TEST 8: The Client with Endocrine Health Problems

Question 1

The Client with Disorders of the Thyroid

1. The nurse is completing a health assessment of a 42-year-old female with suspected Graves’
   disease. The nurse should assess this client for:
2. Anorexia.
3. Tachycardia.
4. Weight gain.
5. Cold skin.

Answer 1

The Client with Disorders of the Thyroid
1. 2. 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.
CN: Physiological adaptation; CL: Analyze

Question 2

2. When conducting a health history with a female client with thyrotoxicosis, the nurse should ask
   about which of the following changes in the menstrual cycle?
3. Dysmenorrhea.
4. Metrorrhagia.
5. Oligomenorrhea.
6. Menorrhagia.

Answer 2

2. 3. A change in the menstrual interval, diminished menstrual flow (oligomenorrhea), or even the
      absence of menstruation (amenorrhea) may result from the hormonal imbalances of thyrotoxicosis.
      Oligomenorrhea in women and decreased libido and impotence in men are common features of
      thyrotoxicosis. Dysmenorrhea is painful menstruation. Metrorrhagia, blood loss between menstrual
      periods, is a symptom of hypothyroidism. Menorrhagia, excessive bleeding during menstrual periods,
      is a symptom of hypothyroidism.
      CN: Physiological adaptation; CL: Analyze

Question 3

3. A 34-year-old female is diagnosed with hypothyroidism. The nurse should assess the client for
which of the following? Select all that apply.
1. Rapid pulse.
2. Decreased energy and fatigue.
3. Weight gain of 10 lb (4.5 kg).
4. Fine, thin hair with hair loss.
5. Constipation.
6. Menorrhagia.

Answer 3

3. 2, 3, 5, 6. Clients with hypothyroidism exhibit symptoms indicating a lack of thyroid hormone.
   Bradycardia, decreased energy and lethargy, memory problems, weight gain, coarse hair,
   constipation, and menorrhagia are common signs and symptoms of hypothyroidism.
   CN: Physiological adaptation; CL: Analyze

Question 4

4. Propylthiouracil (PTU) is prescribed for a client with Graves’ disease. The nurse should teach
   the client to immediately report which of the following?
5. Sore throat.
6. Painful, excessive menstruation.
7. Constipation.
8. Increased urine output.

Answer 4

4. 1. 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 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.
      CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 5

5. A client with thyrotoxicosis says to the nurse, “I am so irritable. I am having problems at work
   because I lose my temper very easily.” Which of the following responses by the nurse would give the
   client the most accurate explanation of her behavior?
6. “Your behavior is caused by temporary confusion brought on by your illness.”
7. “Your behavior is caused by the excess thyroid hormone in your system.”
8. “Your behavior is caused by your worrying about the seriousness of your illness.”
9. “Your behavior is caused by the stress of trying to manage a career and cope with illness.”

Answer 5

5. 2. A typical sign of thyrotoxicosis is irritability caused by the high levels of circulating thyroid
      hormones in the body. This symptom decreases as the client responds to therapy. Thyrotoxicosis does
      not cause confusion. The client may be worried about her illness, and stress may influence her mood;
      however, irritability is a common symptom of thyrotoxicosis and the client should be informed of that
      fact rather than blamed.
      CN: Psychosocial integrity; CL: Synthesize

Question 6

6. The nurse is evaluating a client with hyperthyroidism who is taking Propylthiouracil (PTU)
   100 mg/day in three divided doses for maintenance therapy. Which of the following statements from
   the client indicates the desired outcome of the drug?
7. “I have excess energy throughout the day.”
8. “I am able to sleep and rest at night.”
9. “I have lost weight since taking this medication.”
10. “I do perspire throughout the entire day.

Answer 6

6. 2. PTU is a prototype of thioamide antithyroid drugs. It inhibits production of thyroid hormonesand peripheral conversion of T4 to the more active T3. A client taking this antithyroid drug should be
      able to sleep and rest well at night since the level of thyroid hormones is reduced in the blood.
      Excess energy throughout the day, loss of weight and perspiring through the day are symptoms of
      hyperthyroidism indicating the drug has not produced its outcome.
      CN: Pharmacological and parenteral therapies; CL: Evaluate.

Question 7

7. The nurse should teach the client with Graves’ disease to prevent corneal irritation from mild
   exophthalmos by:
8. Massaging the eyes at regular intervals.
9. Instilling an ophthalmic anesthetic as prescribed.
10. Wearing dark-colored glasses.
11. Covering both eyes with moistened gauze pads.

Answer 7

7. 3. Treatment of mild ophthalmopathy that may accompany thyrotoxicosis includes measures
      such as wearing sunglasses to protect the eyes from corneal irritation. Treatment of ophthalmopathy
      should be performed in consultation with an ophthalmologist. Massaging the eyes will not help to
      protect the cornea. An ophthalmic anesthetic is used to examine and possibly treat a painful eye, not
      protect the cornea. Covering the eyes with moist gauze pads is not a satisfactory nursing measure to
      protect the eyes of a client with exophthalmos because treatment is not focused on moisture to the eye
      but rather on protecting the cornea and optic nerve. In exophthalmos, the retrobulbar connective
      tissues and extraocular muscle volume are expanded because of fluid retention. The pressure is also
      increased.
      CN: Reduction of risk potential; CL: Synthesize

Question 8

8. A client with Graves’ disease is treated with radioactive iodine (RAI) in the form of sodium
   iodide 131 I. Which of the following statements by the nurse will explain to the client how the drug
   works?
9. “The RAI stabilizes the thyroid hormone levels before a thyroidectomy.”
10. “The RAI reduces uptake of thyroxine and thereby improves your condition.”
11. “The RAI lowers the levels of thyroid hormones by slowing your body’s production of them.”
12. “The RAI destroys thyroid tissue so that thyroid hormones are no longer produced.”

Answer 8

8. 4. Sodium iodide 131 I destroys the thyroid follicular cells, and thyroid hormones are no longer
      produced. RAI is commonly recommended for clients with Graves’ disease, especially the elderly.
      The treatment results in a “medical thyroidectomy.” RAI is given in lieu of surgery, not before
      surgery. RAI does not reduce uptake of thyroxine. The outcome of giving RAI is the destruction of the
      thyroid follicular cells. It is possible to slow the production of thyroid hormones with RAI.
      CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 9

9. After treatment with radioactive iodine (RAI) in the form of sodium iodide 131 I, the nurse
   teaches the client to:
10. Monitor for signs and symptoms of hyperthyroidism.
11. Rest for 1 week to prevent complications of the medication.
12. Take thyroxine replacement for the remainder of the client’s life.
13. Assess for hypertension and tachycardia resulting from altered thyroid activity.

Answer 9

9. 3. The client needs to be educated about the need for lifelong thyroid hormone replacement.
      Permanent hypothyroidism is the major complication of RAI 131 I treatment. Lifelong medical follow-
      up and thyroid replacement are warranted. The client needs to monitor for signs and symptoms of
      hypothyroidism, not hyperthyroidism. Resting for 1 week is not necessary. Hypertension and
      tachycardia are signs of hyperthyroidism, not hypothyroidism.
      CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 10

10. 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. The
    expected outcome of using this drug is that it helps:
11. Slow progression of exophthalmos.
12. Reduce the vascularity of the thyroid gland.
13. Decrease the body’s ability to store thyroxine.
14. Increase the body’s ability to excrete thyroxine.

Answer 10

10. 2. 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.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 11

11. The nurse is administering a saturated solution of potassium iodide (SSKI). The nurse should:
12. Pour the solution over ice chips.
13. Mix the solution with an antacid.
14. Dilute the solution with water, milk, or fruit juice and have the client drink it with a straw.
15. Disguise the solution in a pureed fruit or vegetable.

Answer 11

11. 3. SSKI should be diluted well in milk, water, juice, or a carbonated beverage before
       administration to help disguise the strong, bitter taste. Also, this drug is irritating to mucosa if taken
       undiluted. The client should sip the diluted preparation through a drinking straw to help prevent
       staining of the teeth. Pouring the solution over ice chips will not sufficiently dilute the SSKI or cover
       the taste. Antacids are not used to dilute or cover the taste of SSKI. Mixing in a puree would put the
       SSKI in contact with the teeth.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 12

12. Following a subtotal thyroidectomy, the nurse asks the client to speak immediately upon
    regaining consciousness. The nurse does this to monitor for signs of which of the following?
13. Internal hemorrhage.
14. Decreasing level of consciousness.
15. Laryngeal nerve damage.
16. Upper airway obstruction.

Answer 12

12. 3. Laryngeal nerve damage is a potential complication of thyroid surgery because of the
       proximity of the thyroid gland to the recurrent laryngeal nerve. Asking the client to speak helps assess
       for signs of laryngeal nerve damage. Persistent or worsening hoarseness and weak voice are signs of
       laryngeal nerve damage and should be reported to the physician immediately. Internal hemorrhage is
       detected by changes in vital signs. The client’s level of consciousness can be partially assessed by
       asking her to speak, but that is not the primary reason for doing so in this situation. Upper airway
       obstruction is detected by color and respiratory rate and pattern.
       CN: Reduction of risk potential; CL: Analyze

Question 13

13. A client who has undergone a subtotal thyroidectomy is subject to complications in the first
    48 hours after surgery. The nurse should obtain and keep at the bedside equipment to:
14. Begin total parenteral nutrition.
15. Start a cutdown infusion.
16. Administer tube feedings.4. Perform a tracheotomy.

Answer 13

13. 4. Equipment for an emergency tracheotomy should be kept in the room, in case tracheal
       edema and airway occlusion occur. Laryngeal nerve damage can result in vocal cord spasm and
       respiratory obstruction. A tracheostomy set, oxygen and suction equipment, and a suture removal set
       (for respiratory distress from hemorrhage) make up the emergency equipment that should be readily
       available. Total parenteral nutrition is not anticipated for the client undergoing thyroidectomy.
       Intravenous infusion via a cutdown is not an expected possible treatment after thyroidectomy. Tube
       feedings are not anticipated emergency care.
       CN: Reduction of risk potential; CL: Synthesize

Question 14

14. One day following a subtotal thyroidectomy, a client begins to have tingling in the fingers and
    toes. The nurse should first:
15. Encourage the client to flex and extend the fingers and toes.
16. Notify the physician.
17. Assess the client for thrombophlebitis.
18. Ask the client to speak.

