, thready pulse This client's abnormally high blood glucose level indicates hyperglycemia, which typically causes polyuria, polyphagia, and polydipsia. Because polyuria leads to fluid loss, the nurse should expect to assess signs of deficient fluid volume, such as a rapid, thready pulse; decreased blood pressure; and rapid respirations. Cool, moist skin and arm and leg trembling are associated with hypoglycemia. Rapid respirations — not slow, shallow ones — are associated with hyperglycemia.

The nurse is assigned to a client with pheochromocytoma. In providing nursing care for the client, which action should the nurse delegate to the unlicensed assistive personnel (UAP)?

Remind the client not to smoke, drink caffeinated beverages, or change positions suddenly. The UAP is able to gather information such as vital signs, client reports, and make environmental changes, and report these to the nurse. Assessing, teaching, and identifying stressful situations that may trigger a hypertensive crisis requires additional skill and education that is appropriate to the scope of practice of the RN.

The nurse is educating a client on diabetes management. The client is asking questions that cause the nurse to be concerned about the client's ability to retain the information. Which would be the best technique for the nurse to use to enhance the retention of information by the client?

Repeat important information during the presentation. Repetition is an effective means of reinforcing critical information and enhancing content retention. The other options will not increase the client's ability to retain information and may decrease the client's concentration and ability to retain critical information.

The nurse is caring for a client with possible Cushing's syndrome undergoing diagnostic testing. The health care provider orders lab work and a dexamethasone suppression test. Which parameter would the nurse assess on the dexamethasone suppression test?

cortisol levels before and after the system is challenged with a synthetic steroid The dexamethasone suppression test measures cortisol levels before and after the system is challenged with a synthetic steroid. The dexamethasone suppression test does not measure dexamethasone or body chemicals altered in depression. Dexamethasone is used to challenge the cortisol level.

When instructing a client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of

encouraging fluids. The nurse should encourage fluid intake to prevent renal calculi formation. Sodium should be encouraged to replace losses in urine. Restricting potassium isn't necessary in hyperparathyroidism.

The adrenal cortex is responsible for producing which substances?

glucocorticoids and androgens The adrenal glands have two divisions, the cortex and medulla. The cortex produces three types of hormones: glucocorticoids, mineralocorticoids, and androgens. The medulla produces catecholamines — epinephrine and norepinephrine.

The nurse is instructing a college student with Addison's disease how to adjust the dose of glucocorticoids. The nurse should explain that the client may need an increased dosage of glucocorticoids in which situation?

having wisdom teeth extracted Adrenal crisis can occur with physical stress, such as surgery, dental work, infection, flu, trauma, and pregnancy. In these situations, glucocorticoid and mineralocorticoid dosages are increased. Weight loss, not gain, occurs with adrenal insufficiency. Psychological stress has less effect on corticosteroid need than physical stress.

Which condition should a nurse expect to find in a client diagnosed with hyperparathyroidism?

hypercalcemia Hypercalcemia is the hallmark of excess parathyroid hormone levels. Serum phosphate will be low (hyperphosphatemia), and there will be increased urinary phosphate (hyperphosphaturia) because phosphate excretion is increased.

An elderly female client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse should suspect which disorder?

hyperparathyroidism Hyperparathyroidism is most common in older women and is characterized by bone pain and weakness from excess parathyroid hormone. Clients also exhibit hypercalciuria-causing polyuria. Although clients with diabetes mellitus and diabetes insipidus have polyuria, they don't have bone pain and increased sleeping. Hypoparathyroidism is characterized by urinary frequency rather than by polyuria.

The nurse should assess a client taking chlorpropamide for:

hypoglycemia. Chlorpropamide is an antidiabetic agent. Clients should be observed for signs and symptoms of hypoglycemia. Other common side effects include anorexia, nausea, vomiting, and heartburn.The drug does not cause dumping syndrome, oral candidiasis, or extrapyramidal symptoms.

