Final exam - Mostly Thyroid & Diabetes

Question 1

The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). What are characteristics of this disorder?

Answer 1

Nocturia
Incontinence
Enlarged prostate

Nocturia, incontinence, and an enlarged prostate are characteristics of BPH and need to be assessed for in clients over 50 years of age.

Question 2

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data would alert the nurse to this occurrence?

Inability to pass flatus

Loss of anal sphincter control

Severe, constant pain with rapid onset

Firm, nontender mass palpable at the lower right costal margin

Answer 2

Inability to pass flatus

An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually manifests as a more constant generalized discomfort.

Question 3

The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the primary health care provider (PHCP)?

Dark red drainage

Dark brown drainage

Green-tinged drainage

Light yellowish-brown drainage

Answer 3

Dark red drainage

For the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence of bile may cause a green tinge. The PHCP needs to be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours postoperatively.

Question 4

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube?

Checking for normal serum electrolyte levels

Checking for normal pH of the gastric aspirate

Checking for proper nasogastric tube placement

Checking for the presence of bowel sounds in all four quadrants

Answer 4

Checking for the presence of bowel sounds in all four quadrants

Rationale:
Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid from the stomach, relieving distention and vomiting. Bowel sounds return to normal as the obstruction is resolved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, pH of the gastric aspirate, and tube placement are important assessments for the client with a nasogastric tube in place but would not assist in determining the readiness for removing the nasogastric tube.

Question 5

The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction?

“The enema will be given while I am sitting on the toilet.”

“I would try and hold the fluid as long as possible after it is run in.”

“I know that there will be some cramping after the enema solution is run in.”

“I would tell the nurse if cramping occurs when the fluid is running in.”

Answer 5

“The enema will be given while I am sitting on the toilet.”

Rationale:
The enema is never administered while on a toilet due to safety. The enema is administered while the client is in a left side-lying position with the right knee flexed. This allows enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum. It is important for the client to retain the fluid for as long as possible to promote peristalsis and defecation. If the client complains of fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum; this could increase cramping.

Question 6

The nurse would include which interventions in the plan of care for a client with hypothyroidism?

Select all that apply.

Provide a cool environment for the client.

Instruct the client to consume a high-fat diet.
Instruct the client about thyroid replacement therapy.

Encourage the client to consume fluids and high-fiber foods in the diet.

Inform the client that iodine preparations will be prescribed to treat the disorder.

Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain occur.

Answer 6

Instruct the client about thyroid replacement therapy.

Encourage the client to consume fluids and high-fiber foods in the diet.

Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain occur.

Rationale:
The clinical manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormone. Interventions are aimed at replacement of the hormone and providing measures to support the signs and symptoms related to decreased metabolism. The client often has cold intolerance and requires a warm environment. The nurse encourages the client to consume a well-balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to prevent constipation. Iodine preparations may be used to treat hyperthyroidism. Iodine preparations decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone; they are not used to treat hypothyroidism. The client is instructed to notify the PHCP if chest pain occurs because it could be an indication of overreplacement of thyroid hormone.

Question 7

A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder?

Cardiovascular disease

Frequent urinary tract infections

A history of migraine headaches

Frequent upper respiratory infections

Answer 7

Cardiovascular disease

Rationale:
Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma.

Question 8

A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor would the nurse include when responding to the client?

Five blood cultures are negative.

Three sputum cultures are negative.

A blood culture and a chest x-ray are negative.

A sputum culture and a tuberculin skin test are negative.

Answer 8

Three sputum cultures are negative.

Rationale:
The client with tuberculosis must have sputum cultures performed every 2 to 4 weeks after initiation of antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative, because the client is considered noninfectious at that point. Options 1, 3, and 4 are not reliable determinants of a noninfectious status.

Question 9

The nurse is caring for a teenage client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis?

Answer 9

Leukocytosis with a shift to the left

Rationale:
Laboratory findings do not establish the diagnosis of appendicitis, but there is often an elevation of the white blood cell count (leukocytosis) with a shift to the left (an increased number of immature white blood cells).

Question 10

The nurse is caring for a client after an above-the-knee amputation. The nurse assesses the residual limb and expects to note which finding?