Answer 14

14. 2. Tetany may occur after thyroidectomy if the parathyroid glands are accidentally injured or
       removed during surgery. This would cause a disturbance in serum calcium levels. An early sign of
       tetany is numbness and tingling of the fingers or toes and in the circumoral region. Tetany may occur
       from 1 to 7 days postoperatively. Late signs and symptoms of tetany include seizures, contraction of
       the glottis, and respiratory obstruction. The nurse should notify the physician. Exercising the joints in
       the fingers and toes will not relieve the tetany. The client is not exhibiting signs of thrombophlebitis.
       There is no indication of nerve damage that would cause the client not to be able to speak.
       CN: Physiological adaptation; CL: Synthesize

Question 15

15. Which of the following medications should be available to provide emergency treatment if a
    client develops tetany after a subtotal thyroidectomy?
16. Sodium phosphate.
17. Calcium gluconate.
18. Echothiophate iodide.
19. Sodium bicarbonate.

Answer 15

15. 2. 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.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 16

16. A 60-year-old female is diagnosed with hypothyroidism. The nurse should assess the client
for which of the following?
1. Tachycardia.
2. Weight gain.
3. Diarrhea.
4. Nausea.

Answer 16

16. 2. Typical signs and symptoms of hypothyroidism include weight gain, fatigue, decreased
       energy, apathy, brittle nails, dry skin, cold intolerance, hair loss, constipation, and numbness and
       tingling in the fingers. Tachycardia is a sign of hyperthyroidism, not hypothyroidism. Diarrhea and
       nausea are not symptoms of hypothyroidism.
       CN: Physiological adaptation; CL: Analyze

Question 17

17. The nurse should assess a client with hypothyroidism for which of the following?
18. Corneal abrasion due to inability to close the eyelids.
19. Weight loss due to hypermetabolism.
20. Fluid loss due to diarrhea.
21. Decreased activity due to fatigue

Answer 17

17. 4. A major problem for the person with hypothyroidism is fatigue. Other signs and symptoms
       include lethargy, personality changes, generalized edema, impaired memory, slowed speech, cold
       intolerance, dry skin, muscle weakness, constipation, weight gain, and hair loss. Incomplete closure
       of the eyelids, hypermetabolism, and diarrhea are associated with hyperthyroidism.
       CN: Basic care and comfort; CL: Analyze

Question 18

18. When discussing recent onset of feelings of sadness and depression in a client with
    hypothyroidism, the nurse should inform the client that these feelings are:
19. The effects of thyroid hormone replacement therapy and will diminish over time.
20. Related to thyroid hormone replacement therapy and will not diminish over time.
21. A normal part of having a chronic illness.
22. Most likely related to low thyroid hormone levels and will improve with treatment.

Answer 18

18. 4. Hypothyroidism may contribute to sadness and depression. It is good practice for clientswith newly diagnosed depression to be monitored for hypothyroidism by checking serum thyroid
       hormone and thyroid-stimulating hormone levels. This client needs to know that these feelings may be
       related to her low thyroid hormone levels and may improve with treatment. Replacement therapy does
       not cause depression. Depression may accompany chronic illness, but it is not “normal.”
       CN: Psychosocial integrity; CL: Analyze

Question 19

19. The nurse is instructing the client with hypothyroidism who takes levothyroxine (Synthroid)
    100 mcg, digoxin (Lanoxin) and simvastatin (Zocor). Teaching regarding medications is effective if
    the client will take:
20. The Synthroid with breakfast and the other medications after breakfast.
21. The Synthroid before breakfast and the other medications 4 hours later.
22. All medications together 1 hour after eating breakfast.
23. All medications before going to bed.

Answer 19

19. 2. Synthroid (levothyroxine) must be given at the same time each day on an empty stomach,
       preferably 1/2 to 1 hour before breakfast. Other medications may impair the action of levothyroxine
       (Synthroid) absorption; the client should separate doses of other medications by 4 to 5 hours.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 20

The Client with Diabetes Mellitus
20. The nurse is teaching a diabetic client using an empowerment approach. The nurse should
initiate teaching by asking which of the following?
1. “How much does your family need to be involved in learning about your condition?”
2. “What is required for your family to manage your symptoms?”
3. “What activities are most important for you to be able to maintain control of your diabetes?”
4. “What do you know about your medications and condition?”

Answer 20

The Client with Diabetes Mellitus
20. 3. Empowerment is an approach to clinical practice that emphasizes helping people discover
and use their innate abilities to gain mastery over their own condition. Empowerment means that
individuals with a health problem have the tools, such as knowledge, control, resources, and
experience, to implement and evaluate their self-management practices. Involvement of others, such
as asking the client about family involvement, implies that the others will provide the direct care
needed rather than the client. Asking the client what the client needs to know implies that the nurse
will be the one to provide the information. Telling the client what is required does not provide the
client with options or lead to empowerment.
CN: Health promotion and maintenance; CL: Synthesize

Question 21

21. The nurse is obtaining a health history from a client with diabetes mellitus who has been
    taking insulin for many years. Currently the client reports having periods of hypoglycemia followed
    by periods of hyperglycemia. The nurse should specifically ask if the client is
22. Eating snacks between meals.
23. Initiating the use of the insulin pump.
24. Injecting insulin at a site of lipodystrophy.
25. Adjusting insulin according to blood glucose levels.

Answer 21

21. 3. Lipodystrophy, specifically lipohypertrophy, involves swelling of the fat at the site of
       repeated injections, which can interfere with the absorption of insulin, resulting in erratic blood
       glucose levels. Because the client has been receiving insulin for many years, this is the most likely
       cause of poor control. Eating snacks between meals causes hyperglycemia. Adjusting insulin
       according to blood glucose levels would not cause hypoglycemia but normal levels. Initiating an
       insulin pump would not, of itself, cause the periods of hyperglycemia.
       CN: Physiological Integrity; CL: Analyze

Question 22

22. A nurse is participating in a diabetes screening program. Who of the following is (are) at risk
    for developing type 2 diabetes? Select all that apply.
23. A 32-year-old female who delivered a 91⁄2-lb (4,309-g) infant.
24. A 44-year-old Native American (First Nations) who has a body mass index (BMI) of 32.
25. An 18-year-old immigrant from Mexico who jogs four times a week.
26. A 55-year-old Asian who has hypertension and two siblings with type 2 diabetes.
27. A 12-year-old who is overweight.

Answer 22

22. 1, 2, 4, 5. The risk factors for developing type 2 diabetes include giving birth to an infant
    weighing more than 9 lb (4,082 g); obesity (BMI over 30); ethnicity of Asian, African, Native
    American, or First Nations; age greater than 45 years; hypertension; and family history in parents or
    siblings. Childhood obesity is also a risk factor for type 2 diabetes. Maintaining an ideal weight,
    eating a low-fat diet, and exercising regularly decrease the risk of type 2 diabetes.
    CN: Reduction of risk potential; CL: Analyze

Question 23

23. An adult with type 2 diabetes mellitus has been NPO since 10 PM in preparation for having a
    nephrectomy the next day. At 6 AM on the day of surgery, the nurse reviews the client’s chart and
    laboratory results. Which finding should the nurse report to the physician?
24. Urine output of 350 mL in 8 hours.
25. Urine specific gravity of 1.015.
26. Potassium of 4.0 mEq (4 mmol/L).
27. Blood glucose of 140 mg/dL (7.8 mmol/L).

Answer 23

23. 4. 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.
       CN: Reduction of risk potential; CL: Synthesize

Question 24

24. The nurse is checking the laboratory results of an adult client with type 1 diabetes (see chart).
BLOOD GLUCOSE 192 MG/DL
TOTAL CHOLESTEROL 250 MG / DL
HEMOGLOBIN 12.3 MG / DL
LDL 125 MG /DL

What laboratory result indicates a problem that should be managed?

1. Blood glucose.
2. Total cholesterol.
3. Hemoglobin.
4. Low-density lipoprotein (LDL) cholesterol.

Answer 24

24. 1. The elevated blood glucose level indicates hyperglycemia. The hemoglobin is normal. The
       client’s cholesterol and LDL levels are both normal. The nurse should determine if there are standing
       orders for the hyperglycemia or notify the physician.CN: Reduction of risk potential; CL: Analyze

Question 25

25. A client with type 1 diabetes mellitus has diabetic ketoacidosis. Which of the following
    findings has the greatest effect on fluid loss?
26. Hypotension.
27. Decreased serum potassium level.
28. Rapid, deep respirations.
29. Warm, dry skin.

Answer 25

25. 3. Due to the rapid, deep respirations, the client is losing fluid from vaporization from the
       lungs and skin (insensible fluid loss). Normally, about 900 mL of fluid is lost per day through
       vaporization. Decreased serum potassium level has no effect on insensible fluid loss. Hypotension
       occurs due to polyuria and inadequate fluid intake. It may decrease the flow of blood to the skin,
       causing the skin to be warm and dry.
       CN: Reduction of risk potential; CL: Analyze

Question 26

26. A client is to receive glargine insulin in addition to a dose of aspart. When the nurse checks
    the blood glucose level at the bedside, it is greater than 200 mg/dL (11.1 mmol/L). How should the
    nurse administer the insulins?
27. Put air into the glargine insulin vial, and then air into the aspart insulin vial, and draw up the
    correct dose of aspart insulin first.
28. Roll the glargine insulin vial, then roll the aspart insulin vial. Draw up the longer-acting
    glargine insulin first.
29. Shake both vials of insulin before drawing up each dose in separate insulin syringes.
30. Put air into the glargine insulin vial, and draw up the correct dose in an insulin syringe; then,
    with a different insulin syringe, put air into the aspart vial and draw up the correct dose.

Answer 26

26. 4. Glargine is a long-acting recombinant human insulin analog. Glargine should not be mixed
       with any other insulin product. Insulins should not be shaken; instead, if the insulin is cloudy, roll the
       vial or insulin pen between the palms of the hands.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 27

27. The client with type 2 insulin-requiring diabetes asks the nurse about having alcoholic
    beverages. Which of the following is the best response by the nurse?
28. “You can have one or two drinks a day as long as you have something to eat with them.”
29. “Alcohol is detoxified in the liver, so it is not a good idea for you to drink anything with
    alcohol.”
30. “If you are going to have a drink, it is best to consume alcohol on an empty stomach.”
31. “If you do have a drink, the blood glucose value may be elevated at bedtime, and you should
    skip having a snack.”