A client has had an hypophysectomy. What signs of a potential complication should the nurse teach the client to report?

hypopituitarism Most clients who undergo adenoma removal experience a gradual return of normal pituitary secretion and do not experience complications. However, hypopituitarism can cause growth hormone, gonadotropin, thyroid-stimulating hormone, and adrenocorticotropic hormone deficits. The client should be taught to monitor for change in mental status, energy level, muscle strength, and cognitive function. In adults, changes in sexual function, impotence, or decreased libido should be reported. Acromegaly and Cushing's disease are conditions of hypersecretion. Diabetes mellitus is related to the function of the pancreas and is not directly related to the function of the pituitary.

A client newly diagnosed with primary Addison's disease asks the nurse about the cause of the disease. What should the nurse tell the client? "The disease is caused by:

idiopathic atrophy of the adrenal gland." Primary Addison's disease refers to a problem in the gland itself that results from idiopathic atrophy of the glands. The process is believed to be autoimmune in nature. The most common causes of primary adrenocortical insufficiency are autoimmune destruction (70%) and tuberculosis (20%). Insufficient secretion of GH causes dwarfism or growth delay. Hyposecretion of glucocorticoids, aldosterone, and androgens occur with Addison's disease. Pituitary dysfunction can cause Addison's disease, but this is not a primary disease process. Oversecretion of the adrenal medulla causes pheochromocytoma.

For a client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?

increased urine osmolarity In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the urine) increases as glucose particles move into the urine. The client experiences glucosuria and polyuria, losing body fluids and experiencing deficient fluid volume. Cool, clammy skin; jugular vein distention; and a decreased serum sodium level are signs of fluid volume excess, the opposite imbalance.

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?

lactated Ringer's solution Lactated Ringer's solution, with an osmolality of approximately 273 mOsm/L, is isotonic. The nurse shouldn't give half-normal saline solution because it's hypotonic, with an osmolality of 154 mOsm/L. Giving 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) also would be incorrect because these solutions are hypertonic.

A client has been diagnosed with Addison's disease. The nurse should plan with the client to manage which effect of the disease?

lethargy. Although many of the disease signs and symptoms are vague and nonspecific, most clients experience lethargy and depression as early symptoms. Other early signs and symptoms include mood changes, emotional lability, irritability, weight loss, muscle weakness, fatigue, nausea, and vomiting. Most clients experience a loss of appetite. Muscles become weak, not spastic, because of adrenocortical insufficiency.

During surgery, a patient develops hypothermia. The circulating nurse would monitor the patient closely for which finding?

metabolic acidosis When a patient's temperature falls, glucose metabolism is reduced. As a result, metabolic acidosis may develop. Rebound hyperthermia, anaphylaxis, and alkalosis are not associated with hypothermia during surgery.

A client has been diagnosed with hyperthyroidism and presents with heat intolerance and a blood pressure of 174/70 mm Hg; she is 3 months pregnant. The nurse anticipates that the physician will order which medication?

methimazole Methimazole is the drug of choice for this client. Radioactive iodine is usually used for hyperthyroidism but is contraindicated in pregnancy. Levothyroxine sodium is for hypothyroidism. Lisinopril is an ACE inhibitor (ACEI) — all ACEIs are contraindicated in pregnancy.

Which goal is a priority for the diabetic client who is taking insulin and has nausea and vomiting from a viral illness or influenza?

obtaining adequate food intake The priority goal for the client with diabetes mellitus who is experiencing vomiting with influenza is to obtain adequate nutrition. The diabetic client should eat small, frequent meals of 50 g of carbohydrate or food equal to 200 cal every 3 to 4 hours. If the client cannot eat the carbohydrates or take fluids, the health care provider (HCP) should be called, or the client should go to the emergency department. The diabetic client is in danger of complications with dehydration, electrolyte imbalance, and ketoacidosis. Increasing the client's health management skills is important to lifestyle behaviors, but it is not a priority during this acute illness of influenza. Pain relief may be a need for this client, but it is not the priority at this time; neither is increasing activity during the illness.

A client concerned about being diagnosed with type 2 diabetes tells a nurse, "My parent suffered with diabetes for many years and finally died of kidney failure in spite of treatment. Why should I try if I'm going to go through the same thing?" What is the nurse's most appropriate response?

