Unit R-Endocrine Flashcards
(99 cards)
1
Q
Which statement best describes idiopathic hypopituitarism?
a. Growth is normal during the first 3 years of life.
b. Weight is usually more retarded than height.
c. Skeletal proportions are normal for age.
d. Most of these children have subnormal intelligence.
A
ANS: C
In children with idiopathic hypopituitarism, the skeletal proportions are normal. Growth is
within normal limits for the first year of life. Height is usually more delayed than weight.
Intelligence is not affected by hypopituitarism
2
Q
A child with growth hormone (GH) deficiency is receiving GH therapy. What is the best time for the GH to be administered? a. At bedtime b. After meals c. Before meals d. On arising in the morning
A
ANS: A
Injections are best given at bedtime to more closely approximate the physiologic release of
GH. Before or after meals and on arising in the morning are times that do not mimic the
physiologic release of the hormone.
3
Q
What is the priority nursing goal for a 14 year old diagnosed with Graves’ disease?
a. Relieving constipation
b. Allowing the adolescent to make decisions about whether or not to take medication
c. Verbalizing the importance of monitoring for medication side effects
d. Developing alternative educational goals
A
ANS: C
Children being treated with propylthiouracil or methimazole must be carefully monitored for
side effects of the drug. Because sore throat and fever accompany the grave complication of
leukopenia, these children should be seen by a health care practitioner if such symptoms
occur. Parents and children should be taught to recognize and report symptoms immediately.
The adolescent with Graves’ disease is not likely to be constipated. Adherence to the
medication schedule is important to ensure optimal health and wellness. Medications should
not be skipped and dose regimens should not be tapered by the child without consultation with
the child’s medical provider. The management of Graves’ disease does not interfere with
school attendance and does not require alternative educational plans.
4
Q
Diabetes insipidus is a disorder of which organ?
a. Anterior pituitary
b. Posterior pituitary
c. Adrenal cortex
d. Adrenal medulla
A
ANS: B
The principal disorder of posterior pituitary hypofunction is diabetes insipidus. The anterior
pituitary produces hormones such as growth hormone, thyroid-stimulating hormone,
adrenocorticotropic hormone, gonadotropin, prolactin, and melanocyte-stimulating hormone.
The adrenal cortex produces aldosterone, sex hormones, and glucocorticoids. The adrenal
medulla produces catecholamines.
5
Q
The nurse is caring for a child with suspected diabetes insipidus. Which clinical manifestation would be observable? a. Oliguria b. Glycosuria c. Nausea and vomiting d. Polydipsia
A
ANS: D
Excessive urination accompanied by insatiable thirst is the primary clinical manifestation of
diabetes. These symptoms may be so severe that the child does little other than drink and
urinate. Oliguria is decreased urine production and is not associated with diabetes insipidus.
Glycosuria is associated with diabetes mellitus. Nausea and vomiting are associated with
inappropriate antidiuretic hormone secretion.
6
Q
What is a common clinical manifestation of juvenile hypothyroidism?
a. Insomnia
b. Diarrhea
c. Dry skin
d. Accelerated growth
A
ANS: C
Dry skin, mental decline, and myxedematous skin changes are associated with juvenile
hypothyroidism. Children with hypothyroidism are usually sleepy. Constipation is associated
with hypothyroidism. Decelerated growth is common in juvenile hypothyroidism.
7
Q
The nurse is teaching the parents of a child who is receiving propylthiouracil for the treatment
of hyperthyroidism (Graves’ disease). Which statement made by the parent indicates a correct
understanding of the teaching?
a. “I would expect my child to gain weight while taking this medication.”
b. “I would expect my child to experience episodes of ear pain while taking this
medication.”
c. “If my child develops a sore throat and fever, I should contact the physician
immediately.”
d. “If my child develops the stomach flu, my child will need to be hospitalized.”
A
ANS: C
Children being treated with propylthiouracil must be carefully monitored for the side effects
of the drug. Parents must be alerted that sore throat and fever accompany the grave
complication of leukopenia. These symptoms should be immediately reported. Weight gain,
episodes of ear pain, and stomach flu are not usually associated with leukopenia.
