CHAPTER 11- Endocrine System

Question 1

The nurse practitioner is reviewing the laboratory values of a 28-year-old male patient who presents to the office to establish care with a primary care provider. The lab results from the previous week indicate an A1C of 7.2. The nurse practitioner obtains a fasting blood sugar in the office of 142. The patient denies any significant past medical history and states that he “feels fine.” The nurse practitioner recognizes that:

1. The patient has developed type 1 diabetes.
2. The patient has developed type 2 diabetes.
3. The patient has diabetes and further testing is required.
4. The patient has pre-diabetes.

Answer 1

3. The patient has diabetes and further testing is required.

The patient meets the criteria to be diagnosed with diabetes. The clinician would be unable to determine what type of diabetes the patient has without further testing.

Question 2

The nurse practitioner has been working with a 40-year-old diabetic, single mother of two teenage children. The patient has an A1C of 8.0%. The patient and provider agree upon a plan that is designed to achieve glycemic control and set a target date of 6 months. When the patient returns six months later, her A1C is 7.8%. The NP would then:

1. Encourage the patient to take a greater responsibility for her health, reinforcing the concept that she is a role model for her children.
2. Reassess the plan and consider barriers such as income, health literacy, and family dynamics.
3. Encourage the patient to design a plan that will meet the needs of both herself and her family.
4. Explain to the patient that as long as there was improvement in her A1C, the plan is a success.

Answer 2

2. Reassess the plan and consider barriers such as income, health literacy, and family dynamics.

The clinician needs to reassess the plan and work with the patient to identify barriers that are preventing the patient from achieving the goal.

Question 3

The nurse practitioner is reviewing the laboratory values of a patient during a follow-up office visit. The NP observes the following results in the chart: September: A1C = 6.6 Fasting glucose = 118; December: A1C = 6.8 Fasting glucose = 122. The nurse practitioner is correct in noting:

1. The patient does not meet the criteria to establish a diagnosis of diabetes mellitus.
2. The patient partially meets the criteria to establish a diagnosis of diabetes mellitus, but further confirmatory testing is required.
3. The patient has diabetes mellitus.
4. The A1C and fasting tests should be repeated in 3 months to confirm a diagnosis of diabetes mellitus.

Answer 3

3. The patient has diabetes mellitus.

The patient has diabetes mellitus and meets the criteria to establish diagnosis with an A1C3 6.5% and confirmatory testing.

Question 4

The American Diabetes Association (ADA) recommends the use of laboratory testing to screen for pre-diabetes in asymptomatic people. The recommendation is to perform this screening on:

1. All children who are overweight or obese.
2. All adults with a BMI > 25 with one or more risk factors for diabetes mellitus.
3. All adults and children as part of their complete routine physical exams.
4. All children who were born to mothers that have had gestational diabetes.

Answer 4

2. All adults with a BMI > 25 with one or more risk factors for diabetes mellitus.

The ADA recommends screening for pre-diabetes and diabetes in all adults with a BMI > than 25 and at least one other risk factor.

Question 5

Impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) are both markers for pre-diabetes. Both IFG and IGT are closely associated with:

1. Autoimmune disorders such as hypothyroidism, rheumatoid arthritis, and Sjögren’s syndrome.
2. Elevations in liver enzymes and inflammatory markers such as C-reactive protein.
3. Obesity, coronary artery disease, and peripheral vascular disease.
4. Central obesity, high triglycerides, low HDLs, and hypertension.

Answer 5

4. Central obesity, high triglycerides, low HDLs, and hypertension.

Central obesity, high triglycerides, and low HDLs are consistent with metabolic syndrome and are closely associated with pre-diabetes and diabetes.

Question 6

Which of the following laboratory results would be a strong indicator that the patient has pre-diabetes?

1. An A1C between 5.5 and 5.7
2. A 2-hour post-prandial glucose between 110 and 140, after a 75 gm oral glucose tolerance test.
3. A fasting glucose between 100 and 125 after an 8-hour fasting interval.
4. AnA1C of greater than or equal to 6.5%.

Answer 6

3. A fasting glucose between 100 and 125 after an 8-hour fasting interval.

An individual may be diagnosed with pre-diabetes if the fasting glucose (8-hour fast) is 100–125. If the fasting glucose is > 125 on two or more occasions, the patient would be diagnosed with diabetes mellitus.