"Are you worried that you'll have the same experience as your parent?" Asking if the client feels they will have the same experience as their parent gives the client an opportunity to vent underlying anxiety. There's nothing to indicate that the client's parent's diabetes wasn't under good control or that the parent had substandard care. Saying there's no guarantee about how diabetes will progress doesn't appropriately address the client's concerns and may increase their anxiety. After the nurse has addressed the client's anxiety, the nurse can more easily address more-specific teaching needs.

When referred to a podiatrist, a client newly diagnosed with diabetes mellitus asks, "Why do you need to check my feet when I'm having a problem with my blood sugar?" The nurse's most helpful response to this statement is

"Diabetes can affect sensation in your feet and you can hurt yourself without realizing it." The nurse should make the client aware that diabetes affects sensation in the feet and that they might hurt their foot but not feel the wound. Although it's important that the client's shoes fit properly, this isn't the only reason the client's feet need to be checked. Telling the client that diabetes mellitus increases the risk of infection or stating that the circulation in the client's feet indicates the severity of their diabetes doesn't provide the client with complete information.

A client has an adrenal tumor and is scheduled for a bilateral adrenalectomy. During preoperative teaching, the nurse teaches the client how to do deep-breathing exercises after surgery. What should the nurse tell the client to do?

"Hold your abdomen firmly with a pillow, and take several deep breaths." Effective splinting for a high incision reduces stress on the incision line, decreases pain, and increases the client's ability to deep-breathe effectively. Deep breathing should be done hourly by the client after surgery. Sitting upright ignores the need to splint the incision to prevent pain. Tightening the stomach muscles is not an effective strategy for promoting deep breathing. Raising the shoulders is not a feature of deep-breathing exercises.

A client has been diagnosed with hypothyroidism. Which statement by the client would demonstrate appropriate teaching by the nurse?

"I will increase fiber and fluids in my diet." Clients with hypothyroidism typically have constipation. A diet high in fiber and fluids can help prevent this. Group activities have nothing to do with the current issue. A nurse would not change medical prescriptions by telling the client to stop taking the prescribed aspirin. Increasing caloric consumption is not appropriate with hypothyroidism.

The nurse teaches a client with diabetes mellitus about proper foot care. Which statement indicates the client understands the teaching?

"I'll wear cotton socks with well-fitting shoes." The client demonstrates an understanding of proper foot care when stating they'll wear cotton socks with well-fitting shoes; cotton socks wick moisture away from the skin, helping to prevent fungal infections, and well-fitting shoes help avoid pressure areas. Aching isn't a common sign of foot problems; however, a tingling sensation in the feet indicates neurovascular changes. Clients with diabetes should not soak feet unless specifically directed by a healthcare provider as softening the skin may make it more prone to injury. Although lotions are acceptable, the client should not apply it between the toes, as this could promote a fungal infection.

An obese client, age 65, is diagnosed with type 2 diabetes. When educating this client about the diagnosis, the nurse knows that more education is needed when the client says which statement? Select all that apply.

"If I follow my diet and exercise, I won't have diabetes any more." "I can never eat a hot fudge sundae again." "I guess I will need to stop meeting my friends at the coffee shop." Patients with type 2 diabetes who follow a diet and exercise program will likely be able to achieve normal blood sugar levels, but cannot consider themselves "cured" of diabetes. Renal failure is a possible complication of uncontrolled diabetes. People with well controlled diabetes can modify their diet to include occasional treats like ice cream if they select sugar free versions. Meeting friends for coffee is fine as long as the client does not include high sugar items along with the beverage. Type 2 diabetes can often be controlled with oral hypoglycemics.

A client newly diagnosed with hypothyroidism asks the nurse how long it will be necessary to take the prescribed synthroid. What should the nurse tell the client?

"It will be necessary to take the medication for the rest of your life." Thyroid replacement is a lifelong maintenance therapy. The medication is usually given as one dose in the morning. It cannot be tapered or discontinued because the client needs thyroid supplementation to maintain health. The medication cannot be discontinued after the TSH level is normal; the dose will be maintained at the level that normalizes the TSH concentration.

A client with diabetes is explaining to the nurse how to care for the feet at home. Which statement indicates that the client understands proper foot care?