Pink color to the skin flap

Hot feeling on palpation of the skin flap

Serous fluid leaking from the skin flap incision

Absent pulse at the proximal pulse point site closest to the skin flap

Answer 10

Pink color to the skin flap

Rationale:
Following above-the-knee amputation, the nurse’s primary focus is to monitor for signs indicating that there is sufficient tissue perfusion and no hemorrhage. The skin flap at the end of the residual (remaining) limb would be pink in a light-skinned person and not discolored (lighter or darker than other skin pigmentation) in a dark-skinned person. The area would be warm but not hot. If the area is hot, this could indicate inflammation or infection. The incision would be clean and dry with no serous or other fluid leaking from it. There should be a pulse at the closest proximal pulse point. If no pulse is felt, the nurse would assess for a pulse using a Doppler. If no pulse is detected using the Doppler device, this could indicate lack of perfusion, and the surgeon would need to be notified.

Question 11

A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear?

Pruritus

Tinnitus

Hearing loss

Burning in the ear

Answer 11

Tinnitus

Rationale:
Tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client’s thinking process and attention span.

Question 12

The nurse notes that the primary health care provider has documented a diagnosis of presbycusis on a client’s chart. Based on this information, what action would the nurse take?

Speak loudly, but mumble or slur the words.

Speak loudly and clearly while facing the client.

Speak loudly and directly into the client’s affected ear.

Speak at normal tone and pitch, slowly and clearly.

Answer 12

Speak at normal tone and pitch, slowly and clearly.

Rationale:
Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. When communicating with a client with this condition, the nurse would speak at a normal tone and pitch, slowly and clearly. It is not appropriate to speak loudly, mumble or slur words, or speak into the client’s affected ear.

Question 13

The nurse is caring for a hearing-impaired client. Which approach will facilitate communication?

Speak loudly.

Speak frequently.

Speak at a normal volume.

Speak directly into the impaired ear.

Answer 13

Speak at a normal volume.

Rationale:
Speaking in a normal tone to the client with impaired hearing and not shouting are important. The nurse would talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse would express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse would avoid talking directly into the impaired ear.

Question 14

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated prescription?

Endotracheal intubation

100 units of NPH insulin

Intravenous infusion of normal saline

Intravenous infusion of sodium bicarbonate

Answer 14

Intravenous infusion of normal saline

Rationale:
The primary goal of treatment in hyperosmolar hyperglycemic syndrome (HHS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous (IV) fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHS.

Question 15

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose would be taken if which symptom or symptoms develop? Select all that apply.

Polyuria

Shakiness

Palpitations

Blurred vision

Light-headedness

Fruity breath odor

Answer 15

Shakiness
Palpitations
Light-headedness

Rationale:
Shakiness, palpitations, and light-headedness are signs/symptoms of hypoglycemia and would indicate the need for food or glucose. Polyuria, blurred vision, and a fruity breath odor are manifestations of hyperglycemia.

Question 16

A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse would next prepare to administer which medication?

An ampule of 50% dextrose

NPH insulin
subcutaneously

IV fluids containing dextrose

Phenytoin for the prevention of seizures

Answer 16

IV fluids containing dextrose

Rationale:
Emergency management of DKA focuses on correcting fluid and electrolyte imbalances and normalizing the serum glucose level. If the corrections occur too quickly, serious consequences, including hypoglycemia and cerebral edema, can occur. During management of DKA, when the blood glucose level falls to 250 to 300 mg/dL (14.2 to 17.1 mmol/L), the IV infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL (14.2 mmol/L), or until the client recovers from ketosis. Fifty percent dextrose is used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin is not a usual treatment measure for DKA.

Question 17

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed?

Polyuria

Diaphoresis

Pedal edema

Decreased respiratory rate

Answer 17

Polyuria

Rationale:
Chronic hyperglycemia, resulting from poor glycemic control, contributes to the microvascular and macrovascular complications of diabetes mellitus. Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in hypoglycemia. Hypoglycemia is an acute complication of diabetes mellitus; however, it does not predispose a client to the chronic complications of diabetes mellitus. Therefore, option 2 can be eliminated because this finding is characteristic of hypoglycemia. Options 3 and 4 are not associated with diabetes mellitus.