Question 7

Immune mediated diabetes accounts for 5–10% of all diabetes mellitus and is caused by autoimmune destruction of the pancreatic beta cells. Which of the following statements is true regarding immune-mediated diabetes?

1. It will develop during early childhood or adolescence.
2. Patients with immune-mediated diabetes have a BMI less than 25.
3. The rate of beta cell destruction is more rapid in some individuals and slower in others.
4. Initial treatment with oral hypoglycemic agents is appropriate until there is a complete loss of beta cell function.

Answer 7

4. Initial treatment with oral hypoglycemic agents is appropriate until there is a complete loss of beta cell function.

The rate of beta cell destruction with immune-mediated diabetes mellitus is highly individualized.

Question 8

Type 2 diabetes mellitus is associated with insulin resistance. Which of the following statements about insulin resistance is true?

1. Patients with insulin resistance have decreased insulin production.
2. Insulin resistance may improve with weight loss.
3. Insulin resistance and type 2 diabetes mellitus are progressive diseases that will eventually lead to absolute insulin deficiency.
4. Insulin resistance is a genetic trait and thus cannot be altered or improved.

Answer 8

2. Insulin resistance may improve with weight loss.

Weight loss is one of the only non-pharmacologic interventions that may reduce insulin resistance.

Question 9

The most common comorbidities that occur with type 2 diabetes mellitus are:

1. Depression, cancer, obstructive sleep apnea.
2. Obesity, coronary artery disease, sedentary lifestyle.
3. Hypertension, hyperlipidemia, obesity.
4. Hypothyroidism, hyperlipidemia, chronic kidney disease.

Answer 9

3. Hypertension, hyperlipidemia, obesity.

The most common comorbid conditions associated with type 2 diabetes are hyperlipidemia, hypertension, and obesity. There is a strong correlation between metabolic syndrome and the development of type 2 diabetes.

Question 10

DSME (diabetes self-management education) encourages the patient to make informed decisions. This approach is most successful when:

1. The diabetic is provided with enough education and information that he or she can make an informed decision.
2. It is patient-centered and responsive to individual preferences, needs, and values.
3. The patient is given written directions that outline a specific medication regimen and goal.
4. A consensus model is used which considers multiple disciplines involved in the care of the diabetic individual.

Answer 10

2. It is patient-centered and responsive to individual preferences, needs, and values.

DSME must be patient-centered and responsive to the individual’s needs, otherwise it is unlikely to be successful.

Question 11

Medical nutritional therapy (MNT) is an integral part of diabetes self-management education. Which of the following aspects of MNT would be most supportive to the patient?

1. All patients with type 2 diabetes should be encouraged to lose between 2 and 8 kilograms of their body weight.
2. All members of the health care team involved with the diabetic individual should be knowledgeable about MNT and support its implementation.
3. All patients with diabetes mellitus need to know how to count carbohydrates and limit the amount of carbohydrates in each meal.
4. Provide the patient with menus and recipes that will be easy for the patient to create at home.

Answer 11

2. All members of the health care team involved with the diabetic individual should be knowledgeable about MNT and support its implementation.

All members of the health care team involved in the care of a diabetic individual should be familiar with MNT (medical nutrition therapy) and be consistent with the recommendations of these life-long behavioral modifications.

Question 12

Patients who are diagnosed as pre-diabetic may begin pharmacologic therapy. The strongest evidence-based pharmacologic therapy to prevent the patient’s progression to diabetes is to initiate therapy with:

1. A DPP4 such as saxagliptin.
2. A basal insulin such as glargine.
3. A GLP-1 receptor agonist such as liraglutide.
4. A biguanide such as metformin.

Answer 12

4. A biguanide such as metformin.

Metformin has the strongest evidence-base as a pharmacologic therapy for diabetes prevention.

Question 13

Patients who are on intensive insulin regimens should monitor their blood glucose multiple times throughout the day. The patient should be instructed that monitoring of blood glucose is essential:

1. Before every meal.
2. Before engaging in exercise.
3. Upon awakening in the morning.
4. Before driving a car.

Answer 13

4. Before driving a car.

Although all answers are acceptable, the patient treated with an intensive insulin therapy poses the greatest risk to self and others when driving.