"It's important to dry my feet carefully after my bath." It is important to dry the feet carefully after a bath to prevent a fungal infection. Clients with diabetes should seek medical attention when they injure their toes or feet to prevent complications. Iodine is highly toxic to the tissues. Clients with diabetes should inspect their feet daily and should wear shoes that support their feet while in the house.

A 24-year-old client with diabetes mellitus sustains a large laceration that requires suturing. Which statement indicates that the client understands wound healing?

"It's so hard to predict when this scar will disappear." In a client with diabetes, wound healing is delayed and unable to be predicted. A specific time frame for healing is unrealistic as is the statement that suturing does not produce a scar.

The client who has been hospitalized with pancreatitis does not drink alcohol because of religious convictions. The client becomes upset when the health care provider (HCP) persists in asking about alcohol intake. What should the nurse tell the client about the reason for these questions?

"There is a strong link between alcohol use and acute pancreatitis." Alcoholism is a major cause of acute pancreatitis in the United States and Canada. Because some clients are reluctant to discuss alcohol use, staff may inquire about it in several ways. Generally, alcohol intake does not interfere with the tests used to diagnose pancreatitis. Recent ingestion of large amounts of alcohol, however, may cause an increased serum amylase level. Large amounts of ethyl and methyl alcohol may produce an elevated urinary amylase concentration. All clients are asked about alcohol and drug use on hospital admission, but this information is especially pertinent for clients with pancreatitis. HCPs do need to seek facts, but this can be done while respecting the client's religious beliefs. Respecting religious beliefs is important in providing holistic client care.

A client diagnosed with thyroid cancer signed a living will that states the client doesn't want ventilatory support if the condition deteriorates. As the client's condition worsens, the client states, "I changed my mind. I want everything done for me." Which response by the nurse is best?

"What exactly do you mean by wanting 'everything' done for you?" Asking the client what they mean is the best response. The nurse should clarify the client's request and get as much information as possible before notifying the physician of the client's wishes. Asking the physician to revoke the client's do-not-resuscitate (DNR) order makes an assumption about the client's wishes without obtaining clarification of their statement. The client might want aggressive treatment without reversing the DNR order. Asking the client if they understand that they'll be placed on a ventilator places the client on the defensive. Telling the client to talk with family is an inappropriate response; the client has the right to change their treatment plan without input from their family.

A physician orders blood glucose levels every 4 hours for a 4-year-old child with brittle type 1 diabetes. The parents are worried that drawing so much blood will traumatize their child. How can the nurse best reassure the parents?

"Your child will need less blood work as their glucose levels stabilize." Telling the parents that the number of blood draws will decrease as their child's glucose levels stabilize engages them in the learning process and gives them hope that the present discomfort will end as the child's condition improves. Telling the parents that their child won't remember the experience disregards their concerns and anxiety. The nurse shouldn't offer to ask the physician to reduce the number of blood draws; the physician needs the laboratory results to monitor the child's condition properly. Although telling the parents that the laboratory technicians are gentle and use tiny needles may be reassuring, it isn't the most appropriate response.

A client with type 1 diabetes presents with a decreased level of consciousness and a fingerstick glucose level of 39 mg/dl (2.2 mmol/L). A family member reports the client has been skipping meals in an effort to lose weight. What is the next action by the nurse?

Administer 1 ampule of 50% dextrose solution IV. The client with a decreased level of consciousness and a fingerstick glucose result of 39 mg/dL is experiencing dangerous hypoglycemia. The nurse would first administer 50% dextrose solution IV to restore the client's physiological integrity. Because of the decreased level of consciousness, offering the client orange juice and crackers would put the client at risk for aspiration. Referring the client to a diabetes educator is important to address the methods of weight loss, but this would be appropriate after the hypoglycemia is treated. The nurse would treat the dangerous hypoglycemia with the ordered dextrose solution before contacting a healthcare provider to prevent further complications of hypoglycemia.

A nurse has been caring for a client newly diagnosed with diabetes mellitus. The client is overwhelmed by the diagnosis and not sure about injecting insulin. This client has been discharged and the charge nurse is insisting the nurse hurry because the space is needed for clients being admitted. How should the nurse handle the situation? Select all that apply.