Recall that poor glycemic control contributes to development of the chronic complications of diabetes mellitus. Remember the 3 Ps associated with hyperglycemia—polyuria, polydipsia, and polyphagia.

Question 18

The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching?

“I need to stop my insulin.”

“I need to increase my fluid intake.”

“I need to monitor my blood glucose every 3 to 4 hours.”

“I need to call the primary health care provider (PHCP) because of these symptoms.”

Answer 18

“I need to stop my insulin.”

Rationale:
When a client with diabetes mellitus is unable to eat normally because of illness, the client still needs to take the prescribed insulin or oral medication. The client would consume additional fluids and needs to notify the PHCP. The client needs to monitor the blood glucose level every 3 to 4 hours. The client would also monitor the urine for ketones during illness.

Question 19

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise?

“I would not exercise since I am taking insulin.”

“The best time for me to exercise is after breakfast.”

“The best time for me to exercise is mid- to late afternoon.”

“NPH is a basal insulin, so I need to exercise in the evening.”

Answer 19

“The best time for me to exercise is after breakfast.”

Rationale:
Exercise is an important part of diabetes management. It promotes weight loss, decreases insulin resistance, and helps to control blood glucose levels. A hypoglycemic reaction may occur in response to increased exercise, so clients need to exercise either an hour after mealtime or after consuming a 10- to 15-gram carbohydrate snack, and they would check their blood glucose level before exercising. Option 1 is incorrect because clients with diabetes would exercise, though they need to check with their primary health care provider before starting a new exercise program. Option 3 in incorrect; clients need to avoid exercise during the peak time of insulin. NPH insulin peaks at 4 to 12 hours; therefore, afternoon exercise takes place during the peak of the medication. Option 4 is incorrect; NPH insulin in an intermediate-acting insulin, not a basal insulin.

Question 20

The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8 mmol/L), temperature of 101° F (38.3° C), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse?

Answer 20

Temperature

Rationale:
In the client with type 2 diabetes mellitus, an elevated temperature may indicate infection. Infection is a leading cause of hyperosmolar hyperglycemic syndrome in the client with type 2 diabetes mellitus. The other findings are within normal limits or are expected.

Question 21

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client?

Hypoglycemia

Level of hoarseness

Respiratory distress

Edema at the surgical site

Answer 21

Respiratory distress

Rationale:
Thyroidectomy is the removal of the thyroid gland, which is located in the anterior neck. It is very important to monitor airway status, as any swelling to the surgical site could cause respiratory distress. Although all of the options are important for the nurse to monitor, the priority nursing action is to monitor the airway.

Question 22

The nurse is caring for a client after thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which purpose?

To treat thyroid storm

To prevent cardiac irritability

To treat hypocalcemic tetany

To stimulate release of parathyroid hormone

Answer 22

To treat hypocalcemic tetany

Rationale:
Hypocalcemia, resulting in tetany, can develop after thyroidectomy if the parathyroid glands are accidentally removed during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips, or toes; muscle spasms; or twitching, the primary health care provider is notified immediately. Calcium gluconate needs to be readily available in the nursing unit.

Question 23

A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is providing instructions regarding the program. Which instruction would the nurse include in the teaching plan?

Try to exercise before mealtimes.

Administer insulin after exercising.

Take a blood glucose test before exercising.

Exercise is best performed during peak times of insulin.

Answer 23

Take a blood glucose test before exercising.

Rationale:
A blood glucose test performed before exercising provides the client with information regarding the need to consume a snack before exercising. Exercising during the peak times of insulin or before mealtimes places the client at risk for hypoglycemia. Insulin needs to be administered as prescribed.

Question 24

The nurse would include which interventions in the plan of care for a client with hyperthyroidism? Select all that apply.

Provide a warm environment for the client.

Instruct the client to consume a low-fat diet.

A thyroid-releasing inhibitor will be prescribed.

Encourage the client to consume a well-balanced diet.

Instruct the client that thyroid replacement therapy will be needed.

Instruct the client that episodes of chest pain are expected to occur.