Question 14

The “Rule of 15” is used when the diabetic experiences hypoglycemia. The “Rule of 15” instructs the patient to:

1. Take 15 units of insulin for every 15 grams of carbohydrate ingested.
2. The patient should try to have 15 grams of protein, 15 grams of fat, and 15 grams of carbohydrate in equal portions for each meal.
3. The patient should ingest 15 grams of carbohydrate, wait 15 minutes, and re-check their blood glucose level. Repeat as necessary until symptoms abate or blood glucose is > 100.
4. Immediately inject 15 milligrams of a glucagon hypoglycemic emergency kit into their mid-thigh muscle.

Answer 14

3. The patient should ingest 15 grams of carbohydrate, wait 15 minutes, and re-check their blood glucose level. Repeat as necessary until symptoms abate or blood glucose is > 100.

The “Rule of 15” was created to simplify treatment for the hypoglycemic patient while that person remains capable of assisting themselves to correct their hypoglycemia. When patients are hypoglycemic, they often have impaired judgment. Teaching the patient this simple rule can help prevent a further decline in blood glucose and prevent overcorrection of their low blood sugar.

Question 15

The patient is started on metformin therapy. The nurse practitioner should explain to the patient that a potentially fatal side effect of metformin is:

1. Nausea and diarrhea.
2. Lactic acidosis.
3. Ketoacidosis.
4. Pancreatitis.

Answer 15

2. Lactic acidosis.

All patients that are on metformin therapy must be aware of the potential for lactic acidosis, which can be fatal.

Question 16

An overweight diabetic patient verbalizes that he is interested in beginning therapy with a GLP-1 RA to improve his diabetic control and assist with weight loss. The nurse practitioner must first assess the patient for:

1. A personal or family history of medullary thyroid cancer.
2. A personal or family history of papillary thyroid cancer.
3. A personal or family history of familial hereditary polyposis.
4. A personal or family history of polycystic kidney disease.

Answer 16

1. A personal or family history of medullary thyroid cancer.

A black box warning exists for all GLP-1 RAs if there is a family or personal history of medullary thyroid cancer or a history of MEN2 (multiple endocrine neoplasia syndrome). During clinical trials conducted on rats, there was an increase in the development of medullary thyroid cancer when given high-dose concentrations of GLP-1 RA.

Question 17

A patient presents to the primary care office for an initial evaluation. The patient is complaining of polyuria and polydipsia and exhibits symptoms of dehydration. An A1C is obtained that reveals an A1C of 12.7%. The nurse practitioner should initiate therapy with:

1. Metformin.
2. A GLP-1 RA.
3. Insulin.
4. A sulfonylurea.

Answer 17

3. Insulin.

A patient with an A1C of 12.7% is considered to be “glucose toxic,” and insulin is the recommended therapy. Later, when the A1C improves to < 9%, the patient may consider alternative therapies.

Question 18

The patient is reviewing her labs with the nurse practitioner. She inquires about the significance of the hemoglobin A1C test. The nurse practitioner explains:

1. “It represents the serum glucose level.”
2. “It reflects the post-prandial (after-meal) increase of the serum glucose.”
3. “It represents the percentage of red blood cells that contain hemoglobin.”
4. “It correlates with the average serum glucose level of the previous 90 days.”

Answer 18

4. “It correlates with the average serum glucose level of the previous 90 days.”

The A1C reflects the average percentage of glucose within the red blood cells. RBCs have a life expectancy of approximately 90 days.

Question 19

A type 2 diabetic patient is started on pharmacologic therapy that is expected to assist with weight loss. Which pharmacologic therapy may assist with weight loss?

1. A dipeptidyl peptidase inhibitor (DPP-4 inhibitor)
2. A thiazolinedione (TZD)
3. A sodium-glucose co-transporter 2 inhibitor (SGLT-2 inhibitor)
4. A sulfonylurea

Answer 19

3. A sodium-glucose co-transporter 2 inhibitor (SGLT-2 inhibitor)

Of the pharmacologic therapies listed, only the SGLT-2 inhibitor contributes to weight loss through the loss of glucose (and therefore calories) by increasing glucose filtrate in the urine.

Question 20

What is the most common side effect of metformin therapy?

1. Hypoglycemia
2. Gastrointestinal upset
3. Weight gain
4. Fungal infections

Answer 20

2. Gastrointestinal upset

Metformin commonly causes gastrointestinal side effects.