Answer 27

27. 1. A modest alcohol intake (1 to 2 drinks/day) may be incorporated into the nutrition plan for
       individuals who choose to drink. Alcohol is detoxified in the liver where glycogen reserves are
       stored and normally released in case of hypoglycemia. At the time alcohol is consumed, glucose
       values will likely rise because of the carbohydrate in the beer, wine or mixed drinks; however, the
       later and more dangerous effect of alcohol is a hypoglycemic effect. Alcohol should be consumed
       with food; even if blood glucose values are elevated, the bedtime snack should not be skipped.
       CN: Health promotional; CL: Synthesize

Question 28

28. An adult client with type 2 diabetes is taking metformin (Glucophage) 1,000 mg two times
    every day. After the nurse provides instructions regarding the interaction of alcohol and metformin,
    the nurse evaluates that the client understands the instructions when the client says:
29. “If I know I’ll be having alcohol, I must not take metformin; I could develop lactic acidosis.”
30. “If my physician approves, I may drink alcohol with my metformin.”
31. “Adverse effects I should watch for are feeling excessively energetic, unusual muscle stiffness,
    low back pain, and a rapid heartbeat.”
32. “If I feel bloated, I should call my physician.”

Answer 28

28. 1. A rare but serious adverse effect of metformin (Glucophage) is lactic acidosis; half the
       cases are fatal. Ideally, one should stop metformin for 2 days before and 2 days after drinking
       alcohol. Signs and symptoms of lactic acidosis are weakness, fatigue, unusual muscle pain, dyspnea,
       unusual stomach discomfort, dizziness or light-headedness, and bradycardia or cardiac arrhythmias.
       Bloating is not an adverse effect of metformin.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 29

29. A client has recently been diagnosed with type 2 diabetes mellitus and is to take tolbutamide.
    When teaching the client about the drug, the nurse explains that tolbutamide is believed to lower theblood glucose level by which of the following actions?
30. Potentiating the action of insulin.
31. Lowering the renal threshold of glucose.
32. Stimulating insulin release from functioning beta cells in the pancreas.
33. Combining with glucose to render it inert.

Answer 29

29. 3. Oral hypoglycemic agents of the sulfonylurea group, such as tolbutamide, lower the blood
       glucose level by stimulating functioning beta cells in the pancreas to release insulin. These agents
       also increase insulin’s ability to bind to the body’s cells. They may also act to increase the number of
       insulin receptors in the body. Tolbutamide does not potentiate the action of insulin. Tolbutamide does
       not lower the renal threshold of glucose, which would not be a factor in the treatment of diabetes in
       any case. Tolbutamide does not combine with glucose to render it inert.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 30

30. Which information should the nurse include when developing a teaching plan for a client
    newly diagnosed with type 2 diabetes mellitus? Select all that apply.
31. A major risk factor for complications is obesity and central abdominal obesity.
32. Supplemental insulin is mandatory for controlling the disease.
33. Exercise increases insulin resistance.
34. The primary nutritional source requiring monitoring in the diet is carbohydrates.
35. Annual eye and foot examinations are recommended by the American and Canadian Diabetes
    Associations.

Answer 30

30. 1, 5. Being overweight and having a large waist-hip ratio (central abdominal obesity)
    increase insulin resistance, making control of diabetes more difficult. The American and Canadian
    Diabetes Associations recommend a yearly referral to an ophthalmologist and podiatrist. Exercise
    and weight management decrease insulin resistance. Insulin is not always needed for type 2 diabetes;
    diet, exercise, and oral medications are the first-line treatment. The client must monitor all nutritional
    sources for a balanced diet—fats, carbohydrates, and protein.
    CN: Reduction of risk potential; CL: Create

Question 31

31. When teaching the diabetic client about foot care, the nurse should instruct the client to do
which of the following?
1. Avoid going barefoot.
2. Buy shoes a half size larger.
3. Cut toenails at angles.
4. Use heating pads for sore feet.

Answer 31

31. 1. The client with diabetes is prone to serious foot injuries secondary to peripheral
       neuropathy and decreased circulation. The client should be taught to avoid going barefoot to preventinjury. Shoes that do not fit properly should not be worn because they will cause blisters that can
       become nonhealing, serious wounds for the diabetic client. Toenails should be cut straight across. A
       heating pad should not be used because of the risk of burns due to insensitivity to temperature.
       CN: Reduction of risk potential; CL: Synthesize

Question 32

32. A client with diabetes mellitus asks the nurse to recommend something to remove corns from
    the toes. The nurse should advise the client to:
33. Apply a high-quality corn plaster to the area.
34. Consult a physician or podiatrist about removing the corns.
35. Apply iodine to the corns before peeling them off.
36. Soak the feet in borax solution to peel off the corns.

Answer 32

32. 2. A client with diabetes should be advised to consult a physician or podiatrist for corn
       removal because of the danger of traumatizing the foot tissue and potential development of ulcers. The
       diabetic client should never self-treat foot problems but should consult a physician or podiatrist.
       CN: Reduction of risk potential; CL: Synthesize

Question 33

33. A client with diabetes mellitus comes to the clinic for a regular 3-month follow-up
    appointment. The nurse notes several small bandages covering cuts on the client’s hands. The client
    says, “I’m so clumsy. I’m always cutting my finger cooking or burning myself on the iron.” Which of
    the following responses by the nurse would be most appropriate?
34. “Wash all wounds in isopropyl alcohol.”
35. “Keep all cuts clean and covered.”
36. “Why don’t you have your children do the cooking and ironing?”
37. “You really should be fine as long as you take your daily medication.”

Answer 33

33. 2. Proper and careful first-aid treatment is important when a client with diabetes has a skin cut
       or laceration. The skin should be kept supple and as free of organisms as possible. Washing and
       bandaging the cut will accomplish this. Washing wounds with alcohol is too caustic and drying to the
       skin. Having the children help is an unrealistic suggestion and does not educate the client about
       proper care of wounds. Tight control of blood glucose levels through adherence to the medication
       regimen is vitally important; however, it does not mean that careful attention to cuts can be ignored.
       CN: Reduction of risk potential; CL: Synthesize

Question 34

34. The client with diabetes mellitus says, “If I could just avoid what you call carbohydrates in
    my diet, I guess I would be okay.” The nurse should base the response to this comment on the
    knowledge that diabetes affects metabolism of which of the following?
35. Carbohydrates only.
36. Fats and carbohydrates only.
37. Protein and carbohydrates only.
38. Proteins, fats, and carbohydrates.

Answer 34

34. 4. 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.
       CN: Basic care and comfort; CL: Apply

Question 35

35. A client with type 1 diabetes mellitus is admitted to the emergency department. Which of the
    following respiratory patterns requires immediate action?1. Deep, rapid respirations with long expirations.
36. Shallow respirations alternating with long expirations.
37. Regular depth of respirations with frequent pauses.
38. Short expirations and inspirations

Answer 35

35. 1. Deep, rapid respirations with long expirations are indicative of Kussmaul’s respirations,
       which occur in metabolic acidosis. The respirations increase in rate and depth, and the breath has a
       “fruity” or acetone-like odor. This breathing pattern is the body’s attempt to blow off carbon dioxide
       and acetone, thus compensating for the acidosis. The other breathing patterns listed are not related to
       ketoacidosis and would not compensate for the acidosis.
       CN: Physiological adaptation; CL: Analyze

Question 36

36. The client has been recently diagnosed with type 2 diabetes, and is taking metformin
    (Glucophage) two times per day, 1,000 mg before breakfast and 1,000 mg before supper. The client is
    experiencing diarrhea, nausea, vomiting, abdominal bloating, and anorexia on admission to the
    hospital. The admission prescriptions include metformin (Glucophage). The nurse should do which of
    the following? Select all that apply.
37. Discontinue the metformin (Glucophage).
38. Administer glargine (Lantus) insulin rather than the metformin (Glucophage).
39. Inform the client that the adverse effects of diarrhea, nausea, and upset stomach gradually
    subside over time.
40. Assess the client’s renal function.
41. Monitor the client’s glucose value prior to each meal

Answer 36

36. 3, 4, 5. The nurse may not discontinue a medication without a physician’s prescription, and the
    nurse may not substitute one medication for another. Maximum doses may be better tolerated if given
    with meals. Before therapy begins, and at least annually thereafter, assess the client’s renal function; if
    renal impairment is detected, a different antidiabetic agent may be indicated. To evaluate the
    effectiveness of therapy, the client’s glucose value must be monitored regularly. The prescriber must
    be notified if the glucose value increases, despite therapy.
    CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 37

37. A client is prescribed exenatide (Byetta). The nurse should instruct the client about which of
    the following? Select all that apply.
38. To review the one-time set-up for each new pen.
39. Inject in the thigh, abdomen, or upper arm.
40. Administer the drug within 60 minutes before morning and evening meals.
41. That there is a low incidence of hypoglycemia when taken with insulin.
42. If a dose is missed, take the dose of exenatide (Byetta) as soon as the client remembers.

Answer 37

37. 1, 2, 3. Client teaching includes reviewing proper use and storage of the exenatide (Byetta)
    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.
    CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 38

38. The nurse is administering the initial dose of a rapid-acting insulin to a client with type 1
    diabetes. The nurse should assess the client for hypoglycemia within:
39. 0.5 hours.
40. 1 hour.
41. 2 hours.
42. 3 hours.

Answer 38

38. 4. Rapid-acting insulin has an onset in 15 minutes, peaks at 1 hour, and lasts for 3 to 4 hours.
       Rapid-acting insulin is administered right before or right after a meal. The nurse should assess the
       client for hypoglycemia 1 hour following administration of the drug.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 39

39. The nurse notes grapefruit juice on the breakfast tray of a client who is taking repaglinide.
    The nurse should:
40. Contact the manager of the Food and Nutrition Department.
41. Request that the dietitian discuss the drug-food interaction between repaglinide and grapefruit
    juice with the client.
42. Substitute a half grapefruit in place of the grapefruit juice.
43. Remove the grapefruit juice from the client’s tray and bring another juice of the client’s
    preference.

Answer 39

39. 4. There is a drug-food interaction between repaglinide and grapefruit juice that may inhibit
       metabolism of repaglinide; the fresh grapefruit also interacts with repaglinide. It is not necessary that
       the dietitian inform the client of the drug-food interaction first. To contact the manager of the Food and
       Nutrition Department is not an intervention that will bring about prompt removal of the juice.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 40

40. Which of the following findings should the nurse report to the client’s physician for a client
    with unstable type 1 diabetes mellitus? Select all that apply.
41. Systolic blood pressure, 145 mm Hg.
42. Diastolic blood pressure, 87 mm Hg.
43. High-density lipoprotein (HDL), 30 mg/dL (1.7 mmol/L).
44. Glycosylated hemoglobin (HbA 1c ), 10.2% (0.1).5. Triglycerides, 425 mg/dL (23.6 mmol/L).
45. Urine ketones, negative.