Answer 24

A thyroid-releasing inhibitor will be prescribed.

Encourage the client to consume a well-balanced diet.

Rationale:
The clinical manifestations of hyperthyroidism are the result of increased metabolism caused by high levels of thyroid hormone. Interventions are aimed at reduction of the hormones and measures to support the signs and symptoms related to an increased metabolism. The client often has heat intolerance and requires a cool environment. The nurse encourages the client to consume a well-balanced diet because clients with this condition experience increased appetite. Iodine preparations are used to treat hyperthyroidism. Iodine preparations decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone. Thyroid replacement is needed for hypothyroidism. The client would notify the primary health care provider if chest pain occurs because it could be an indication of an excessive medication dose.

Question 25

A client with diabetes mellitus is being discharged following treatment for hyperosmolar hyperglycemic syndrome (HHS) precipitated by acute illness. The client tells the nurse, “I will call my doctor the next time I can’t eat for more than a day or so.” Which statement reflects the most appropriate analysis of this client’s level of knowledge?

The client needs immediate education before discharge.

The client requires follow-up teaching regarding the administration of oral antidiabetics.

The client’s statement is inaccurate, and the client needs to be scheduled for outpatient diabetic counseling.

The client’s statement is inaccurate, and the client needs to be scheduled for educational home health visits.

Answer 25

The client needs immediate education before discharge.

Rationale:
If the client becomes ill and cannot retain fluids or food for a period of 4 hours, the physician needs to be notified. The client’s statement indicates a need for immediate education to prevent hyperosmolar hyperglycemic syndrome (HHS), a life-threatening emergency. Although all of the other options may be true, the most appropriate analysis is that the client requires immediate education.

Question 26

A client with type 1 diabetes mellitus is having trouble remembering the types, duration, and onset of the action of insulin. The client tells the nurse that family members have not been supportive. Which response by the nurse is best?

“What is it that you don’t understand?”

“You can’t always depend on your family to help.”

“It’s not really necessary for you to remember this.”

“Let me go over the types of insulins with you again.”

Answer 26

“Let me go over the types of insulins with you again.”

Rationale:
Reinforcement of knowledge and behaviors is vital to the success of the client’s self-care. All of the other options do not address the need for client instructions and are not therapeutic responses.

Question 27

A client arrives in the hospital emergency department in an unconscious state. As reported by the spouse, the client has diabetes mellitus and began to show symptoms of hypoglycemia. A blood glucose level is obtained for the client, and the result is 40 mg/dL (2.28 mmol/L). Which medication would the nurse anticipate will be prescribed for the client?

Glucagon
Glyburide
Metformin
Regular insulin

Answer 27

Glucagon

Rationale:
A blood glucose level lower than 50 mg/dL (2.85 mmol/L) is considered to be critically low. Glucagon is used to treat hypoglycemia because it increases blood glucose levels. Insulin would lower the client’s blood glucose and would not be an appropriate treatment for hypoglycemia. Glyburide and metformin are oral hypoglycemic agents used to treat type 2 diabetes mellitus and would not be given to a client with hypoglycemia. In addition, an oral medication would not be administered to an unconscious client.

Question 28

A client arrives in the hospital emergency department complaining of severe thirst and polyuria. The client tells the nurse that they have a history of diabetes mellitus. A blood glucose level is drawn, and the result is 685 mg/dL (39.1 mmol/L). Which intervention would the nurse anticipate to be prescribed initially for the client?

Glyburide via the oral route

Glucagon via the subcutaneous route

Insulin aspart via the subcutaneous route

Regular insulin via the intravenous (IV) route

Answer 28

Regular insulin via the intravenous (IV) route

Rationale:
The client is most likely in diabetic ketoacidosis (DKA). Regular insulin via the IV route is the preferred treatment for DKA. Regular insulin is a short-acting insulin and can be given intravenously; it is titrated to the client’s high blood glucose levels. Glucagon is used to treat hypoglycemia, and glyburide is an oral hypoglycemic agent used to treat type 2 diabetes mellitus. Insulin aspart is a short-acting insulin and is not appropriate for the emergency treatment of DKA.