8
Q
A child diagnosed with hypoparathyroidism is receiving vitamin D therapy. The parents
should be advised to watch for which sign of vitamin D toxicity?
a. Headache and seizures
b. Physical restlessness and voracious appetite without weight gain
c. Weakness and lassitude
d. Anorexia and insomnia
A
ANS: C
Vitamin D toxicity can be a serious consequence of therapy. Parents are advised to watch for
signs including weakness, fatigue, lassitude, headache, nausea, vomiting, and diarrhea. Renal
impairment is manifested through polyuria, polydipsia, and nocturia. Headaches may be a sign
of vitamin D toxicity, but seizures are not. Physical restlessness and a voracious appetite with
weight loss are manifestations of hyperthyroidism. Anorexia and insomnia are not
characteristic of vitamin D toxicity.
9
Q
Glucocorticoids, mineralocorticoids, and sex steroids are secreted by which organ?
a. Thyroid gland
b. Parathyroid glands
c. Adrenal cortex
d. Anterior pituitary
A
ANS: C
These hormones are secreted by the adrenal cortex. The thyroid gland produces thyroid
hormone and thyrocalcitonin. The parathyroid glands produce parathyroid hormone. The
anterior pituitary produces hormones such as growth hormone, thyroid-stimulating hormone,
adrenocorticotropic hormone, gonadotropin, prolactin, and melanocyte-stimulating hormone.
10
Q
Chronic adrenocortical insufficiency is also referred to as what?
a. Graves’ disease
b. Addison’s disease
c. Cushing’s syndrome
d. Hashimoto’s disease
A
ANS: B
Addison’s disease is chronic adrenocortical insufficiency. Graves’ and Hashimoto’s diseases
involve the thyroid gland. Cushing’s syndrome is a result of excessive circulation of free
cortisol.
11
Q
What is the characteristic of the immune-mediated type 1 diabetes mellitus?
a. Ketoacidosis is infrequent
b. Onset is gradual
c. Age at onset is usually younger than 18 years
d. Oral agents are often effective for treatment
A
ANS: C
The immune-mediated type 1 diabetes mellitus typically has its onset in children or young
adults. Peak incidence is between the ages of 10 and 15 years. Infrequent ketoacidosis,
gradual onset, and treatment with oral agents are more consistent with type 2 diabetes.
12
Q
Which symptom is considered a cardinal sign of diabetes mellitus?
a. Nausea
b. Seizures
c. Impaired vision
d. Frequent urination
A
ANS: D
Hallmarks of diabetes mellitus are glycosuria, polyuria, and polydipsia. Nausea and seizures
are not clinical manifestations of diabetes mellitus. Impaired vision is a long-term
complication of the disease.
13
Q
Type 1 diabetes mellitus is suspected in an adolescent. Which clinical manifestation may be present? a. Moist skin b. Weight gain c. Fluid overload d. Poor wound healing
A
ANS: D
Poor wound healing is often an early sign of type 1 diabetes mellitus. Dry skin, weight loss,
and dehydration are clinical manifestations of type 1 diabetes mellitus.
14
Q
A parent asks the nurse why self-monitoring of blood glucose is being recommended for her
child with diabetes. The nurse should base the explanation on what information?
a. It is a less expensive method of testing.
b. It is not as accurate as laboratory testing.
c. Children need to learn to manage their diabetes.
d. The parents are better able to manage the disease.
A
ANS: C
Blood glucose self-management has improved diabetes management and can be used
successfully by children from the time of diagnosis. Insulin dosages can be adjusted based on
blood sugar results. Blood glucose monitoring is more expensive but provides improved
management. It is as accurate as equivalent testing done in laboratories. The ability to self-test
allows the child to balance diet, exercise, and insulin. The parents are partners in the process,
but the child should be taught how to manage the disease.
15
Q
The parents of a child who has just been diagnosed with type 1 diabetes ask about exercise.