Answer 40

40. 1, 2, 3, 4, 5. The client with unstable diabetes mellitus is at risk for many complications.
    Heart disease is the leading cause of mortality in clients with diabetes. The goal blood pressure for
    diabetics is less than 130/80 mm Hg. Therefore, the nurse would need to report any findings greater
    than 130/80 mm Hg. The goal of HbA 1c is less than 7% (0.07); thus, a level of 10.2% (0.1) must be
    reported. HDL less than 40 mg/dL (2.2 mmol/L) and triglycerides greater than 150 mg/dL (8.3
    mmol/L) are risk factors for heart disease. The nurse would need to report the client’s HDL and
    triglyceride levels. The urine ketones are negative, but this is a late sign of complications when there
    is a profound insulin deficiency.
    CN: Reduction of risk potential; CL: Analyze

Question 41

41. The nurse should caution the client with diabetes mellitus who is taking a sulfonylurea that
    alcoholic beverages should be avoided while taking these drugs because they can cause which of the
    following?
42. Hypokalemia.
43. Hyperkalemia.
44. Hypocalcemia.
45. Disulfiram (Antabuse)–like symptoms.

Answer 41

41. 4. A client with diabetes who takes any first- or second-generation sulfonylurea should be
       advised to avoid alcohol intake. Sulfonylureas in combination with alcohol can cause serious
       disulfiram (Antabuse)–like reactions, including flushing, angina, palpitations, and vertigo. Serious
       reactions, such as seizures and possibly death, may also occur. Hypokalemia, hyperkalemia, and
       hypocalcemia do not result from taking sulfonylureas in combination with alcohol.
       CN: Physiological adaptation; CL: Apply

Question 42

42. Which of the following conditions is the most significant risk factor for the development of
type 2 diabetes mellitus?
1. Cigarette smoking.
2. High-cholesterol diet.
3. Obesity.
4. Hypertension.

Answer 42

42. 3. The most important factor predisposing to the development of type 2 diabetes mellitus is
       obesity. Insulin resistance increases with obesity. Cigarette smoking is not a predisposing factor, but
       it is a risk factor that increases complications of diabetes mellitus. A high-cholesterol diet does not
       necessarily predispose to diabetes mellitus, but it may contribute to obesity and hyperlipidemia.
       Hypertension is not a predisposing factor, but it is a risk factor for developing complications of
       diabetes mellitus.
       CN: Health promotion and maintenance; CL: Apply

Question 43

43. Which of the following indicates a potential complication of diabetes mellitus?
44. Inflamed, painful joints.
45. Blood pressure of 160/100 mm Hg.
46. Stooped appearance.
47. Hemoglobin of 9 g/dL (90 g/L).

Answer 43

43. 2. The client with diabetes mellitus is especially prone to hypertension due to atherosclerotic
       changes, which leads to problems of the microvascular and macrovascular systems. This can result in
       complications in the heart, brain, and kidneys. Heart disease and stroke are twice as common among
       people with diabetes mellitus as among people without the disease. Painful, inflamed joints
       accompany rheumatoid arthritis. A stooped appearance accompanies osteoporosis with narrowing of
       the vertebral column. A low hemoglobin concentration accompanies anemia, especially iron
       deficiency anemia and anemia of chronic disease.
       CN: Reduction of risk potential; CL: Analyze

Question 44

44. The nurse is teaching the client about home blood glucose monitoring. Which of the following
    blood glucose measurements indicates hypoglycemia?
45. 59 mg/dL (3.3 mmol/L).
46. 75 mg/dL (4.2 mmol/L).
47. 108 mg/dL (6 mmol/L).
48. 119 mg/dL (6.6 mmol/L).

Answer 44

44. 1. Although some individual variation exists, when the blood glucose level decreases to less
       than 70 mg/dL (3.9 mmol/L), the client experiences or is at risk for hypoglycemia. Hypoglycemia canoccur in both type 1 and type 2 diabetes mellitus, although it is more common when the client is taking
       insulin. The nurse should instruct the client on the prevention, detection, and treatment of
       hypoglycemia.
       CN: Physiological adaptation; CL: Analyze

Question 45

45. Assessment of the diabetic client for common complications should include examination of
the:
1. Abdomen.
2. Lymph glands.
3. Pharynx.
4. Eyes.

Answer 45

45. 4. Diabetic retinopathy, cataracts, and glaucoma are common complications in diabetics,
       necessitating eye assessment and examination. The feet should also be examined at each client
       encounter, monitoring for thickening, fissures, or breaks in the skin; ulcers; and thickened nails.
       Although assessments of the abdomen, pharynx, and lymph glands are included in a thorough
       examination, they are not pertinent to common diabetic complications.
       CN: Reduction of risk potential; CL: Analyze

Question 46

46. The client with type 1 diabetes mellitus is taught to take isophane insulin suspension NPH
    (Humulin N) at 5 PM each day. The client should be instructed that the greatest risk of hypoglycemia
    will occur at about what time?
47. 11 AM , shortly before lunch.
48. 1 PM , shortly after lunch.
49. 6 PM , shortly after dinner.
50. 1 AM , while sleeping.

Answer 46

46. 4. The client with diabetes mellitus who is taking NPH insulin (Humulin N) in the evening is
       most likely to become hypoglycemic shortly after midnight because this insulin peaks in 6 to 8 hours.
       The client should eat a bedtime snack to help prevent hypoglycemia while sleeping.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 47

47. A nurse is teaching a client with type 1 diabetes mellitus who jogs daily about the preferred
    sites for insulin absorption. What is the most appropriate site for a client who jogs?
48. Arms.2. Legs.
49. Abdomen.
50. Iliac crest.

Answer 47

47. 3. If the client engages in an activity or exercise that focuses on one area of the body, that area
       may cause inconsistent absorption of insulin. A good regimen for a jogger is to inject the abdomen for
       1 week and then rotate to the buttock. A jogger may have inconsistent absorption in the legs or arms
       with strenuous running. The iliac crest is not an appropriate site due to a lack of loose skin and
       subcutaneous tissue in that area.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 48

48. A client with diabetes is taking insulin lispro (Humalog) injections. The nurse should advise
    the client to eat:
49. Within 10 to 15 minutes after the injection.
50. 1 hour after the injection.
51. At any time, because timing of meals with lispro injections is unnecessary.
52. 2 hours before the injection.

Answer 48

48. 1. Insulin lispro (Humalog) begins to act within 10 to 15 minutes and lasts approximately 4
       hours. A major advantage of Humalog is that the client can eat almost immediately after the insulin is
       administered. The client needs to be instructed regarding the onset, peak, and duration of all insulin,
       as meals need to be timed with these parameters. Waiting 1 hour to eat may precipitate hypoglycemia.
       Eating 2 hours before the insulin lispro could cause hyperglycemia if the client does not have
       circulating insulin to metabolize the carbohydrate.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 49

49. The best indicator that the client has learned how to give an insulin self-injection correctly is
    when the client can:
50. Perform the procedure safely and correctly.
51. Critique the nurse’s performance of the procedure.
52. Explain all steps of the procedure correctly.
53. Correctly answer a posttest about the procedure.

Answer 49

49. 1. The nurse should judge that learning has occurred from the evidence of a change in the
       client’s behavior. A client who performs a procedure safely and correctly demonstrates that he has
       acquired a skill. Evaluation of this skill acquisition requires performance of that skill by the client
       with observation by the nurse. The client must also demonstrate cognitive understanding, as shown by
       the ability to critique the nurse’s performance. Explaining the steps demonstrates acquisition of
       knowledge at the cognitive level only. A posttest does not indicate the degree to which the client has
       learned a psychomotor skill.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 50

The nurse is instructing the client on insulin administration. The client is performing a return
demonstration for preparing the insulin. The client’s morning dose of insulin is 10 units of regular and
22 units of NPH. The nurse checks the dose accuracy with the client. The nurse determines that the
client has prepared the correct dose when the syringe reads how many units?
____________________ units.

Answer 50

50. 32 units
    Clients commonly need to mix insulin, requiring careful mixing and calculation. The total dosage
    is 10 units plus 22 units, for a total of 32 units.
    CN: Pharmacological and parenteral therapies; CL: Apply

Question 51

51. Angiotensin-converting enzyme (ACE) inhibitors may be prescribed for the client with
    diabetes mellitus to reduce vascular changes and possibly prevent or delay development of:
52. Chronic obstructive pulmonary disease (COPD).
53. Pancreatic cancer.
54. Renal failure.
55. Cerebrovascular accident.

Answer 51

51. 3. Renal failure frequently results from the vascular changes associated with diabetesmellitus. ACE inhibitors increase renal blood flow and are effective in decreasing diabetic
       nephropathy. Chronic obstructive pulmonary disease is not a complication of diabetes, nor is it
       prevented by ACE inhibitors. Pancreatic cancer is neither prevented by ACE inhibitors nor
       considered a complication of diabetes. Cerebrovascular accident is not directly prevented by ACE
       inhibitors, although management of hypertension will decrease vascular disease.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 52

52. The nurse should teach the diabetic client that which of the following is the most common
symptom of hypoglycemia?
1. Nervousness.
2. Anorexia.
3. Kussmaul's respirations.
4. Bradycardia.

Answer 52

52. 1. 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.
       CN: Reduction of risk potential; CL: Apply

Question 53

53. The nurse is assessing the client’s use of medications. Which of the following medications
    may cause a complication with the treatment plan of a client with diabetes?
54. Aspirin.
55. Steroids.
56. Sulfonylureas.
57. Angiotensin-converting enzyme (ACE) inhibitors.

Answer 53

53. 2. Steroids can cause hyperglycemia because of their effects on carbohydrate metabolism,
       making diabetic control more difficult. Aspirin is not known to affect glucose metabolism.
       Sulfonylureas are oral hypoglycemic agents used in the treatment of diabetes mellitus. ACE inhibitors
       are not known to affect glucose metabolism.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 54

54. A client with type 1 diabetes mellitus has influenza. The nurse should instruct the client to:
55. Increase the frequency of self-monitoring (blood glucose testing).
56. Reduce food intake to diminish nausea.3. Discontinue that dose of insulin if unable to eat.
57. Take half of the normal dose of insulin.