Question 29

The nurse is providing instructions to a client newly diagnosed with diabetes mellitus. The nurse gives the client a list of the signs of hyperglycemia. Which specific sign of this complication would be included on the list?

Shakiness

Increased thirst

Profuse sweating

Decreased urine output

Answer 29

Increased thirst

Rationale:
The classic signs of hyperglycemia include polydipsia, polyuria, and polyphagia. Profuse sweating and shakiness would be noted in a hypoglycemic condition.

Question 30

The emergency department nurse is preparing a plan for initial care of a client with a diagnosis of hyperosmolar hyperglycemic syndrome (HHS). The nurse recognizes that the hyperglycemia associated with this disorder results from which occurrence?

Increased use of glucose

Overproduction of insulin

Increased production of glucose

Increased osmotic movement of water

Answer 30

Increased production of glucose

Rationale:
Hyperglycemia results from decreased use and increased production of glucose. Increased use of glucose and overproduction of insulin would most likely cause hypoglycemia. Option 4 is incorrect.

Question 31

The nurse is developing a plan of care for a client who is scheduled for a thyroidectomy. The nurse focuses on psychosocial needs, knowing that which is likely to occur in the client?

Infertility
Gynecomastia
Sexual dysfunction
Body image changes

Answer 31

Body image changes

Rationale:
Because of the location of the incision in the neck area, many clients are afraid of thyroid surgery for fear of having a visible large scar postoperatively. Having all or part of the thyroid gland removed will not cause the client to experience gynecomastia. Sexual dysfunction and infertility could occur if the entire thyroid is removed and the client is not placed on thyroid replacement medications.

Question 32

The nurse is performing an assessment on a client with a diagnosis of myxedema (hypothyroidism). Which assessment finding would the nurse expect to note in this client?

Dry skin
Thin, silky hair
Bulging eyeballs
Fine muscle tremors

Answer 32

Dry skin

Rationale:
Myxedema is a deficiency of thyroid hormone. The client will present with a puffy, edematous face, especially around the eyes (periorbital edema), along with coarse facial features; dry skin; and dry, coarse hair and eyebrows. The remaining options are noted in the client with hyperthyroidism.

Question 33

The nurse is performing an assessment on a client with a diagnosis of hyperthyroidism. Which assessment finding would the nurse expect to note in this client?

Dry skin
Bulging eyeballs
Periorbital edema
Coarse facial features

Answer 33

Bulging eyeballs

Rationale:
Hyperthyroidism is clinically manifested by goiter (increase in the size of the thyroid gland) and exophthalmos (bulging eyeballs). Other clinical manifestations include nervousness, fatigue, weight loss, muscle cramps, and heat intolerance. Additional signs found in this disorder include tachycardia; shortness of breath; excessive sweating; fine muscle tremors; thin, silky hair and thin skin; infrequent blinking; and a staring appearance.

Question 34

The nurse is providing instructions regarding insulin administration for a client newly diagnosed with diabetes mellitus. The primary health care provider has prescribed a mixture of NPH insulin and regular insulin. The nurse would instruct the client that which is the first step in this procedure?

Draw up the correct dosage of NPH insulin into the syringe.

Draw up the correct dosage of regular insulin into the syringe.

Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin.

Inject air equal to the amount of regular insulin prescribed into the vial of regular insulin.

Answer 34

Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin.

Rationale:
The initial step in preparing an injection of insulin that is a mixture of NPH and regular insulin is to inject air into the NPH insulin bottle equal to the amount of insulin prescribed. The client would then be instructed to inject an amount of air equal to the amount of prescribed insulin into the regular insulin bottle. The regular insulin would then be withdrawn, followed by the NPH insulin. Contamination of regular insulin with NPH insulin will convert part of the regular insulin into a longer-acting form.

Question 35

The nurse is monitoring a client with diabetes mellitus for signs of hypoglycemia. Which manifestations are associated with this complication?

Slow pulse; lethargy; warm, dry skin

Elevated pulse; lethargy; warm, dry skin

Elevated pulse; shakiness; cool, clammy skin

Slow pulse, confusion, increased urine output

Answer 35

Elevated pulse; shakiness; cool, clammy skin

Rationale:
Signs and symptoms of mild hypoglycemia include tachycardia; shakiness; and cool, clammy skin. The remaining options do not specify the manifestations of hypoglycemia.