Question 21

A type 2 diabetic patient presents for a diabetic follow-up visit. The patient has a history of hypertension and persistent microalbuminuria. The patient verbalizes that he regularly takes lisinopril (20 milligrams daily). The nurse practitioner observes that the patient’s most recent GFR (glomerular filtration rate) is 29 and knows that the recommended management for this patient is to:

1. Refer them to a nephrologist.
2. Repeat the GFR in 3 months and monitor electrolytes, bicarbonate, and calcium.
3. Obtain a 24-hour urine sample for creatinine clearance.
4. Obtain a renal ultrasound to assess for renal artery stenosis.

Answer 21

1. Refer them to a nephrologist.

A diabetic patient that has either persistent microalbuminuria or a GFR < 30 should be referred to a nephrologist.

Question 22

Diabetic retinopathy is the most common cause of new cases of blindness among adults age 20–74 years. It is associated with the duration of the disease, as well as microvascular damage. Which of the following conditions, when present, would alert the nurse practitioner to recommend an immediate ophthalmic evaluation?

1. Orthostatic hypotension
2. Nephropathy
3. Coronary artery disease
4. Gastroparesis

Answer 22

2. Nephropathy

Nephropathy, retinopathy, and DPN (diabetic peripheral neuropathy) are all manifestations of long-term microvascular damage. The presence of one of these is a strong indicator for the presence of another.

Question 23

A 38-year-old female patient with type 1 diabetes has developed persistent microalbuminuria, as evidenced by two specimens collected over a 6-month period. The patient is normotensive. The nurse practitioner would be correct in recommending that the patient:

1. Continue with watchful waiting and repeat urine microalbumin annually.
2. Restrict the protein in their diet to no more than 60 kilograms of protein per day.
3. Obtain a serum pregnancy test, and if negative, initiate ACE-inhibitor therapy.
4. Repeat the test using a first morning urine sample obtained with a clean-catch, midstream collection method.

Answer 23

3. Obtain a serum pregnancy test, and if negative, initiate ACE-inhibitor therapy.

ACE inhibitors have been shown to decrease and sometimes reverse the progression of microalbuminuria and so should be initiated on all non-pregnant females with persistent microalbuminuria. ACE inhibitors are not necessarily recommended for normotensive patients that do not have microalbuminuria present.

Question 24

A 75-year-old patient with a 20-year history of type 2 diabetes presents to the office for a follow-up evaluation. She brings her most recent 3 months of blood glucose logs, which reveal a morning fasting glucose of 58–75. Her A1C is 6.0%. The nurse practitioner reviews her medication regimen, which is: Metformin 1000 mg po BID; Sitagliptin 100 mg po once daily; Glargine insulin 10 units SQ at HS. The nurse practitioner discusses with the patient her concerns regarding persistent hypoglycemia and recommends that the patient:

1. Discontinue the metformin.
2. Discontinue the sitagliptin.
3. Discontinue the glargine insulin.
4. Reduce the metformin dose to 1000 mg daily in the a.m.

Answer 24

3. Discontinue the glargine insulin.

The patient is demonstrating significant hypoglycemia, which is particularly dangerous in the elderly diabetic patient. Metformin and sitagliptin are unlikely to cause any hypoglycemia. The insulin should be discontinued.

Question 25

A 10-year-old male patient is seen in his PCP’s office. The patient has a negative PMH and a glucose reading of 626. The patient has been complaining of abdominal pain and nausea. The NP notes that the patient is breathing with deep, labored, and rapid respirations, and is lethargic. What is the most likely cause of the patient’s condition?

1. HHS caused by type II DM
2. DKA caused by type I DM
3. Uncontrolled hyperglycemia with dehydration
4. Diabetes exacerbation related to pneumonia

Answer 25

2. DKA caused by type I DM

The patient is exhibiting Kussmaul’s respirations and clinically presents as diabetic ketoacidosis.

Question 26

The NP is working in the ED when a patient with known DM 1 is brought in by ambulance. The patient states that she has been sick with the flu and has not been able to control her blood sugar despite taking her usual doses of short-acting insulin. The patient’s BS is 522 upon admission to the ED. Serum and urine Ketones are +. Blood gas reveals a PH of 7.25. The NP is aware that the first step in treatment is:

1. Initiate hydration with IV NS.
2. Initiate a regular insulin IV.
3. Initiate IV bicarbonate therapy.
4. Initiate treatment of the underlying causes of elevated BS.