Ask the physician to delay the discharge because the client requires further teaching Ask the physician for a referral for a diabetes nurse-educator to see the client before discharge. The nurse's primary concern should be the safety of the client after discharge. The nurse should provide succinct information to the physician concerning the client's needs; express concern about ensuring the client's safety; and ask the physician to delay the client's discharge, and to provide a referral for the diabetes nurse educator. The nurse should not suggest that the client rely on a friend or family member because the nurse doesn't know if a friend or family member will be available to help. Telling the charge nurse to do the education is not appropriate because the charge nurse has too many other obligations to be able to effectively offer the client thorough education. Offering the unit phone number is not a good option because the client shouldn't be discharged until the client can safely carry out aftercare.

On the day of surgery, a client with diabetes who takes insulin on a sliding scale is to have nothing by mouth and all medications withheld. The client's 0600 glucose level is 300 mg/dL (16.7 mmol/L). What should the nurse do?

Call the health care provider (HCP) for specific prescriptions based on the glucose level. The nurse should notify the HCP directly for specific prescriptions based on the client's glucose level. The nurse cannot ignore the elevated glucose level. The surgical experience is stressful, and the client needs specific insulin coverage during the perioperative period. The nurse should not administer the insulin without checking with the surgeon because there are specific prescriptions to withhold all medications. It is not necessary to notify the surgery department unless the HCP cancels the surgery.

A client with type 2 diabetes has just started to take dulaglutide. The client reports having severe nausea. What should the nurse instruct the client to do to manage the nausea? Select all that apply.

Eat small meals more frequently. Drink ginger tea. Avoid fried foods. Nausea is a common side effect when clients first start taking dulaglutide. To manage the nausea the nurse can suggest that the client eat smaller meals more frequently, drink beverages with ginger in them, and avoid fried foods. The client should decrease the fat content in the diet. The client should not stop using the drug unless prescribed by the health care provider.

A nurse is preparing to palpate a client's thyroid gland. Which action by the nurse is appropriate?

Encircle the client's neck with both hands, have the client slightly extend their neck, and ask them to swallow. When palpating the thyroid gland, the nurse should encircle the client's neck with both hands, have the client slightly extend their neck, and ask them to swallow. As the client swallows, the gland is palpated for enlargement as the tissue rises and falls. Having the client flex their neck wouldn't allow for palpation. Massaging the area or checking during inhalation doesn't allow for the movement of tissue that swallowing provides.

Which instruction should be included in the discharge teaching plan for a client after thyroidectomy for Graves' disease?

Have regular follow-up care. The nurse should instruct the client with Graves' disease to have regular follow-up care because most cases of Graves' disease eventually result in hypothyroidism. Annual thyroid-stimulating hormone tests and the client's ability to recognize signs and symptoms of thyroid dysfunction will help detect thyroid abnormalities early. Recording intake and output is important for clients with fluid and electrolyte imbalances but not thyroid disorders. DDAVP is used to treat diabetes insipidus. Although exercise to improve cardiovascular fitness is important, the importance of regular follow-up is most critical for this client.

The nurse is preparing a client for paracentesis. What should the nurse do?

Have the client void before the procedure. Before paracentesis, the client is asked to void. This is done to collapse the bladder and decrease the risk of accidental bladder perforation. The abdomen is not prepared with an antiseptic cleansing solution. The client is placed in a Fowler's position. The client does not need to be put on NPO status before the procedure.

A client with a history of Addison's disease is experiencing weakness and headache. The vital signs are blood pressure of 100/60 and heart rate of 80. Laboratory values are Na 130, potassium 4.8, and blood glucose 70. Which solution would the nurse expect to administer?

I.V. normal saline and glucocorticoids The client with Addison's is expected to have hypotension and inadequate corticosteroids. There is no evidence that the client would be anemic. Although the blood pressure may be a little below normal, there is no indication for an inotropic drug such as dopamine to increase perfusion. There is no indication that the client would be weak and hypoglcemic.

Which nursing diagnosis takes highest priority for a client with hyperthyroidism?