The nurse should provide the parents with what information to address the child’s safety
needs?
a. Exercise will increase blood glucose.
b. Exercise should be restricted.
c. Extra snacks are needed before exercise.
d. Extra insulin is required during exercise.
A
ANS: C
Exercise lowers blood glucose levels, which can be compensated for by extra snacks. Exercise
is encouraged and not restricted unless indicated by other health conditions. Extra insulin is
contraindicated because exercise decreases blood glucose levels.
16
Q
A child eats some sugar cubes after experiencing symptoms of hypoglycemia. This
rapid-releasing sugar should be followed by:
a. saturated and unsaturated fat.
b. fruit juice.
c. several glasses of water.
d. complex carbohydrate and protein.
A
ANS: D
Symptoms of hypoglycemia are treated with a rapid-releasing sugar source followed by a
complex carbohydrate and protein. Saturated and unsaturated fat, fruit juice, and several
glasses of water do not provide the child with complex carbohydrate and protein necessary to
stabilize the blood sugar.
17
Q
What are the manifestations of hypoglycemia?
a. Lethargy
b. Thirst
c. Nausea and vomiting
d. Shaky feeling and dizziness
A
ANS: D
Some of the clinical manifestations of hypoglycemia include shaky feelings; dizziness;
difficulty concentrating, speaking, focusing, and coordinating; sweating; and pallor. Lethargy,
thirst, and nausea and vomiting are manifestations of hyperglycemia
18
Q
The nurse is caring for an 11-year-old boy who has recently been diagnosed with diabetes.
What should be included in the teaching plan for daily injections?
a. The parents do not need to learn the procedure.
b. He is old enough to give most of his own injections.
c. Self-injections will be possible when he is closer to adolescence.
d. He can learn about self-injections when he is able to reach all injection sites.
A
ANS: B
School-age children are able to give their own injections. Parents should participate in
learning and giving the insulin injections. He is already old enough to administer his own
insulin. The child is able to use thighs, abdomen, part of the hip, and arm. Assistance can be
obtained if other sites are used.
19
Q
The nurse is discussing various sites used for insulin injections with a child and her family.
Which site usually has the fastest rate of absorption?
a. Arm
b. Leg
c. Buttock
d. Abdomen
A
ANS: D
The abdomen has the fastest rate of absorption but the shortest duration. The arm has a fast
rate of absorption but short duration. The leg has a slow rate of absorption but a long duration.
The buttock has the slowest rate of absorption and the longest duration.
20
Q
What should a nurse advise the parents of a child with type 1 diabetes mellitus who is not
eating as a result of a minor illness?
a. Give the child half his regular morning dose of insulin.
b. Substitute simple carbohydrates or calorie-containing liquids for solid foods.
c. Give the child plenty of unsweetened, clear liquids to prevent dehydration.
d. Take the child directly to the emergency department
A
ANS: B
A sick-day diet of simple carbohydrates or calorie-containing liquids will maintain normal
serum glucose levels and decrease the risk of hypoglycemia. The child should receive his
regular dose of insulin even if he does not have an appetite. If the child is not eating as usual,
he needs calories to prevent hypoglycemia. During periods of minor illness, the child with
type 1 diabetes mellitus can be managed safely at home.
21
Q
Which laboratory finding confirms that a child with type 1 diabetes is experiencing diabetic ketoacidosis? a. No urinary ketones b. Low arterial pH c. Elevated serum carbon dioxide d. Elevated serum phosphorus
A
ANS: B
Severe insulin deficiency produces metabolic acidosis, which is indicated by a low arterial
pH. Urinary ketones, often in large amounts, are present when a child is in diabetic
ketoacidosis. Serum carbon dioxide is decreased in diabetic ketoacidosis. Serum phosphorus
is decreased in diabetic ketoacidosis.
22
Q
A child diagnosed with hypopituitarism is being started on growth hormone (GH) therapy.