Answer 54

54. 1. Colds and influenza present special challenges to the client with diabetes mellitus because
       the body’s need for insulin increases during illness. Therefore, the client must take the prescribed
       insulin dose, increase the frequency of blood glucose testing, and maintain an adequate fluid intake to
       counteract the dehydrating effect of hyperglycemia. Clear fluids, juices, and Gatorade are encouraged.
       Not taking insulin when sick, or taking half the normal dose, may cause the client to develop
       ketoacidosis.
       CN: Reduction of risk potential; CL: Synthesize

Question 55

55. Which of the following is a priority goal for the diabetic client who is taking insulin and has
    nausea and vomiting from a viral illness or influenza?
56. Obtaining adequate food intake.
57. Managing own health.
58. Relieving pain.
59. Increasing activity.

Answer 55

55. 1. 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 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.
       CN: Basic care and comfort; CL: Analyze

Question 56

56. A client with diabetes begins to cry and says, “I just cannot stand the thought of having to give
    myself a shot every day.” Which of the following would be the best response by the nurse?
57. “If you do not give yourself your insulin shots, you will die.”
58. “We can teach your daughter to give the shots so you will not have to do it.”
59. “I can arrange to have a home care nurse give you the shots every day.”
60. “What is it about giving yourself the insulin shots that bothers you?

Answer 56

56. 4. The best response is to allow the client to verbalize her fears about giving herself a shot
       each day. Tactics that increase fear are not effective in changing behavior. If possible, the client needs
       to be responsible for her own care, including giving self-injections. It is unlikely that the client’s
       insurance company will pay for home-care visits if the client is capable of self-administration.
       CN: Psychosocial integrity; CL: Synthesize

Question 57

The Client with Pituitary Adenoma
57. A client is to have a transsphenoidal hypophysectomy to remove a large, invasive pituitary
tumor. The nurse should instruct the client that the surgery will be performed through an incision in
the:
1. Back of the mouth.
2. Nose.
3. Sinus channel below the right eye.
4. Upper gingival mucosa in the space between the upper gums and lip.

Answer 57

The Client with Pituitary Adenoma
57. 4. With transsphenoidal hypophysectomy, the sella turcica is entered from below, through the
sphenoid sinus. There is no external incision; the incision is made between the upper lip and gums.CN: Reduction of risk potential; CL: Apply

Question 58

58. To help minimize the risk of postoperative respiratory complications after a hypophysectomy,
    during preoperative teaching, the nurse should instruct the client how to:
59. Use incentive spirometry.
60. Turn in bed.
61. Take deep breaths.
62. Cough.

Answer 58

58. 3. Deep breathing is the best choice for helping prevent atelectasis. The client should be
       placed in the semi-Fowler’s position (or as prescribed) and taught deep breathing, sighing, mouth
       breathing, and how to avoid coughing. Blow bottles are not effective in preventing atelectasis
       because they do not promote sustained alveolar inflation to maximal lung capacity. Frequent position
       changes help loosen lung secretions, but deep breathing is most important in preventing atelectasis.
       Coughing is contraindicated because it increases intracranial pressure and can cause cerebrospinal
       fluid to leak from the point at which the sella turcica was entered.
       CN: Reduction of risk potential; CL: Synthesize

Question 59

59. Following a transsphenoidal hypophysectomy, the nurse should assess the client for:
60. Cerebrospinal fluid (CSF) leak.
61. Fluctuating blood glucose levels.
62. Cushing’s syndrome.
63. Cardiac arrhythmias.

Answer 59

59. 1. A major focus of nursing care after transsphenoidal hypophysectomy is the prevention of
       and monitoring for a CSF leak. CSF leakage can occur if the patch or incision is disrupted. The nurse
       should monitor for signs of infection, including elevated temperature, increased white blood cell
       count, rhinorrhea, nuchal rigidity, and persistent headache. Hypoglycemia and adrenocortical
       insufficiency may occur. Monitoring for fluctuating blood glucose levels is not related specifically to
       transsphenoidal hypophysectomy. The client will be given IV fluids postoperatively to supply
       carbohydrates. Cushing’s disease results from adrenocortical excess, not insufficiency. Monitoring for
       cardiac arrhythmias is important, but arrhythmias are not anticipated following a transsphenoidal
       hypophysectomy.
       CN: Reduction of risk potential; CL: Analyze

Question 60

60. A male client expresses concern about how a hypophysectomy will affect his sexual function.
    Which of the following statements provides the most accurate information about the physiologic
    effects of hypophysectomy?
61. Removing the source of excess hormone should restore the client’s libido, erectile function,
    and fertility.
62. Potency will be restored, but the client will remain infertile.
63. Fertility will be restored, but impotence and decreased libido will persist.
64. Exogenous hormones will be needed to restore erectile function after the adenoma is removed.

Answer 60

60. 1. The client’s sexual problems are directly related to the excessive prolactin level. Removing
       the source of excessive hormone secretion should allow the client to return gradually to a normal
       physiologic pattern. Fertility will return, and erectile function and sexual desire will return to
       baseline as hormone levels return to normal.
       CN: Physiological adaptation; CL: Apply

Question 61

61. Before undergoing a transsphenoidal hypophysectomy for pituitary adenoma, the client asks
    the nurse how the surgeon will close the incision made in the dura. The nurse should respond based
    on the knowledge that:
62. Dissolvable sutures are used to close the dura.
63. Nasal packing provides pressure until normal wound healing occurs.
64. A patch is made with a piece of fascia.
65. A synthetic mesh is placed to facilitate healing.

Answer 61

61. 3. The dural opening is typically repaired with a patch of muscle or fascia taken from the
       abdomen or thigh. The client should be prepared preoperatively for the presence of this additional
       incision in the abdomen or thigh. The client will need the patch of muscle or fascia to replace the
       dura. Disposable sutures alone will not provide an intact suture line. Nasal packing will not provide
       closure for the dural opening. A synthetic mesh is not the tissue of choice for surgical repair of the
       dura.
       CN: Reduction of risk potential; CL: Apply

Question 62

62. Initial treatment for a cerebrospinal fluid (CSF) leak after transsphenoidal hypophysectomy
    would most likely involve:
63. Repacking the nose.
64. Returning the client to surgery.
65. Enforcing bed rest with the head of the bed elevated.
66. Administering high-dose corticosteroid therapy.

Answer 62

62. 3. If CSF leakage is suspected or confirmed, the client is treated initially with bed rest with
       the head of the bed elevated to decrease pressure on the graft site. Most leaks heal spontaneously, but
       occasionally surgical repair of the site in the sella turcica is needed. Repacking the nose will not heal
       the leak at the graft site in the dura. The client will not be returned to surgery immediately because
       most leaks heal spontaneously. High-dose corticosteroid therapy is not effective in healing a CSF
       leak.
       CN: Physiological adaptation; CL: Apply

Question 63

63. To provide oral hygiene for a client recovering from transsphenoidal hypophysectomy, the
    nurse should instruct the client to:
64. Rinse the mouth with saline solution.
65. Perform frequent toothbrushing.
66. Clean the teeth with an electric toothbrush.
67. Floss the teeth thoroughly.

Answer 63

63. 1. After transsphenoidal surgery, the client must be careful not to disturb the suture line while
       healing occurs. Frequent oral care should be provided with rinses of saline, and the teeth may be
       gently cleaned with Toothettes. Frequent or vigorous toothbrushing or flossing is contraindicatedbecause it may disturb or cause tension on the suture line.
       CN: Physiological adaptation; CL: Synthesize

Question 64

64. The nurse teaches the client to report signs and symptoms of which potential complication
after hypophysectomy?
1. Acromegaly.
2. Cushing's disease.
3. Diabetes mellitus.
4. Hypopituitarism.

Answer 64

64. 4. 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.
       CN: Reduction of risk potential; CL: Analyze

Question 65

65. After pituitary surgery, the nurse should assess the client for which of the following?
66. Urine specific gravity less than 1.010.
67. Urine output between 1 and 2 L/day.
68. Blood glucose level higher than 300 mg/dL (16.7 mmol/L).
69. Urine negative for glucose and ketones.

Answer 65

65. 1. Pituitary diabetes insipidus is a potential complication after pituitary surgery because of
       possible interference with the production of antidiuretic hormone (ADH). One major manifestation of
       diabetes insipidus is polyuria because lack of ADH results in insufficient water reabsorption by the
       kidneys. The polyuria leads to a decreased urine specific gravity (between 1.001 and 1.010). The
       client may drink and excrete 5 to 40 L of fluid daily. Diabetes insipidus does not affect metabolism. A
       blood glucose level higher than 300 mg/dL (16.7 mmol/L) is associated with impaired glucose
       metabolism or diabetes mellitus. Urine negative for sugar and ketones is normal.
       CN: Reduction of risk potential; CL: Analyze

Question 66

66. Vasopressin is administered to the client with diabetes insipidus because it:
67. Decreases blood pressure.
68. Increases tubular reabsorption of water.
69. Increases release of insulin from the pancreas.
70. Decreases glucose production within the liver.

Answer 66

66. 2. 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.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 67

67. Which of the following indicates that the client with diabetes insipidus understands how to
    manage care?
68. The client will maintain normal fluid and electrolyte balance.
69. The client will select a diabetic diet correctly.
70. The client will state dietary restrictions.
71. The client will exhibit serum glucose level within normal range.

Answer 67

67. 1. 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.
       CN: Physiological adaptation; CL: Evaluate

Question 68

The Client with Addison’s Disease
68. The nurse is instructing a young adult 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 of the following situations?
1. Completing the spring semester of school.
2. Gaining 4 lb (1.8 kg).
3. Becoming engaged.
4. Undergoing a root canal.

Answer 68

The Client with Addison’s Disease
68. 4. 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.
CN: Reduction of risk potential; CL: Synthesize

Question 69

69. Which of the following is the priority for a client in addisonian crisis?
70. Controlling hypertension.
71. Preventing irreversible shock.
72. Preventing infection.
73. Relieving anxiety.

Answer 69

69. 2. Addison’s disease is caused by a deficiency of adrenal corticosteroids and can result insevere 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.
       CN: Physiological adaptation; CL: Synthesize

Question 70

70. Which of the following would be an expected finding in a client with adrenal crisis
(addisonian crisis)?
1. Fluid retention.
2. Pain.
3. Peripheral edema.
4. Hunger.