Question 36

The nurse has developed a postoperative plan of care for a client who had a thyroidectomy and documents that the client is at risk for developing an ineffective breathing pattern. Which nursing intervention would the nurse include in the plan of care?

Maintain a supine position.

Monitor for neck swelling.

Maintain a pressure dressing on the operative site.

Encourage deep-breathing exercises and vigorous coughing exercises.

Answer 36

Monitor for neck swelling.

Rationale:
After thyroidectomy, the nurse needs to check the client’s neck frequently to assess for the occurrence of postoperative edema; edema could lead to airway obstruction. The client would be placed in an upright position to facilitate air exchange and prevent edema at the surgical site. A pressure dressing is not placed on the operative site because it may restrict breathing. The nurse would monitor the dressing closely and would loosen the dressing if necessary. The nurse would assist the client with deep-breathing exercises, but coughing is minimized to prevent tissue damage and stress to the incision.

Question 37

The nurse is monitoring a client for signs of hypocalcemia after thyroidectomy. Which sign or symptom, if noted in the client, would most likely indicate the presence of hypocalcemia?

Bradycardia
Flaccid paralysis
Tingling around the mouth
Absence of Chvostek’s sign

Answer 37

Tingling around the mouth

Rationale:
After thyroidectomy the nurse assesses the client for signs of hypocalcemia and tetany. Early signs include tingling around the mouth and in the fingertips, muscle twitching or spasms, palpitations or arrhythmias, and Chvostek’s and Trousseau’s signs. Bradycardia, flaccid paralysis, and absence of Chvostek’s sign are not signs of hypocalcemia.

Question 38

The nurse is caring for a client after thyroidectomy. The client expresses concern about the postoperative voice hoarseness she is experiencing and asks if the hoarseness will subside. The nurse would provide the client with which information?

It indicates nerve damage.

The hoarseness is permanent.

It is normal during this time and will subside.

It will worsen before it subsides, which may take 6 months.

Answer 38

Rationale:
Hoarseness in the postoperative period usually is the result of laryngeal pressure or edema and will resolve within a few days. The client would be reassured that the effects are transitory. The other options are incorrect.

Hoarseness is normal

Huskiness is not

Question 39

The nursing instructor asks a nursing student to identify the risk factors associated with the development of thyrotoxicosis. The student demonstrates understanding of the risk factors by identifying an increased risk for thyrotoxicosis in which client?

A client with hypothyroidism

A client with Graves’ disease who is having surgery

A client with diabetes mellitus scheduled for a diagnostic test

A client with diabetes mellitus scheduled for debridement of a foot ulcer

Answer 39

A client with Graves’ disease who is having surgery

Rationale:
Thyrotoxicosis usually is seen in clients with Graves’ disease in whom the symptoms are precipitated by a major stressor. This complication typically occurs during periods of severe physiological or psychological stress such as trauma, sepsis, delivery, or major surgery. It also must be recognized as a potential complication after thyroidectomy. The client conditions in the remaining options are not associated with thyrotoxicosis.

Question 40

A client has been hospitalized for an endocrine system dysfunction of the pancreas. The registered nurse asks the new orientee nurse what kind of problem a client hospitalized for endocrine dysfunction of the pancreas would expect. The new orientee nurse demonstrates understanding if which statement is made?

“Lipase levels will decrease.”

“Insulin production will be decreased.”

“There will be overproduction of trypsin.”

“Amylase will be secreted in excess amounts.”

Answer 40

“Insulin production will be decreased.”

Rationale:
The pancreas produces both endocrine and exocrine secretions as part of its normal function. The organ secretes insulin as a key endocrine hormone to regulate the blood glucose level. When there is endocrine dysfunction, insulin production is affected due to damage to beta cells. Other pancreatic endocrine hormones are glucagon and somatostatin. The exocrine pancreas produces digestive enzymes such as amylase, lipase, and trypsin.