Imbalanced nutrition: Less than body requirements related to thyroid hormone excess In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism. These conditions may result in a negative nitrogen balance, increased protein synthesis and breakdown, decreased glucose tolerance, and fat mobilization and depletion. These changes put the client at risk for marked nutrient and calorie deficiency, making Imbalanced nutrition: Less than body requirements related to thyroid hormone excess the most important nursing diagnosis. Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing and Disturbed body image related to weight gain and edema may be appropriate for a client with hypothyroidism, which slows the metabolic rate.

The nurse is developing a teaching plan for the client with hepatitis A. What should the nurse tell the client to do?

Increase carbohydrates and protein in the diet. A low-fat, high-protein, high-carbohydrate diet is encouraged for a client with hepatitis to promote liver rejuvenation. Nutrition intake is important because clients may be anorexic and experience weight loss. Activity should be modified and adequate rest obtained to promote recovery. Social isolation should be avoided, and education on preventing transmission should be provided; the client does not need to sleep in a separate room.

A nurse is caring for a client with a low calcium level. Place the following options in chronological order to indicate the regulatory feedback mechanism of parathyroid hormone (PTH) release in relation to calcium levels. All options must be used.

Low serum calcium level stimulates parathyroid gland. Parathyroid gland releases PTH. Calcium is reabsorbed. High serum calcium level inhibits PTH secretion. Simple feedback occurs when the level of one substance regulates the secretion of hormones. A low calcium level stimulates the parathyroid gland to release PTH, which promotes resorption of calcium, resulting in normalized calcium levels. When calcium levels are elevated, PTH secretion is inhibited.

A client with type I diabetes mellitus is scheduled to have surgery. The client has been nothing-by-mouth (NPO) since midnight. In the morning, the nurse notices the client's daily insulin has not been prescribed. Which action should the nurse do first?

Obtain the client's blood glucose at the bedside. The nurse should first obtain the blood glucose level and then contact the health care provider to clarify whether the client's usual insulin dose should be given before surgery; having the blood glucose level is objective information that the health care provider may need to know before making a final decision as to the insulin dosage. The nurse should not assume that the usual insulin dose is to be given. It is not appropriate for the nurse to defer decision-making on this issue until after the surgery.

The nurse administers lactulose to a client with cirrhosis. What is the expected outcome from the administration of the lactulose?

Reduced serum ammonia levels. Lactulose is used to treat hepatic encephalopathy by reducing serum ammonia levels. It is not used to stimulate bowel peristalsis, even though diarrhea can be a side effect of the drug. Lactulose does not have any effect on edema, ascites, or hemorrhage.

Which assessment in a client that has just returned from having a modified radical neck dissection with skin flap would require a nurse to take immediate action?

The skin flap appears white. A white skin flap indicates lack of perfusion and the healthcare provider should be notified immediately. Hoarseness may be due to trauma from the endotracheal tube that is inserted during surgery. Sutures may be visible after this surgery. An absence of bowel sounds is a normal finding immediately post surgery with general anesthesia.

A nurse is caring for a client with diabetes insipidus. The nurse should anticipate administering

vasopressin. Vasopressin is given subcutaneously to manage diabetes insipidus. Insulin is used to manage diabetes mellitus. Furosemide causes diuresis. Potassium chloride is given for hypokalemia.

The nurse is receiving results of a blood glucose level from the laboratory over the telephone. What should the nurse do?

Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller. To assure client safety, the nurse first writes the results on the chart, then reads them back to the caller and waits for the caller to confirm that the nurse has understood the results. The nurse may receive results by telephone; and although electronic transfer to the client's medical record is appropriate, the nurse can also accept the telephone results if the laboratory has called the results to the nurses station.

An elderly client who is receiving steroids has secondary diabetes and chronic kidney disease (CKD) and takes insulin. The client has had episodes of hypoglycemia. The nurse should:

continue to monitor the client's blood glucose values. The nurse should continue to monitor glucose in the blood to prevent the client from continuing to experience hypoglycemia. One of the risk factors for hypoglycemia is decreased insulin clearance as with impaired kidney function and/or renal failure. Another risk factor for hypoglycemia is increased glucose utilization when there is too much activity or exercise without enough food.Protein is digested slower than carbohydrate, but with chronic kidney disease (CKD) it is more difficult for the kidneys to rid the body of metabolic waste products.