Answer 26

1. Initiate hydration with IV NS.

Initial treatment for DKA is hydration with an IV of normal saline until euvolemia is established.

Question 27

A female patient with type II DM on oral hypoglycemic therapy is seen in the office for a follow-up evaluation. The patient states that she was recently diagnosed with a UTI over the weekend and went to a walk-in treatment center. She started on antibiotic therapy 24 hours ago. She continues to complain of UTI symptoms. Additionally, her BS has been consistently elevated in the 250–300 range. The NP would be correct in considering:

1. Sending the patient to the ED for evaluation of HHS.
2. Initiating treatment with insulin in the office and adding an insulin regimen at home to cover the patient’s “sick days.”
3. Intensifying the oral hypoglycemic therapy.
4. Obtaining stat ABGs to assess for acidosis.

Answer 27

2. Initiating treatment with insulin in the office and adding an insulin regimen at home to cover the patient’s “sick days.”

All patients with diabetes mellitus should have a “sick days” plan in place in order to prevent more severe consequences of hyperglycemia. It is reasonable to have this patient use short-term insulin therapy while recovering from her UTI. The patient does not exhibit any signs or symptoms of HHS or DKA.

Question 28

Both DKA and HHS can be seen in the diabetic patient. The NP should be aware that the most common reason for development of these two conditions are:

1. Non-adherence to the diabetic medication regimen.
2. Non-adherence to the diet and exercise regimen.
3. An underlying medical condition causing physiologic stress.
4. A lack of understanding by the patient about these two conditions.

Answer 28

3. An underlying medical condition causing physiologic stress.

Both DKA and HHS are often associated with underlying physiologic stress. 40% of the time it is associated with an illness that is either medical or surgical in origin.

Question 29

A patient with type 2 DM is being evaluated in the NP’s office. The patient states that she has lost a lot of weight lately “without even trying” and expects that the NP will be pleased. The patient’s BS in the office is 524. She has lost 20 pounds since her last visit one month ago. The patient verbalizes profound fatigue. The NP is aware that the patient is most likely experiencing:

1. Fatigue related to her rapid weight loss and malnutrition.
2. Fatigue related to severe dehydration, which is likely caused by HHS.
3. Fatigue related to an underlying infection.
4. Fatigue related to severe hyperglycemia.

Answer 29

2. Fatigue related to severe dehydration, which is likely caused by HHS.

The 20-pound weight loss in a 30-day period is most likely caused by severe dehydration. This is consistent with the very high blood sugar and profound fatigue. The patient is exhibiting signs of HHS and should be hospitalized for treatment.

Question 30

The most sensitive laboratory indicator of overall thyroid function is to evaluate the level of circulating:

1. Free T4.
2. Free T3.
3. TSH.
4. TPO (thyroid peroxidase antibody).

Answer 30

3. TSH.

TSH is both sensitive and specific for determining circulating T4 and T3 and is used for evaluating both hyperthyroidism and hypothyroidism.

Question 31

An individual is being evaluated by the NP for a thyroid disorder. The NP notes that the TSH is 0.01 mcg U/L. What should the NP do next?

1. Repeat the TSH.
2. Obtain total T3 and free T4 levels.
3. Perform an ultrasound-guided FNA (fine needle aspiration) of the thyroid gland.
4. Order a test of TBGs (thyroid binding immunoglobulins).

Answer 31

2. Obtain total T3 and free T4 levels.

Total T3 and free T4 levels can help the NP evaluate whether the patient has overt or subclinical hyperthyroidism. There is no need to repeat the TSH at this time.

Question 32

A 38-year-old female with a negative past medical history is being evaluated by the NP. The patient complains of weight loss, hand tremors, and “feeling like my heart is pounding.” Her apical pulse is regular at 104 BPM. The NP orders TFTs (thyroid function tests), which reveal a TSH of

1. Obtain a stat pregnancy test. If negative, order ablative therapy with radioactive iodine 131.
2. Obtain a stat pregnancy test. If negative, order a benzodiazepine to reduce tremors and anxiety.
3. Obtain a stat pregnancy test. If negative, initiate therapy with a thioamide.
4. Obtain a stat pregnancy test. If negative, initiate beta-blocker therapy with propranolol.

Answer 32

4. Obtain a stat pregnancy test. If negative, initiate beta-blocker therapy with propranolol.

The patient’s lab values reveal hyperthyroid state. The patient is symptomatic. Therapy with a beta-blocking agent should be initiated to alleviate symptomology. Treatment with radioactive iodine or thioamides will be necessary, but will not provide immediate relief of the symptoms.