Nursing considerations should be based on which information?
a. Treatment is most successful if it is started during adolescence.
b. Treatment is considered successful if children attain full stature by adulthood.
c. Replacement therapy requires daily subcutaneous injections.
d. Replacement therapy will be required throughout the child’s lifetime.
A
ANS: C
Additional support is required for children who require hormone replacement therapy, such as
preparation for daily subcutaneous injections and education for self-management during the
school-age years. Young children, obese children, and those who are severely GH deficient
have the best response to therapy. When therapy is successful, children can attain their actual
or near-final adult height at a slower rate than their peers. Replacement therapy is not needed
after attaining final height. They are no longer GH deficient.
23
Q
The nurse is admitting a toddler with the diagnosis of juvenile hypothyroidism. Which is a
common clinical manifestation of this disorder?
a. Insomnia
b. Diarrhea
c. Dry skin
d. Accelerated growth
A
ANS: C
Dry skin, mental decline, and myxedematous skin changes are associated with juvenile
hypothyroidism. Children with hypothyroidism are usually sleepy. Constipation is associated
with hypothyroidism. Decelerated growth is common in juvenile hypothyroidism.
24
Q
Which clinical manifestation may occur in the child who is prescribed methimazole for the
treatment of hyperthyroidism (Graves’ disease)?
a. Seizures
b. Enlargement of all lymph glands
c. Pancreatitis or cholecystitis
d. Sore throat or fever
A
ANS: D
Children being treated with propylthiouracil or methimazole must be carefully monitored for
side effects of the drug. Because sore throat and fever accompany the grave complication of
leukopenia, these children should be seen by a health care practitioner if such symptoms
occur. Neither seizures, cholecystitis nor pancreatitis are associated with the administration of
methimazole. Enlargement of the salivary and cervical lymph glands may occur.
25
The parent of a child diagnosed with diabetes mellitus asks the nurse when urine testing will
be necessary. The nurse should explain that urine testing is necessary for which reason?
a. Glucose is needed before administration of insulin.
b. Glucose is needed 4 times a day.
c. Glycosylated hemoglobin is required.
d. Ketonuria is suspected.
ANS: D
Urine testing is still performed to detect evidence of ketonuria. Urine testing for glucose is no
longer indicated for medication administration because of the poor correlation between blood
glucose levels and glycosuria. Glycosylated hemoglobin analysis is performed on a blood
sample.
26
To help the adolescent deal with diabetes, the nurse must consider which characteristic of
adolescence?
a. Desire to be unique
b. Preoccupation with the future
c. Need to be perfect and similar to peers
d. Need to make peers aware of the seriousness of hypoglycemic reactions
ANS: C
Adolescence is a time when the individual wants to be perfect and similar to peers. Having
diabetes makes adolescents different from their peers. Adolescents do not wish to be unique;
they desire to fit in with the peer group and are usually not future oriented. Forcing peer
awareness of the seriousness of hypoglycemic reactions would further alienate the adolescent
with diabetes since the peer group would likely focus on the differences.
27
The nurse is implementing care for a school-age child admitted to the pediatric intensive care
experiencing symptomology associated with diabetic ketoacidosis (DKA). Which prescribed
intervention should the nurse implement first?
a. Begin 0.9% saline solution intravenously as prescribed.
b. Administer regular insulin intravenously as prescribed.
c. Place child on a cardiac monitor.
d. Place child on a pulse oximetry monitor.
ANS: A
All patients with DKA experience dehydration (10% of total body weight in severe
ketoacidosis) because of the osmotic diuresis, accompanied by depletion of electrolytes
(sodium, potassium, chloride, phosphate, and magnesium). The initial hydrating solution is
0.9% saline solution. Insulin therapy should be started after the initial rehydration bolus
because serum glucose levels fall rapidly after volume expansion. The child should be placed
on the cardiac and pulse oximetry monitors after the rehydrating solution has been initiated.