When reviewing the urinalysis report of a client with newly diagnosed diabetes mellitus, the nurse would expect which urine characteristics to be abnormal? Select all that apply.

amount odor glucose level ketone bodies Diabetes mellitus is associated with increased amounts of urine, a sweet or fruity odor, and glucose and ketone bodies in the urine. It does not affect the urine's pH or specific gravity.

The nursing is caring for a newly admitted client with diabetes insipidus. When forming the plan of care, which nursing diagnoses are anticipated? Select all that apply.

anxiety activity intolerance Diabetes insipidus is characterized by excessive output of dilute urine. Common signs and symptoms include massive diuresis, dehydration, and thirst. Additional findings include malaise, lethargy, and irritability. Nursing diagnoses that aim at providing interventions to decrease the symptoms include Anxiety (irritability) and activity intolerance (due to lethargy). The client has a fluid volume deficit due to the excessive output of urine. Though the client urinates frequently, there is no reason to believe that there is an impaired physical mobility or self-care deficit. A client has symptoms of hyperglycemia with diabetes mellitus.

During the first 24 hours after a client is diagnosed with addisonian crisis, which intervention should the nurse perform frequently?

assess vital signs. Because the client in addisonian crisis is unstable, vital signs and fluid and electrolyte balance should be assessed every 30 minutes until the client is stable. Daily weights are sufficient when assessing the client's condition. The client shouldn't have ketones in their urine, so there is no need to assess the urine for their presence. Oral hydrocortisone isn't administered during the first 24 hours in severe adrenal insufficiency.

Which medication should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy?

calcium gluconate The client with tetany is suffering from hypocalcemia, which is treated by administering an IV preparation of calcium, such as calcium gluconate or calcium chloride. Oral calcium is then necessary until normal parathyroid function returns. Sodium phosphate is a laxative. Echothiophate iodide is an eye preparation used as a miotic for an antiglaucoma effect. Sodium bicarbonate is a potent systemic antacid.

A nurse should expect to administer which medication to a client with gout?

colchicine A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The physician orders colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin reduces joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no effect on urate crystal formation. Furosemide, a diuretic, doesn't relieve gout. Calcium gluconate reverses a negative calcium balance and relieves muscle cramps; it doesn't treat gout.

During shift report, the nurse learns the following laboratory values: pH, 7.44; PCO2, 30mmHg; and HCO3,21 mEq/L for a client with noted acid-base disturbances. Which acid-base imbalance is the client most likely experiencing?

compensated respiratory alkalosis The question states that the client has a history of acid-base disturbance. The nurse would first note that the pH has returned to close to normal indicating compensation. The nurse then assess the PCO2 (normal: 35 to 45 mm Hg) and HCO3 (normal: 22 to 27mEq/L) levels. In a respiratory condition, the pH and the PCO2 move in opposite direction; thus, the pH rises and the PCO2 drops (alkalosis) or vice versa (acidosis). In a metabolic condition, the pH and the bicarbonate move in the same direction; if the pH is low, the bicarbonate level will be low, also. In this client, the pH is at the high end of normal, indicating compensation and alkalosis. The PCO2 is low, indicating a respiratory condition (opposite direction of the pH).

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?

confusion and seizures Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.

Several hours into a shift, a nurse on a very busy medical-surgical unit privately asks the charge nurse to change the nurse's assignment. The nurse is frustrated because so much time and energy has had to be devoted to helping a newly licensed nurse provide discharge teaching for clients with diabetes mellitus. The charge nurse should

offer to assist with the discharge teaching needs. Staff members need to know the charge nurse is a supportive leader who respects their honesty and stands behind them. By offering to help with discharge teaching, the charge nurse is actively engaging with the staff at a time of need. Changing all the assignments on this extremely busy floor would be counterproductive. Insisting that the staff member follow through with their assignment disrespects the nurse's request and genuine need. Providing a float nurse could help, but there are no guarantees a float nurse is available.

When evaluating a client's arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?

pH 7.48 Metabolic alkalosis is a clinical disturbance characterized by a high pH and high plasma bicarbonate concentration. The HCO3 value is below normal. The PaCO2 value and the oxygen saturation level are within a normal range.