Question 41

The nurse is caring for a client with a serum phosphorus level of 5.0 mg/dL (1.61 mmol/L). What other laboratory value might the nurse expect to note in the medical record?

Calcium level of 8 mg/dL (2.0 mmol/L)

Calcium level of 11.2 mg/dL (2.8 mmol/L)

Potassium level of 2.9 mEq/L (2.9 mmol/L)

Potassium level of 5.6 mEq/L (5.6 mmol/L)

Answer 41

Calcium level of 8 mg/dL (2.0 mmol/L)

Rationale:
Parathyroid hormone is responsible for maintaining serum calcium and phosphorus levels within normal range. Therefore, if these laboratory values are altered, this suggests dysfunction of the parathyroid gland. When calcium levels are elevated (normal is 9 to 10.5 mg/dL [2.25 to 2.75 mmol/L]) and phosphorous levels are decreased (normal is 3.0 to 4.5 mg/dL [0.97 to 1.45 mmol/L]), this suggests hyperparathyroidism. If the phosphorus level is elevated, the nurse would expect the calcium level to be low. Therefore, option 1 is the correct answer.

Question 42

A client with an endocrine disorder has experienced recent weight loss and exhibits tachycardia. Based on the clinical manifestations, the nurse would suspect dysfunction of which endocrine gland?

Thyroid
Pituitary
Parathyroid
Adrenal cortex

Answer 42

Thyroid

Rationale:
The thyroid gland is responsible for a number of metabolic functions in the body. Among these are metabolism of nutrients such as fats and carbohydrates. Increased metabolic function places a demand on the cardiovascular system for a higher cardiac output. A client with increased activity of the thyroid gland will experience weight loss from the higher metabolic rate and will have an increased pulse rate. The anterior pituitary gland produces growth hormone, luteinizing hormone, and follicle-stimulating hormone. Antidiuretic hormone (ADH) and oxytocin are secreted by the posterior pituitary gland. Both ADH and oxytocin are synthesized by the hypothalamus and stored in the posterior pituitary gland. These hormones are released as needed into the bloodstream. Parathyroid hormone is responsible for maintaining serum calcium and phosphorus levels within normal range. The adrenal cortex is responsible for the production of glucocorticoids and mineralocorticoids.

Question 43

A client has abnormal amounts of circulating thyronine (T3) and thyroxine (T4). While obtaining the health history, the nurse asks the client about dietary intake. Lack of which dietary element is most likely the cause?

Answer 43

Iodine

Rationale:
Adequate dietary iodine is needed to produce T3 and T4. The other requirements for adequate T3 and T4 production are an intact thyroid gland and a functional hypothalamus-pituitary-thyroid feedback system. The remaining options are not responsible for the abnormal amounts of circulating T3 and T4.

Question 44

A client with hypovolemia experiences activation of the renin-angiotensin system to maintain blood pressure. The registered nurse determines that the new nurse understands that what substance is secreted if which statement is made?

“Cortisol will be secreted.”
“Aldosterone will be secreted.”
“Additional glucagon will be produced.”
“Adrenocorticotropic hormone production will increase.”

Answer 44

“Aldosterone will be secreted.”

Rationale:
Aldosterone is the primary mineralocorticoid that is produced and secreted in response to lowered blood volume. Cortisol is a glucocorticoid. Glucagon is produced by the pancreas and functions to oppose the action of insulin in regulating blood glucose levels. Adrenocorticotropic hormone is produced by the pituitary gland and stimulates the adrenal cortex to produce glucocorticoids and mineralocorticoids.

Question 45

A client has overactivity of the thyroid gland. The nurse would expect which finding?

Weight gain
Nutritional deficiencies
Low blood glucose levels
Increased body fat stores

Answer 45

Nutritional deficiencies

Rationale:
Although the client may experience an increased appetite with overactivity of the thyroid gland, food intake does not meet energy demands, and nutritional deficiencies can develop. Weight loss occurs as a result of the increased metabolic activity. Glucose tolerance is decreased, and the client experiences hyperglycemia. Overactivity of the thyroid gland also causes increased metabolism, including fat metabolism. This leads to decreased levels of fat in the bloodstream, including cholesterol, and decreased body fat stores.