28
A nurse is reviewing the laboratory results on a school-age child diagnosed with
hypoparathyroidism. Which results are consistent with this condition?
a. Decreased serum phosphorus
b. Decreased serum calcium
c. Increased serum glucose
d. Decreased serum cortisol
ANS: B
The diagnosis of hypoparathyroidism is made on the basis of clinical manifestations
associated with decreased serum calcium and increased serum phosphorus. Decreased serum
phosphorus would be seen in hyperparathyroidism, elevated glucose in diabetes, and
decreased serum cortisol in adrenocortical insufficiency (Addison’s disease).
29
A nurse is planning care for a school-age child diagnosed with type 1 diabetes. Which insulin
preparations are either rapid or short acting? (Select all that apply.)
a. Novolin N
b. Lantus
c. NovoLog
d. Novolin R
ANS: C, D
Rapid-acting insulin (e.g., NovoLog) reaches the blood within 15 minutes after injection. The
insulin peaks 30 to 90 minutes later and may last as long as 5 hours. Short-acting (regular)
insulin (e.g., Novolin R) usually reaches the blood within 30 minutes after injection. The
insulin peaks 2 to 4 hours later and stays in the blood for about 4 to 8 hours.
Intermediate-acting insulins (e.g., Novolin N) reach the blood 2 to 6 hours after injection. The
insulins peak 4 to 14 hours later and stay in the blood for about 14 to 20 hours. Long-acting
insulin (e.g., Lantus) takes 6 to 14 hours to start working. It has no peak or a very small peak
10 to 16 hours after injection. The insulin stays in the blood between 20 and 24 hours.
30
The clinic nurse is reviewing hemoglobin A1c levels on several children with type 1 diabetes.
Hemoglobin A1c levels of less than _____% are a goal for children with type 1 diabetes.
Record your answer as a whole number.
ANS:
7
The measurement of glycosylated hemoglobin (hemoglobin A1c) levels is a satisfactory
method for assessing control of type 1 diabetes. As red blood cells circulate in the
bloodstream, glucose molecules gradually attach to the hemoglobin A molecules and remain
there for the lifetime of the red blood cell, approximately 120 days. The attachment is not
reversible; therefore, this glycosylated hemoglobin reflects the average blood glucose levels
over the previous 2 to 3 months. The test is a satisfactory method for assessing control,
detecting incorrect testing, monitoring the effectiveness of changes in treatment, defining
patients’ goals, and detecting nonadherence. Hemoglobin A1c levels of less than 7% are a
well-established goal at most care centers.
31
```
The nurse assesses an older client. What age-related physiologic changes would the nurse
expect?
a. Heat intolerance
b. Rheumatoid arthritis
c. Dehydration
d. Increased appetite
```
ANS: C
As people age, the many of the endocrine glands decrease hormone production, including a
decrease in antidiuretic hormone production. This change, in addition to less body fluid being
present as one ages, can cause dehydration. Older adults usually have cold intolerance and a
decrease in appetite. Rheumatoid arthritis is not an age-related change; osteoarthritis causes
primarily by aging.
32
A client is scheduled to have a glycosylated hemoglobin (A1C) drawn and asks the nurse why
she has to have it. How would the nurse respond?
a. “It measures your average blood glucose level for the past 3 months.”
b. “It determines what type of anemia you may have.”
c. “It measures the amount of liver glycogen you have.”
d. “It determines you have some type of leukemia or other blood cancer.”
ANS: A
A1C measures the average blood glucose level to determine if the client is a diabetic or how
controlled a diabetic client is.
33
The nurse assesses a client who is scheduled to have a laboratory test to determine if the
client’s adrenal glands are hypoactive. What type of testing would the client likely have?
a. Catecholamine testing
b. Suppression testing
c. Bone marrow testing
d. Provocative testing
ANS: D
Provocative testing is done to determine if an endocrine gland is capable of producing its
normal level of hormone(s), especially when a client is suspected of having a hypoactive
endocrine gland.
34
A nurse assesses a client who is prescribed a medication that stimulates beta1 receptors.