When obtaining the nursing history of a client who has diabetes mellitus, the nurse should assess the client for which of the following early symptom of renal insufficiency?

polyuria In early renal insufficiency, the kidneys lose the ability to concentrate urine, resulting in polyuria. Oliguria occurs later. Dysuria and hematuria are not associated with renal insufficiency.

A client is to use an insulin pen. Which action indicates the client is using the pen correctly? Select all that apply.

primes the pen by expelling any air injects the insulin in sites around the abdomen stores the unopened pens in the refrigerator Insulin pens should be stored in the refrigerator before use; once opened they can be stored at a cool room temperature. The pen needs to be primed by expelling air before injecting the insulin. After the injection, the site can be patted, but not massaged. Needles cannot be reused; the client should remove the needle and place in a hard plastic container for disposal.

A client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which "related-to" phrase should the nurse add?

related to bone demineralization resulting in pathologic fractures Poorly controlled hyperparathyroidism may cause an elevated serum calcium level. This increase, in turn, may diminish calcium stores in the bone, causing bone demineralization and setting the stage for pathologic fractures and a risk for injury. Hyperparathyroidism doesn't accelerate the metabolic rate. A decreased thyroid hormone level, not an increased parathyroid hormone level, may cause edema and dry skin secondary to fluid infiltration into the interstitial spaces. Hyperparathyroidism causes hypercalcemia, not hypocalcemia; therefore, it isn't associated with tetany.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH?

restricting fluids to 800 ml/day Excessive release of antidiuretic hormone (ADH) disturbs fluid and electrolyte balance in SIADH. The excessive ADH causes an inability to excrete dilute urine, retention of free water, expansion of extracellular fluid volume, and hyponatremia. Symptomatic treatment begins with restricting fluids to 800 ml/day. Vasopressin is administered to clients with diabetes insipidus a condition in which circulating ADH is deficient. Elevating the head of the bed decreases vascular return and decreases atrial-filling pressure, which increases ADH secretion, thus worsening the client's condition. The client's sodium is low and, therefore, shouldn't be restricted.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?

serum sodium level of 124 mEq/L In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.

When teaching a client when to take glipizide in order to maximize the effectiveness of the drug, the nurse should instruct the client to:

take glipizide 30 minutes before breakfast. Glipizide is most effective when taken 30 minutes before breakfast. The duration of action is 10 to 24 hours.If the drug needs to be taken more than once a day, the dosage may be divided and taken twice a day before meals.It is not as effective to take the drug after meals.Although blood glucose levels will be monitored, the values do not dictate when the drug should be taken.

A nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication?

tetany Tetany may result if the parathyroid glands are excised or damaged during thyroid surgery. Hemorrhage is a potential complication after thyroid surgery but is characterized by tachycardia, hypotension, frequent swallowing, feelings of fullness at the incision site, choking, and bleeding. Thyroid storm is another term for severe hyperthyroidism — not a complication of thyroidectomy. Laryngeal nerve damage may occur postoperatively, but its signs include a hoarse voice and, possibly, acute airway obstruction.

Which findings should a nurse expect to assess in client with Hashimoto's thyroiditis?

weight gain, decreased appetite, and constipation Hashimoto's thyroiditis, an autoimmune disorder, is the most common cause of hypothyroidism. It's seen most frequently in women older than age 40. Signs and symptoms include weight gain, decreased appetite; constipation; lethargy; dry cool skin; brittle nails; coarse hair; muscle cramps; weakness; and sleep apnea. Weight loss, increased appetite, and hyperdefecation are characteristic of hyperthyroidism. Weight loss, increased urination, and increased thirst are characteristic of uncontrolled diabetes mellitus. Weight gain, increased urination, and purplish-red striae are characteristic of hypercortisolism.

Pancreatic enzyme replacements are prescribed for the client with chronic pancreatitis. When should the nurse instruct the client to take them to obtain the most therapeutic effect?

with each meal and snack In chronic pancreatitis, destruction of pancreatic tissue requires pancreatic enzyme replacement. Pancreatic enzymes are prescribed to facilitate the digestion of proteins and fats and should be taken in conjunction with every meal and snack. Specified hours or limited times for administration are ineffective because the enzymes must be taken in conjunction with food ingestion.