Answer 70

70. 2. Adrenal hormone deficiency can cause profound physiologic changes. The client may
       experience severe pain (headache, abdominal pain, back pain, or pain in the extremities). Inhibited
       gluconeogenesis commonly produces hypoglycemia, and impaired sodium retention causes decreased,
       not increased, fluid volume. Edema would not be expected. Gastrointestinal disturbances, including
       nausea and vomiting, are expected findings in Addison’s disease, not hunger.
       CN: Physiological adaptation; CL: Analyze

Question 71

71. The client is receiving an IV infusion of 5% dextrose in normal saline running at 125 mL/h.
    When hanging a new bag of fluid, the nurse notes swelling and hardness at the infusion site. The nurse
    should first:
72. Discontinue the infusion.
73. Apply a warm soak to the site.
74. Stop the flow of solution temporarily.
75. Irrigate the needle with normal saline.

Answer 71

71. 1. Signs of infiltration include slowing of the infusion and swelling, pain, hardness, pallor,
       and coolness of the skin at the site. If these signs occur, the IV line should be discontinued and
       restarted at another infusion site. The new anatomic site, time, and type of cannula used should be
       documented. The nurse may apply a warm soak to the site, but only after the IV line is discontinued.
       Parenteral administration of fluids should not be stopped intermittently. Stopping the flow does not
       treat the problem, nor does it address the client’s needs for fluid replacement. Infiltrated IV sites
       should not be irrigated; doing so will only cause more swelling and pain.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 72

72. The client’s wife asks the nurse whether the IV infusion is meeting her husband’s nutritional
    needs because he has vomited several times. The nurse’s response should be based on the knowledge
    that 1 L of 5% dextrose in normal saline solution delivers:
73. 170 cal.
74. 250 cal.
75. 340 cal.
76. 500 cal.

Answer 72

72. 1. Each liter of 5% dextrose in normal saline solution contains 170 cal. The nurse should
       consult with the physician and dietitian when a client is on IV therapy or is on nothing-by-mouth status
       for an extended period because further electrolyte supplementation or alimentation therapy may be
       needed.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 73

73. A client with Addison’s disease is admitted to the medical unit. The client 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 of the following fluids would be most
    appropriate?
74. Milk and diet soda.
75. Water and eggnog.
76. Bouillon and juice.
77. Coffee and milkshakes.

Answer 73

73. 3. Electrolyte imbalances associated with Addison’s disease include hypoglycemia,
       hyponatremia, and hyperkalemia. Salted bouillon 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.
       CN: Basic care and comfort; CL: Apply

Question 74

74. After stabilization of Addison’s disease, the nurse teaches the client about stress management.
    The nurse should instruct the client to:
75. Remove all sources of stress from daily life.
76. Use relaxation techniques such as music.
77. Take antianxiety drugs daily.
78. Avoid discussing stressful experiences.

Answer 74

74. 2. Finding alternative methods of dealing with stress, such as relaxation techniques, is a
       cornerstone of stress management. Removing all sources of stress from one’s life is not possible.
       Antianxiety drugs are prescribed for temporary management during periods of major stress, and they
       are not an intervention in stress management classes. Avoiding discussion of stressful situations will
       not necessarily reduce stress.
       CN: Psychosocial integrity; CL: Synthesize

Question 75

75. When teaching a client newly diagnosed with primary Addison’s disease, the nurse should
    explain that the disease results from:
76. Insufficient secretion of growth hormone (GH).
77. Dysfunction of the hypothalamic pituitary.
78. Idiopathic atrophy of the adrenal gland.
79. Oversecretion of the adrenal medulla.

Answer 75

75. 3. 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 ofglucocorticoids, 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.
       CN: Physiological adaptation; CL: Apply

Question 76

76. The nurse is conducting discharge education with a client newly diagnosed with Addison’s
    disease. Which information should be included in the client and family teaching plan? Select all that
    apply.
77. Addison’s disease will resolve over a few weeks, requiring no further treatment.
78. Avoiding stress and maintaining a balanced lifestyle will minimize risk for exacerbations.
79. Fatigue, weakness, dizziness, and mood changes need to be reported to the physician.
80. A medical identification bracelet should be worn.
81. Family members need to be informed about the warning signals of adrenal crisis.
82. Dental work or surgery will require adjustment of daily medication.

Answer 76

76. 2, 3, 4, 5, 6. Addison’s disease occurs when the client does not produce enough steroids from
    the adrenal cortex. Lifetime steroid replacement is needed. The client should be taught lifestyle
    management techniques to avoid stress and maintain rest periods. A medical identification bracelet
    should be worn and the family should be taught signs and symptoms that indicate an impending
    adrenal crisis, such as fatigue, weakness, dizziness, or mood changes. Dental work, infections, and
    surgery commonly require an adjusted dosage of steroids.
    CN: Physiological adaptation; CL: Create

Question 77

77. The nurse should assess a client with Addison’s disease for which of the following?
78. Weight gain.
79. Hunger.
80. Lethargy.
81. Muscle spasms.

Answer 77

77. 3. 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.
       CN: Physiological adaptation; CL: Analyze

Question 78

78. Which topic is most important to include in the teaching plan for a client newly diagnosed
    with Addison’s disease who will be taking corticosteroids?
79. The importance of watching for signs of hyperglycemia.
80. The need to adjust the steroid dose based on dietary intake and exercise.
81. To notify the health care provider when the blood pressure is suddenly high.
82. How to decrease the dose of the corticosteroids when the client experiences stress.

Answer 78

78. 1. Since Addison’s disease can be life threatening, treatment often begins with administration
       of corticosteroids. Corticosteroids, such as prednisone, may be taken orally or intravenously,
       depending on the client. A serious adverse effect of corticosteroids is hyperglycemia. Clients do not
       adjust their steroid dose based on dietary intake and exercise, insulin is adjusted based on diet and
       exercise. Addisonian crisis can occur secondary to hypoadrenocorticism resulting in a crisis situation
       of acute hypotension, not increased blood pressure. Addison’s disease is a disease of inadequate
       adrenal hormone and therefore the client will have inadequate response to stress. If the client takes
       more medication than prescribed, there can be a potential increase in potassium depletion, fluid
       retention, and hyperglycemia. Taking less medication than was prescribed can trigger Addisonian
       crisis state which is a medical emergency manifested by signs of shock.
       CN: Physiological adaptation; CL: Synthesize

Question 79

79. The client with Addison’s disease is taking glucocorticoids at home. Which of the following
    statements indicate that the client understands how to take the medication?
80. “Various circumstances increase the need for glucocorticoids, so I will need to adjust the
    dosage.”
81. “My need for glucocorticoids will stabilize and I will be able to take a predetermined dose
    once a day.”
82. “Glucocorticoids are cumulative, so I will take a dose every third day.”
83. “I must take a dose every 6 hours to ensure consistent blood levels of glucocorticoids.”

Answer 79

79. 1. 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 8 AM and the remainder at about 4 PM . This schedule approximates the diurnal pattern of
       normal secretion, with highest levels between 4 and 6 AM and lowest levels in the evening.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 80

80. Cortisone acetate and fludrocortisone acetate are prescribed as replacement therapy for a
    client with Addison’s disease. What administration schedule should be followed for this therapy?1. Take both drugs three times a day.
81. Take the entire dose of both drugs first thing in the morning.
82. Take all the fludrocortisone acetate and two-thirds of the cortisone acetate in the morning, and
    take the remaining cortisone acetate in the afternoon.
83. Take half of each drug in the morning and the remaining half of each drug at bedtime.

Answer 80

80. 3. Fludrocortisone acetate can be administered once a day, but cortisone acetate
       administration should follow the body’s natural diurnal pattern of secretion. Greater amounts of
       cortisol are secreted during the day to meet the increased demand of the body. Typically, baseline
       administration of cortisone acetate is 25 mg in the morning and 12.5 mg in the afternoon. Taking it
       three times a day would result in an excessive dose. Taking the drug only in the morning would notmeet the needs of the body later in the day and evening.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 81

81. The nurse should tell the client to do which of the following when teaching the client about
    taking oral glucocorticoids?
82. “Take your medication with a full glass of water.”
83. “Take your medication on an empty stomach.”
84. “Take your medication at bedtime to increase absorption.”
85. “Take your medication with meals or with an antacid.”

Answer 81

81. 4. Oral steroids can cause gastric irritation and ulcers and should be administered with meals,
       if possible, or otherwise with an antacid. Only instructing the client to take the medication with a full
       glass of water will not help prevent gastric complications from steroids. Steroids should never be
       taken on an empty stomach. Glucocorticoids should be taken in the morning, not at bedtime.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 82

82. Which of the following is the best indicator for determining whether a client with Addison’s
    disease is receiving the correct amount of glucocorticoid replacement?
83. Skin turgor.
84. Temperature.
85. Thirst.
86. Daily weight.

Answer 82

82. 4. Measuring daily weight is a reliable, objective way to monitor fluid balance. Rapid
       variations in weight reflect changes in fluid volume, which suggests insufficient control of the disease
       and the need for more glucocorticoids in the client with Addison’s disease. Nurses should instruct
       clients taking oral steroids to weigh themselves daily and to report any unusual weight loss or gain.
       Skin turgor testing does supply information about fluid status, but daily weight monitoring is more
       reliable. Temperature is not a direct measurement of fluid balance. Thirst is a nonspecific and very
       late sign of weight loss.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 83

83. Which of the following indicates that the client with Addison's disease is receiving too much
glucocorticoid replacement?
1. Anorexia.
2. Dizziness.
3. Rapid weight gain.
4. Poor skin turgor.

Answer 83

83. 3. Rapid weight gain, because it reflects excess fluids, is a warning sign that the client is
       receiving too much hormone replacement. It may be difficult to individualize the correct dosage for a
       client taking glucocorticoids, and the therapeutic range between underdosage and overdosage is
       narrow. Maintaining the client on the lowest dose that provides satisfactory clinical response is
       always the goal of pharmacotherapeutics. Fluid balance is an important indicator of the adequacy of
       hormone replacement. Anorexia is not present with glucocorticoid therapy because these drugs
       increase the appetite. Dizziness is not specific to the effects of glucocorticoid therapy. Poor skin
       turgor is a late sign of fluid volume deficit.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 84

84. Which of the following is a priority outcome for the client with Addison’s disease?
85. Maintenance of medication compliance.
86. Avoidance of normal activities with stress.
87. Adherence to a 2-g sodium diet.
88. Prevention of hypertensive episodes.