Which assessment finding would indicate that the medication is effective?
a. Heart rate of 92 beats/min
b. Respiratory rate of 18 breaths/min
c. Oxygenation saturation of 92%
d. Blood pressure of 144/69 mm Hg
ANS: A
Stimulation of beta1 receptor sites in the heart has positive chronotropic and inotropic actions.
The nurse expects an increase in heart rate and increased cardiac output. The other vital signs
are within normal limits and do not indicate any response to the medication.
35
A nurse collaborates with assistive personnel (AP) to provide care for a client who is
prescribed a 24-hour urine specimen collection. Which statement would the nurse include
when teaching the AP about this activity?
a. “Note the time of the client’s first void and collect urine for 24 hours.”
b. “Add the preservative to the container at the end of the test.”
c. “Start the collection by saving the first urine of the morning.”
d. “It is okay if one urine sample during the 24 hours is not collected.”
ANS: A
The collection of a 24-hour urine specimen is often delegated to AP. The nurse must ensure
that the AP understands the proper process for collecting the urine. The 24-hour urine
collection specimen is started after the client’s first urination. The first urine specimen is
discarded because there is no way to know how long it has been in the bladder, but the time of
the client’s first void is noted. The client adds all urine voided after that first discarded
specimen during the next 24 hours. When the 24-hour mark is reached, the client voids one
last time and adds this specimen to the collection. The preservative, if used, must be added to
the container at the beginning of the collection. All urine samples need to be collected for the
test results to be accurate.
36
A nurse assesses a female client who presents with hirsutism. Which question would the nurse
ask when assessing this client?
a. “How do you plan to pay for your treatments?”
b. “How do you feel about yourself?”
c. “What medications are you prescribed?”
d. “What are you doing to prevent this from happening?”
ANS: B
Hirsutism, or excessive hair growth on the face and body, can result from endocrine disorders.
This may cause a disruption in body image, especially for female clients. The nurse would
inquire into the client’s body image and self-perception. Asking about the client’s financial
status or current medications does not address the client’s immediate problem. The client is
not doing anything to herself to cause the problem, nor can the client prevent it from
happening.
37
A nurse is caring for a patient who has excessive catecholamine release. Which assessment
finding would the nurse correlate with this condition?
a. Decreased blood pressure
b. Increased pulse
c. Decreased respiratory rate
d. Increased urine output
ANS: B
Catecholamines are responsible for the fight-or-flight stress response. Activation of the
sympathetic nervous system can be correlated with tachycardia. Catecholamines do not
decrease blood pressure or respiratory rate, nor do they increase urine output.
38
The nurse is teaching assistive personnel (AP) about hormones that are produced by the
adrenal glands. Which hormone has the primary responsibility of maintaining fluid volume
and electrolyte composition?
a. Sodium
b. Magnesium
c. Aldosterone
d. Renin
ANS: C
Aldosterone is a hormone secreted by the adrenal cortex that causes water and sodium
absorption to maintain body fluid volume. Renin is secreted by the kidney to trigger
angiotensinogen converting angiotensin I to angiotensin II to help control blood pressure.
Magnesium and sodium are electrolytes and not hormones.
39
```
The nurse reviews the function of thyroid gland hormones. What is the primary function of
calcitonin?
a. Sodium and potassium balance
b. Magnesium balance
c. Norepinephrine balance
d. Calcium and phosphorus balance
```
ANS: D
Calcitonin is the primary body hormone that is secreted from the thyroid gland and is
responsible for maintaining calcium and phosphorus balance.
40
A nurse teaches an older woman who has a decreased production of estrogen. Which
statement would the nurse include in this client’s teaching to decrease injury?
a. “Drink at least 2 quarts (2 L) of fluids each day.”
b. “Walk around the neighborhood for daily exercise.”
c. “Bathe your perineal area twice a day.”
d. “You should check your blood glucose before meals.”
ANS: B
An older female with decreased production of estrogen is at risk for decreased bone density
and fractures. The nurse would encourage the client to participate in weight-bearing exercises
such as walking. Drinking fluids and performing perineal care will decrease vaginal drying
but not injury. Older adults often have a decreased glucose tolerance, but this is not related to
a decrease in estrogen.