Question 33

Thioamides may cause severe side effects. Before initiating treatment with a thioamide, the NP should obtain a baseline:

1. Coagulation study.
2. Renal function test.
3. CBC with differential.
4. Dexa scan.

Answer 33

3. CBC with differential.

Thioamides have been implicated in causing agranulocytosis in a small number of individuals. A baseline CBC with differential should be obtained.

Question 34

Appropriate thyroid hormone biosynthesis is dependent on the dietary intake of:

1. Calcium.
2. Iron.
3. Magnesium.
4. Iodine.

Answer 34

4. Iodine.

The presence of iodine in the body is essential for the production of thyroid hormone.

Question 35

The NP is evaluating the lab results of a 52-year-old female patient with a history of Hashimotos hypothyroidism. The NP observes that the patient’s TSH indicates overtreatment with her thyroid replacement medication. She instructs the patient to reduce her dosage by taking her levothyroxine 6 days per week instead of 7. The patient responds “I don’t want to do that because it will make me gain weight. Why can’t I just stay at this dose?” What is an appropriate response from the NP?

1. “Thyroid replacement medication is not to be used for weight loss.”
2. “Decreasing the medication dosage one day a week will not have any effect on your weight.”
3. “You may continue at the same dosage for now. If you should start to feel jittery or have symptoms consistent with hyperthyroidism, we will need to reduce your dosage at that time.”
4. “Over-replacement with thyroid hormone puts you at risk for developing cardiac arrhythmias.”

Answer 35

4. “Over-replacement with thyroid hormone puts you at risk for developing cardiac arrhythmias.”

This response by the NP will answer the patient’s question, as well as explain the rationale for avoiding over-replacement with thyroid hormone.

Question 36

A patient is at risk for secondary hypothyroidism if they have which of the following conditions?

1. Adrenal insufficiency
2. Cushing’s disease
3. Pituitary adenoma
4. Systemic lupus erythematous

Answer 36

3. Pituitary adenoma

Most secondary thyroid disorders can be traced to a problem with the pituitary gland or the pituitary-hypothalmic axis.

Question 37

The most common clinical presentation of a patient with hypothyroidism is:

1. The presence of a goiter.
2. Hair loss.
3. Fatigue.
4. Parasthesias.

Answer 37

3. Fatigue.

The most common presenting complaint of untreated hypothyroidism is fatigue. A goiter may be present in both hypothyroidism and hyperthyroidism, and therefore is not useful in determining the disease state.

Question 38

A patient is diagnosed with subclinical hypothyroidism. The NP would expect the laboratory findings to include:

1. An elevated TSH with a normal free T4 level.
2. A suppressed TSH level with a normal free T4 level.
3. A suppressed TSH level with a low free T4 level.
4. An elevated TSH with a low free T4 level.

Answer 38

1. An elevated TSH with a normal free T4 level.

By definition, subclinical hypothyroidism is an elevated TSH (thyroid stimulating hormone) level with a normal thyroxine level (T4).

Question 39

A patient with a known history of hypothyroidism and bipolar disorder informs the NP that lately she has been feeling very sluggish. Her TSH is 12.4 mcg U/L. Upon review of the patient’s medication, the NP observes that the patient is on levothyroxine 112 mcg daily and lithium 300 mg TID. The NP instructs the patient to:

1. Increase the levothyroxine to 125 mcg daily and repeat TSH in 6 weeks.
2. Reduce the lithium dose to 300 mg bid and repeat the TSH in 6 weeks.
3. Reduce the dose of levothyroxine to 100 mcg daily since the TSH level is too high. Repeat TSH in 6 weeks.
4. Stop the lithium and use an alternative treatment for the patient’s bipolar disorder.

Answer 39

1. Increase the levothyroxine to 125 mcg daily and repeat TSH in 6 weeks.

Lithium interferes with the synthesis of thyroid hormone. The patient’s thyroid dose will need to be increased to accommodate for this. It would not be appropriate to adjust the lithium dose.

Question 40

A patient with primary adrenal insufficiency will often have which of the following classic presenting symptoms?

1. Hypertension
2. Weight gain
3. Hyperpigmentation
4. Increased appetite

Answer 40

3. Hyperpigmentation

Hyperpigmentation of the skin is a classic hallmark sign for adrenal insufficiency.