Answer 84

84. 1. Medication compliance is an essential part of the self-care required to manage Addison’s
       disease. The client must learn to adjust the glucocorticoid dose in response to the normal and
       unexpected stresses of daily living. The nurse should instruct the client never to stop taking the drug
       without consulting the health care provider to avoid an addisonian crisis. Regularity in daily habits
       makes adjustment easier, but the client should not be encouraged to withdraw from normal activities
       to avoid stress. The client does not need to restrict sodium. The client is at risk for hyponatremia.
       Hypotension, not hypertension, is more common with Addison’s disease.
       CN: Reduction of risk potential; CL: Evaluate

Question 85

85. The client with Addison’s disease should anticipate the need for increased glucocorticoid
    supplementation in which of the following situations?
86. Returning to work after a weekend.
87. Going on vacation.
88. Having oral surgery.
89. Having a routine medical checkup

Answer 85

85. 3. Illness or surgery places tremendous stress on the body, necessitating increased
       glucocorticoid dosage. Extreme psychological stress also necessitates dosage adjustment. Increased
       dosages are needed in times of stress to prevent drug-induced adrenal insufficiency. Returning to
       work after the weekend, a vacation, or a routine checkup usually will not alter glucocorticoid dosage
       needs.
       CN: Reduction of risk potential; CL: Synthesize

Question 86

86. The nurse should teach the client with Addison’s disease that the bronze-colored skin is
    thought to be caused by which of the following?
87. Hypersensitivity to sun exposure.
88. Increased serum bilirubin level.
89. Adverse effects of the glucocorticoid therapy.
90. Increased secretion of adrenocorticotropic hormone (ACTH).

Answer 86

86. 4. Bronzing, or general deepening of skin pigmentation, is a classic sign of Addison’s disease
       and is caused by melanocyte-stimulating hormone produced in response to increased ACTH
       secretion. The hyperpigmentation is typically found in the distal portion of extremities and in areasexposed to the sun. Additionally, areas that may not be exposed to the sun, such as the nipples,
       genitalia, tongue, and knuckles, become bronze-colored. Treatment of Addison’s disease usually
       reverses the hyperpigmentation. Bilirubin level is not related to the pathophysiology of Addison’s
       disease. Hyperpigmentation is not related to the effects of the glucocorticoid therapy.
       CN: Physiological adaptation; CL: Apply

Question 87

The Client with Cushing’s Disease
87. A client reports that she has gained weight and that her face and body are “rounder,” while
her legs and arms have become thinner. A tentative diagnosis of Cushing’s disease is made. The nurse
should further assess the client for:
1. Orthostatic hypotension.
2. Muscle hypertrophy in the extremities.
3. Bruised areas on the skin.
4. Decreased body hair.

Answer 87

The Client with Cushing’s Disease
87. 3. Skin bruising from increased skin and blood vessel fragility is a classic sign of Cushing’s
disease. Hyperpigmentation and bruising are caused by the hypersecretion of glucocorticoids. Fluid
retention causes hypertension, not hypotension. Muscle wasting occurs in the extremities. Hair on the
head thins, while body hair increases.
CN: Physiological adaptation; CL: Analyze

Question 88

88. A client diagnosed with Cushing’s syndrome is admitted to the hospital and scheduled for a
    dexamethasone suppression test. During this test, the nurse should:
89. Collect a 24-hour urine specimen to measure serum cortisol levels.
90. Administer 1 mg of dexamethasone orally at night and obtain serum cortisol levels the next
    morning.
91. Draw blood samples before and after exercise to evaluate the effect of exercise on serum
    cortisol levels.
92. Administer an injection of adrenocorticotropic hormone (ACTH) 30 minutes before drawing
    blood to measure serum cortisol levels

Answer 88

88. 2. 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 11 PM to suppress secretion of the corticotrophin-releasing hormone. A
       plasma cortisol sample is drawn at 8 AM . Normal cortisol level less than 5 mcg/dL (140 nmol/L)
       indicates normal adrenal response.
       CN: Management of care; CL: Apply

Question 89

89. The nurse should monitor the client with Cushing’s disease for which of the following?
90. Postprandial hypoglycemia.
91. Hypokalemia.
92. Hyponatremia.
93. Decreased urine calcium level.

Answer 89

89. 2. 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.
       CN: Reduction of risk potential; CL: Analyze

Question 90

90. A client with Cushing’s disease tells the nurse that the physician said the morning serum
    cortisol level was within normal limits. The client asks, “How can that be? I’m not imagining all these
    symptoms!” The nurse’s response will be based on which of the following concepts?
91. Some clients are very sensitive to the effects of cortisol and develop symptoms even with
    normal levels.
92. A single random blood test cannot provide reliable information about endocrine levels.
93. The excessive cortisol levels seen in Cushing’s disease commonly result from loss of the
    normal diurnal secretion pattern.
94. Tumors tend to secrete hormones irregularly, and the hormones are generally not present in the
    blood.

Answer 90

90. 3. Cushing’s disease is commonly caused by loss of the diurnal cortisol secretion pattern. The
       client’s random morning cortisol level may be within normal limits, but secretion continues at that
       level throughout the entire day. Cortisol levels should normally decrease after the morning peak.
       Analysis of a 24-hour urine specimen is often useful in identifying the cumulative excess. Clients will
       not have symptoms with normal cortisol levels. Hormones are present in the blood.
       CN: Reduction of risk potential; CL: Apply

Question 91

91. The client with Cushing’s disease needs to modify dietary intake to control symptoms. In
    addition to increasing protein, which strategy would be most appropriate?
92. Increase calories.
93. Restrict sodium.
94. Restrict potassium.
95. Reduce fat to 10%.

Answer 91

91. 2. A primary dietary intervention is to restrict sodium, thereby reducing fluid retention.
       Increased protein catabolism results in loss of muscle mass and necessitates supplemental protein
       intake. The client may be asked to restrict total calories to reduce weight. The client should be
       encouraged to eat potassium-rich foods because serum levels are typically depleted. Although
       reducing fat intake as part of an overall plan to restrict calories is appropriate, fat intake of less than
       20% of total calories is not recommended.
       CN: Basic care and comfort; CL: Synthesize

Question 92

92. Bone resorption is a possible complication of Cushing’s disease. Which of the following
    interventions should the nurse recommend to help the client prevent this complication?
93. Increase the amount of potassium in the diet.2. Maintain a regular program of weight-bearing exercise.
94. Limit dietary vitamin D intake.
95. Perform isometric exercises.

Answer 92

92. 2. Osteoporosis is a serious outcome of prolonged cortisol excess because calcium is
       resorbed out of the bone. Regular daily weight-bearing exercise (eg, brisk walking) is an effective
       way to drive calcium back into the bones. The client should also be instructed to have a dietary orsupplemental intake of calcium of 1,500 mg daily. Potassium levels are not relevant to prevention of
       bone resorption. Vitamin D is needed to aid in the absorption of calcium. Isometric exercises
       condition muscle tone but do not build bones.
       CN: Reduction of risk potential; CL: Synthesize

Question 93

93. 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 by
    telling the client to:
94. “Sit in an upright position and take a deep breath.”
95. “Hold your abdomen firmly with a pillow and take several deep breaths.”
96. “Tighten your stomach muscles as you inhale and breathe normally.”
97. “Raise your shoulders to expand your chest.”

Answer 93

93. 2. 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.
       CN: Physiological adaptation; CL: Apply

Question 94

94. A priority in the first 24 hours after a bilateral adrenalectomy is:
95. Beginning oral nutrition.
96. Promoting self-care activities.
97. Preventing adrenal crisis.
98. Ambulating in the hallway.

Answer 94

94. 3. 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.
       CN: Physiological adaptation; CL: Synthesize

Question 95

95. A client undergoing a bilateral adrenalectomy has postoperative prescriptions for
    hydromorphone hydrochloride (Dilaudid) 2 mg to be given subcutaneously every 4 hours PRN for
    pain. This drug is administered in relatively small doses primarily because it is:
96. Less likely to cause dependency in small doses.
97. Less irritating to subcutaneous tissues in small doses.
98. As potent as most other analgesics in larger doses.
99. Excreted before accumulating in toxic amounts in the body.

Answer 95

95. 3. Hydromorphone hydrochloride (Dilaudid) 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.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 96

96. The nurse is caring for a client who is scheduled for an adrenalectomy. Which of the
    following drugs may be included in the preoperative prescriptions to prevent Addison’s crisis
    following surgery?
97. Prednisone orally.
98. Fludrocortisones subcutaneously.
99. Spironolactone intramuscularly.
100. Methylprednisolone sodium succinate intravenously.

Answer 96

96. 4. 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.
       CN: Physiological integrity; CL: Apply

Question 97

97. Adrenal function is affected by the drug ketoconazole (Nizoral), an antifungal agent used to
    treat severe fungal infections. How is this effect manifested?
98. Ketoconazole suppresses adrenal steroid secretion.
99. Ketoconazole destroys adrenocortical cells, resulting in a “medical” adrenalectomy.
100. Ketoconazole increases adrenocorticotropic hormone (ACTH)–induced corticosteroid serum
     levels.
101. Ketoconazole decreases duration of adrenal suppression when administered with
     corticosteroids.

Answer 97

97. 1. Ketoconazole (Nizoral) suppresses adrenal steroid secretion and may cause acute
       hypoadrenalism. The adverse effect should reverse when the drug is discontinued. Ketoconazole does
       not destroy adrenal cells; mitotane (Lysodren) destroys the cells and may be used to obtain a medical
       adrenalectomy. Ketoconazole decreases, not increases, ACTH-induced serum corticosteroid levels. It
       increases the duration of adrenal suppression when given with steroids.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 98

98. In the early postoperative period after a bilateral adrenalectomy, the client has an increased
    temperature. The nurse should assess the client further for signs of:
99. Dehydration.
100. Poor lung expansion.
101. Wound infection.4. Urinary tract infection

Answer 98

98. 2. Poor lung expansion from bed rest, pain, and retained anesthesia is a common cause of
       slight postoperative temperature elevation. Nursing care includes turning the client and having the
       client cough and deep-breathe every 1 to 2 hours, or more frequently as prescribed. The client will
       have postoperative IV fluid replacement prescribed to prevent dehydration. Wound infectionstypically appear 4 to 7 days after surgery. Urinary tract infections would not be typical with this
       surgery.
       CN: Physiological adaptation; CL: Analyze

Question 99

99. A client who is recovering from a bilateral adrenalectomy has a patient-controlled analgesia
    (PCA) system with morphine sulfate. Which of the following actions is a priority nursing intervention
    for the client?
100. Observing the client at regular intervals for opioid addiction.
101. Encouraging the client to reduce analgesic use and tolerate the pain.
102. Evaluating pain control at least every 2 hours.
103. Increasing the amount of morphine if the client does not administer the medication

Answer 99

99. 3. Pain control should be evaluated at least every 2 hours for the client with a PCA system.
       Addiction is not a common problem for the postoperative client. A client should not be encouraged to
       tolerate pain; in fact, other nursing actions besides PCA should be implemented to enhance the action
       of opioids. One of the purposes of PCA is for the client to determine frequency of administering the
       medication; the nurse should not interfere unless the client is not obtaining pain relief. The nurse
       should ensure that the client is instructed on the use of the PCA control button and that the button is
       always within reach.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 100

100. After surgery for bilateral adrenalectomy, the client is kept on bed rest for several days to
     stabilize the body’s need for steroids postoperatively. Which of the following exercises will be most
     effective for preparing a client for ambulation after a period of bed rest?
101. Alternately flexing and extending the knees.
102. Alternately abducting and adducting the legs.
103. Alternately stretching the Achilles tendons.
104. Alternately flexing and relaxing the quadriceps femoris muscles.