41
A nurse cares for clients with hormone disorders. Which are common key features of
hormones? (Select all that apply.)
a. Hormones may travel long distances to get to their target tissues.
b. Continued hormone activity requires continued production and secretion.
c. Control of hormone activity is caused by negative feedback mechanisms.
d. Most hormones are stored in the target tissues for use later.
e. Most hormones cause target tissues to change activities by changing gene activity.
ANS: A, B, C
Hormones are secreted by endocrine glands and travel through the body to reach their target
tissues. Hormone activity can increase or decrease according to the body’s needs, and
continued hormone activity requires continued production and secretion. Control is
maintained via negative feedback. Hormones are not stored for later use, and they do not alter
genetic activity.
42
A nurse cares for a client with a hypofunctioning anterior pituitary gland. Which hormones
would the nurse expect to be decreased as a result? (Select all that apply.)
a. Thyroid-stimulating hormone
b. Vasopressin
c. Follicle-stimulating hormone
d. Calcitonin
e. Growth hormone
ANS: A, C, E
Thyroid-stimulating hormone, follicle-stimulating hormone, and growth hormone all are
secreted by the anterior pituitary gland. Vasopressin is secreted from the posterior pituitary
gland. Calcitonin is secreted from the thyroid gland.
43
A nurse assesses clients who have endocrine disorders. Which assessment findings are paired
correctly with the endocrine disorder? (Select all that apply.)
a. Excessive thyroid-stimulating hormone—increased bone formation
b. Excessive melanocyte-stimulating hormone—darkening of the skin
c. Excessive parathyroid hormone—synthesis and release of corticosteroids
d. Excessive antidiuretic hormone—increased urinary output
e. Excessive adrenocorticotropic hormone—increased bone resorption
ANS: A, B
Thyroid-stimulating hormone targets thyroid tissue and stimulates the formation of bone.
Melanocyte-stimulating hormone stimulates melanocytes and promotes pigmentation or the
darkening of the skin. Parathyroid hormone stimulates bone resorption. Antidiuretic hormone
targets the kidney and promotes water reabsorption, causing a decrease in urinary output.
Adrenocorticotropic hormone targets the adrenal cortex and stimulates the synthesis and
release of corticosteroids.
44
```
When caring for an older client who has hypothyroidism, what assessment findings will the
nurse expect? (Select all that apply.)
a. Lethargy
b. Diarrhea
c. Low body temperature
d. Tachycardia
e. Slowed speech
f. Weight gain
```
ANS: A, C, E, F
A client who has an underactive thyroid gland has a decreased metabolic rate, resulting in
lethargy and lack of energy, weight gain, slowed speech, and decreased vital signs like a
lowered body temperature. The client also typically has constipation (instead of diarrhea) due
to slower peristalsis and bradycardia (instead of tachycardia).
DIF:
45
The nurse is planning health teaching for a client starting on levothyroxine. What health
teaching about this drug would the nurse include?
a. The need to take the drug when the client feels fatigued and weak.
b. The need to report chest pain and dyspnea when starting the drug.
c. The need to check blood pressure and pulse every day.
d. The need to rotate injection sites when giving self the drug.
ANS: B
Levothyroxine is a replacement hormone for clients who have hypothyroidism and is taken
orally for life. Vital signs do not have to be checked every day, but the client should report
any chest pain and dyspnea when first starting the drug.
46
A nurse assesses a client who is recovering from a subtotal thyroidectomy and observes the
development of stridor. What is the priority action for the nurse to take?
a. Apply oxygen via nasal cannula at 2 L/min.
b. Document the finding and assess the client hourly.
c. Place the client in high-Fowler position in the bed.
d. Contact the Rapid Response Team and prepare for intubation.