Question 41

A patient with primary adrenal insufficiency might be expected to have which of the following lab results?

1. Hypokalemia
2. Hyponatremia
3. Hyperglycemia
4. Hypocalcemia

Answer 41

2. Hyponatremia

A patient with Addison’s disease will often have low aldosterone levels. Aldosterone increases the retention of sodium and causes the excretion of potassium. Therefore, low aldosterone levels may result in hyponatremia.

Question 42

A patient is suspected to have primary adrenal insufficiency. The nurse practitioner notes that the 8:00 a.m. cortisol is low. What would the NP expect to find with regard to other lab values?

1. An elevated plasma ACTH
2. A decreased plasma ACTH
3. Positive adrenal antibodies
4. Elevated aldosterone levels

Answer 42

1. An elevated plasma ACTH

Primary adrenal insufficiency means that the adrenal glands are the source of the deficiency in adrenal hormone. ACTH (from the pituitary gland) should be elevated in an effort to try to increase the cortisol levels through a negative feedback system.

Question 43

A patient is diagnosed with primary adrenal insufficiency. What is an important educational point that the patient needs to understand?

1. The patient will need to take a glucocorticoid replacement during times of physiologic stress.
2. The patient will need glucocorticoid replacement daily and lifelong.
3. Patients should have their glucocorticoid levels checked prior to any surgical or invasive procedure.
4. The patient should always take the glucocorticoid replacement at bedtime.

Answer 43

2. The patient will need glucocorticoid replacement daily and lifelong.

A patient with primary adrenal insufficiency will need glucocorticoid replacement every day for life.

Question 44

Clinical features that can be expected of a patient with Cushing’s syndrome are:

1. Multiple small striae over the hips and breast areas.
2. Hyperpigmentation of skin areas that have not been exposed to the sun.
3. Dizziness and syncopal episodes.
4. Easy bruising and skin atrophy.

Answer 44

4. Easy bruising and skin atrophy.

The patient often presents with bruising and thin, friable skin. Although the patient will also have striae, the striae seen in Cushing’s disease are characteristically wide and purplish in color and widely distributed over all areas of the trunk.

Question 45

Which of the following is a test that is most helpful in diagnosing Cushing’s syndrome?

1. An MRI of the pituitary gland with and without a contrast medium
2. A random serum cortisol level
3. A 1 mg overnight dexamethasone suppression test
4. A random ACTH level

Answer 45

3. A 1 mg overnight dexamethasone suppression test

The 1 mg overnight dexamethasone suppression test is the “gold standard” for determining if the patient has Cushing’s syndrome or Cushing’s disease. Further differentiation is then needed to determine whether it is primary (Cushing’s syndrome—adrenal origin) or secondary (Cushing’s disease—pituitary origin)

Question 46

Of the following, which is associated with Cushing’s syndrome?

1. Hypothalmic-pituitary axis tumors
2. Pituitary tumors
3. Disorders involving the thymus gland
4. Adrenal tumors

Answer 46

4. Adrenal tumors

Adrenal tumors are a common cause of Cushing’s syndrome (second only to exogenous replacement).

Question 47

Which of the following is the most common cause of Cushing’s syndrome?

1. Autoimmune disorders
2. Exogenous replacement with corticosteroids
3. Pituitary microadenomas
4. Adrenal insufficiency

Answer 47

2. Exogenous replacement with corticosteroids

The most common cause of Cushing’s syndrome is exogenous replacement with glucocorticoids.

Question 48

A patient that has hypercortisolemia and an elevated ACTH level would be interpreted as having which of the following?

1. Cushing’s syndrome
2. Cushing’s disease
3. Addison’s disease
4. Primary adrenal insufficiency

Answer 48

2. Cushing’s disease

The patient has Cushing’s disease because the problem is originating in the pituitary gland, which is demonstrated by an inappropriately elevated ACTH level in the presence of high cortisol levels.

Question 49

A patient with an elevated 24-hour urine for cortisol can be diagnosed as having which of the following?

1. Cushing’s disease
2. Cushing’s syndrome
3. Hypercortisolemia of undetermined origin
4. Primary adrenal hyperplasia

Answer 49

3. Hypercortisolemia of undetermined origin

The patient has elevated cortisol levels; however, the source of the high levels cannot be determined without further testing.