Answer 100

100. 4. Alternately flexing and relaxing the quadriceps femoris muscles helps prepare the client
        for ambulation. This exercise helps maintain the strength in the quadriceps, which is the major muscle
        group used when walking. The other exercises listed do not increase a client’s readiness for walking.
        CN: Basic care and comfort; CL: Synthesize

Question 101

101. As the nurse assists the postoperative client out of bed, the client reports having gas pains in
     the abdomen. Which of the following is the most effective nursing intervention to relieve this
     discomfort?
102. Encourage the client to ambulate.
103. Insert a rectal tube.
104. Insert a nasogastric (NG) tube.
105. Encourage the client to drink carbonated liquids.

Answer 101

101. 1. Decreased mobility is one of the most common causes of abdominal distention related to
        retained gas in the intestines. Peristalsis has been inhibited by general anesthesia, analgesics, and
        inactivity during the immediate postoperative period. Ambulation increases peristaltic activity and
        helps move gas. Walking can prevent the need for a rectal tube, which is a more invasive procedure.
        An NG tube is also a more invasive procedure and requires a physician’s prescription. It is not a
        preferred treatment for gas postoperatively. Walking should prevent the need for further interventions.
        Carbonated liquids can increase gas formation.
        CN: Reduction of risk potential; CL: Synthesize

Question 102

102. Because of steroid excess after a bilateral adrenalectomy, the nurse should assess the client
for:
1. Postoperative confusion.
2. Delayed wound healing.
3. Emboli.
4. Malnutrition.

Answer 102

102. 2. 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.
        CN: Reduction of risk potential; CL: Analyze

Question 103

103. The client who has undergone a bilateral adrenalectomy is concerned about persistent body
     changes and unpredictable moods. The nurse should tell the client that:
104. The body changes are permanent and the client will not be the same as before this condition.
105. The body and mood will gradually return to normal.
106. The physical changes are permanent, but the mood swings will disappear.
107. The physical changes are temporary, but the mood swings are permanent.

Answer 103

103. 2. 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.
        CN: Physiological adaptation; CL: Synthesize

Question 104

104. After a bilateral adrenalectomy for Cushing’s disease, the client will receive periodic
     testosterone injections. The expected outcome of these injections is:
105. Balanced reproductive cycle.
106. Restored sodium and potassium balance.
107. Stimulated protein metabolism.
108. Stabilized mood swings.

Answer 104

104. 3. Testosterone is an androgen hormone that is responsible for protein metabolism as well as
        maintenance of secondary sexual characteristics; therefore, it is needed by both males and females.
        Removal of both adrenal glands necessitates replacement of glucocorticoids and androgens.
        Testosterone does not balance the reproductive cycle, stabilize mood swings, or restore sodium and
        potassium balance.
        CN: Physiological adaptation; CL: Apply

Question 105

105. Which of the following should the nurse include in the teaching plan of a female client with
     bilateral adrenalectomy?1. Emphasizing that the client will need steroid replacement for the rest of her life.
106. Instructing the client about the importance of tapering steroid medication carefully to prevent
     crisis.
107. Informing the client that steroids will be required only until her body can manufacture
     sufficient quantities.
108. Emphasizing that the client will need to take steroids whenever her life involves physical or
     emotional stress.

Answer 105

105. 1. Bilateral adrenalectomy requires lifelong adrenal hormone replacement therapy. If
        unilateral surgery is performed, most clients gradually reestablish a normal secretion pattern. Theclient 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.
        CN: Physiological adaptation; CL: Synthesize

Question 106

Managing Care Quality and Safety
106. The nurse is reviewing the postoperative prescriptions (see chart) just written by a
physician for a client with type 1 diabetes who has returned to the surgery floor from the recovery
room following surgery for a left hip replacement. The client has pain of 5 on a scale of 1 to 10. The
hand-off report from the nurse in the recovery room indicated that the vital signs have been stable for
the last 30 minutes. After obtaining the client’s glucose level, the nurse should do which of the
following first?
1. Administer the morphine.
2. Contact the physician to rewrite the insulin prescription.
3. Administer oxygen per nasal canula at 2 L/min.
4. Take the vital signs.

PHYSICIAN PRESCRIPTIONS
Vital signs every 15 minutes for 4 hours, then every hour for 8 hours.
Oxygen 2L/min per nasal cannula
1000 ml NS every 8 hours
10 mg morphine intramuscularly every 4 hours as needed
10 units regular insulin stat

Answer 106

Managing Care Quality and Safety
106. 2. Insulin is on the list of error-prone medications and the nurse should ask the physician to
rewrite the prescription to spell out the word “units” and to indicate the route the drug is to be
administered. The nurse should contact the physician immediately as the nurse is to administer the
insulin now. The nurse can then also report the most current glucose level. While waiting for the
insulin prescription to be rewritten, the nurse can administer the pain medication if needed, start the
oxygen, and check the client’s vital signs.
CN: Safety and infection control; CL: Synthesize

Question 107

107. A client with type 1 diabetes is admitted to the emergency department with dehydration
     following the flu. The client has a blood glucose level of 325 mg/dL (18 mmol/L) and a serum
     potassium level of 3.5 mEq (3.5 mmol/L). The physician has prescribed 1,000 mL 5% dextrose in
     water to be infused every 8 hours. Prior to implementing the physician prescriptions, the nurse should
     contact the physician, explain the situation, provide background information, report the current
     assessment of the client, and:
108. Suggest adding potassium to the fluids.
109. Request an increase in the volume of intravenous fluids.
110. Verify the prescription for 5% dextrose in water.
111. Determine if the client should be placed in isolation.

Answer 107

107. 3. The client needs fluid volume replacement due to the dehydration. However, the nurse
        should verify the prescription for IV dextrose with the physician due to the risk of hyperglycemia that
        dextrose would present when administered to a client with diabetes. The potassium level is within
        normal limits. The client does not have restrictions on oral fluids and the nurse can encourage the
        client to drink fluids. The client does not need to be placed in isolation at this time.
        CN: Management of care; CL: Synthesize

Question 108

108. Glulisine (Apidra) insulin is prescribed to be administered to a client before each meal. To
     assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of
     glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse
     finds that the client is not in the room. The client’s roommate tells the nurse that the client “went for a
     test.” What should the nurse do next?
109. Bring a small glass of juice, and locate the client.
110. Call the client’s physician.
111. Check the computerized care plan to determine what test was scheduled.
112. Send the nurse’s assistant to the x-ray department to bring the client back to his room.

Answer 108

108. 3. Glulisine (Apidra) is a rapid-acting insulin with an action onset of 15 minutes. The client
        could experience hypoglycemia with the insulin in the bloodstream and no breakfast. It is not
        necessary to call the client’s physician; the nurse should determine what test was scheduled and then
        locate the client and provide either breakfast or 4 oz (120 mL) of fruit juice. To bring the client back
        to the room would be wasting valuable time needed to prevent or correct hypoglycemia.
        CN: Management of care; CL: Synthesize

Question 109

109. A young adult 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 receivingciprofloxacin IV. The physician prescribes discontinuation of the insulin drip. The nurse should next?
110. Discontinue the insulin drip, as prescribed.
111. Hang the next IV dose of antibiotic before discontinuing the insulin drip.
112. Inform the physician that the client has not received any subcutaneous insulin yet.
113. Add glargine to the insulin drip before discontinuing it

Answer 109

109. 3. Because 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.
        CN: Management of care; CL: Synthesize

Question 110

110. An elderly client on steroids has secondary diabetes and chronic kidney disease (CKD) and
     takes insulin. The client has had episodes of hypoglycemia. The nurse should:
111. Continue to monitor the client’s blood glucose values.
112. Contact the dietitian to request that one additional serving of protein be added to each meal.
113. Restrict ambulation so there will be less of a chance for hypoglycemia.
114. Contact the physician and recommend that the doses of insulin be evaluated.

Answer 110

110. 1. 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.
        CN: Reduction of risk potential; CL: Synthesize

Question 111

111. The elderly client with type 2 diabetes has hyperglycemic hyperosmolar syndrome (HHS).
     The nurse should monitor the infusion for too rapid correction of the blood glucose in order to
     prevent:
112. Ketone body formation.
113. A major vascular accident.
114. Fluid volume depletion.
115. Cerebral edema.

Answer 111

111. 4. HHS can be caused by acute illness, such as an infection like pneumonia or sepsis. In
        HHS, there is a residual amount of insulin that suppresses ketosis but cannot control hyperglycemia.
        This leads to severe dehydration, and impaired renal function. Ketone bodies are usually absent in
        HHS, and they do not form as a result of too rapid correction of blood glucose. The nurse should
        assess the client for a major vascular accident in the elderly as an etiology for a hyperglycemic crisis.
        Volume depletion must be treated first in HHS. Cerebral edema is a risk with too rapid correction of
        blood glucose.
        CN: Reduction of risk potential; CL: Apply

Question 112

112. A client with type I diabetes has gastroparesis. The nurse must monitor the client for which
of the following?
1. Polyphagia.
2. Anorexia.
3. Paresthesias.
4. Dysphagia.

Answer 112

112. 2. Neuropathy of the gastrointestinal (GI) tract may involve any portion of the system from
        the esophagus to the rectum. There may be anorexia or loss of appetite. Polyphagia or increased
        appetite does not occur with gastroparesis. Paresthesias or abnormal/unusual sensations around the
        mouth may occur with hypoglycemia. Difficulty in swallowing or dysphagia is not present with
        gastroparesis.
        CN: Reduction of risk potential; CL: Analyze