Question 46

A hospitalized client is experiencing an episode of hypoglycemia. The client is lethargic and has no available intravenous (IV) access. Which medication would the nurse anticipate administering?

Insulin
Cortisone
Glucagon
Epinephrine

Answer 46

Glucagon

Rationale:
Glucagon, a natural hormone secreted by the pancreas, is available as a subcutaneous injection to be given when a quick response to severe hypoglycemia is needed. Glucagon is useful in the unconscious hypoglycemic client without established IV access. The remaining options are incorrect treatments.

Question 47

The nurse is caring for a client with a new diagnosis of hypothyroidism. Which clinical manifestations might the nurse expect to note on examination of this client? Select all that apply.

Irritability
Periorbital edema
Coarse, brittle hair
Slow or slurred speech
Abdominal distention
Soft, silky, thinning hair

Answer 47

Periorbital edema
Coarse, brittle hair
Slow or slurred speech
Abdominal distention

Rationale:
The manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormones. The client may exhibit skin manifestations, such as coarse, brittle hair; thick, brittle nails; coarse, scaly skin; delayed wound healing; periorbital edema; and face puffiness. Neuromuscular manifestations include lethargy, slow or slurred speech, and impaired memory. Gastrointestinal manifestations include complaints of constipation, weight gain, and abdominal distention. Irritability and soft, silky, thinning hair on the scalp are manifestations of hyperthyroidism.

Question 48

A test to measure long-term control of diabetes mellitus has been prescribed for a client. In instructing the client about the test, the nurse explains that long-term control can be measured because chronic high blood glucose levels lead to irreversible glucose binding onto what?

Platelets
Muscle tissue
Adipose tissue
Red blood cells (RBCs)

Answer 48

Red blood cells (RBCs)

Rationale:
With chronic high circulating blood glucose levels, some glucose binds irreversibly onto RBCs and remains there for the life of the cell. The average life span of an RBC is 120 days. The measurement of glycosylated hemoglobin A (HbA1c), which detects glucose binding on the RBC membrane, is expressed as a percentage. Glucose does not bind onto platelets in diabetes mellitus. One of the problems in diabetes is that muscle and adipose cells may be unable to transport glucose across cell membranes.

Question 49

A hospitalized client is diagnosed with type 1 diabetes mellitus. The nurse plans care for the client, understanding that which factors are likely causes of the beta cell destruction that accompanies this disorder? Select all that apply.

Viruses
Genetic factors
Autoimmune factors
Human leukocyte antigen (HLA)
Primary failure of glucagon secretion

Answer 49

Viruses
Genetic factors
Autoimmune factors
Human leukocyte antigen (HLA)

Rationale:
Viruses and autoimmune factors are thought to play a role in the development of type 1 diabetes mellitus. Other causes of type 1 diabetes mellitus include genetic factors, specifically the presence of HLA. This factor is found in many clients with type 1 diabetes mellitus. The problem with type 1 diabetes mellitus is destruction of the beta cells. It is not caused by a primary failure of glucagon secretion.

Question 50

A nurse is assigned to care for a client with type 1 diabetes mellitus. During the shift, the nurse would monitor for which manifestation as a sign of hypoglycemia?

Tremors
Anorexia
Hot, dry skin
Muscle cramps

Answer 50

Tremors

Rationale:
Decreased blood glucose levels trigger autonomic nervous system signs and symptoms, such as nervousness, irritability, and tremors. Hot, dry skin accompanies hyperglycemia. Anorexia and muscle cramps are unrelated to hypoglycemia.

Question 51

A client has returned to the nursing unit after a thyroidectomy. The nurse notes that the client is complaining of tingling sensations around the mouth, fingers, and toes. On the basis of these findings, the nurse would next assess the results of which serum laboratory study?

Sodium
Calcium
Potassium
Magnesium

Answer 51

Calcium

Rationale:
After surgery on the thyroid gland, the client may experience a temporary calcium imbalance. This is due to transient malfunction of the parathyroid glands. The nurse also would assess for Chvostek’s and Trousseau’s signs. The correct treatment is administration of calcium gluconate or calcium lactate. The remaining options are unrelated to the client’s complaints.