ANS: D
Stridor on exhalation is a hallmark of respiratory distress, usually caused by obstruction
resulting from edema. The nurse should prepare to assist with emergency intubation or
tracheostomy while notifying the Rapid Response Team. Stridor is an emergency situation;
therefore, reassuring the client, documenting, and reassessing in an hour do not address the
urgency of the situation. Oxygen should be applied, but this action will not keep the airway
open.
47
A nurse assesses a client who is recovering from a subtotal thyroidectomy. On the first
postoperative day before discharge, the client states, “I feel numbness and tingling around my
mouth.” What action does the nurse take?
a. Offer mouth care.
b. Loosen the dressing.
c. Assess for muscle twitching.
d. Ask the client orientation questions.
ANS: C
Numbness and tingling around the mouth or in the fingers and toes are manifestations of
hypocalcemia, which could progress to cause tetany and seizure activity. The nurse would
assess for muscle twitching and, if present, notify the surgeon or Rapid Response Team to
give calcium gluconate or other IV calcium replacement. Mouth care, loosening the dressing,
and orientation questions do not provide important information to prevent complications of
low calcium levels.
48
A nurse assesses a client on the medical-surgical unit. Which statement made by the client
alerts the nurse to assess the patient for hypothyroidism?
a. “My sister has thyroid problems.”
b. “I seem to feel the heat more than other people.”
c. “Food just doesn’t taste good without a lot of salt.”
d. “I am always tired, even with 12 hours of sleep.”
D
Clients with hypothyroidism usually feel tired or weak despite getting many hours of sleep.
Most thyroid problems are not inherited, although they may occur in families. Heat
intolerance is indicative of hyperthyroidism. Loss of taste is not a manifestation of
hypothyroidism. The nurse would assess the client further for hypothyroidism.
49
A nurse cares for a client who presents with bradycardia secondary to hypothyroidism. Which
medication does the nurse prepare to administer?
a. Atropine sulfate
b. Levothyroxine
c. Propranolol
d. Epinephrine
ANS: B
The treatment for bradycardia from hypothyroidism is to treat the hypothyroidism using
levothyroxine. If the heart rate were so slow that it became an emergency, then atropine or
epinephrine might be an option for short-term management. Propranolol is a beta blocker and
would be contraindicated for a client with bradycardia.
50
```
A nurse plans care for a client with hypothyroidism. Which priority problem does the nurse
address first for this client?
a. Heat intolerance
b. Body image problems
c. Depression and withdrawal
d. Obesity and water retention
```
ANS: C
Hypothyroidism causes many problems in psychosocial functioning. Depression is the most
common reason for seeking medical attention. Memory and attention span may be impaired.
The client’s family may have great difficulty accepting and dealing with these changes. The
client is often unmotivated to participate in self-care. Lapses in memory and attention require
the nurse to ensure that the patient’s environment is safe. Heat intolerance is seen in
hyperthyroidism. Body image problems and weight issues do not take priority over mental
status and safety.
51
A nurse cares for a client who has hypothyroidism as a result of Hashimotothyroiditis. The
client asks, “How long will I need to take this thyroid medication?” How would the nurse
respond?
a. “You will need to take the thyroid medication until the goiter is completely gone.”
b. “Thyroiditis is cured with antibiotics. Then you won’t need thyroid medication.”
c. “You’ll need thyroid pills for life because your thyroid won’t start working again.”
d. “When blood tests indicate normal thyroid function, you can stop the medication.”
ANS: C
Hashimoto thyroiditis results in a permanent loss of thyroid function. The client will need
lifelong thyroid replacement therapy and will not be able to stop taking the medication.
52
The nurse is caring for a client who is starting on propylthiouracil for hyperthyroidism. What
statement by the client indicates a need for further teaching?
a. “I will let my provider know if I have weight gain and cold intolerance.”
b. “I will let my provider know if I have a metallic taste or stomach upset.”
c. “I will avoid crowds and other people who have infection.”
d. “I am aware that if the drug changes the color of my urine, I should stop it.”
ANS: B
If the client’s urine turns dark and/or the skin has a yellow appearance, the client may have
possible liver toxicity from the drug. This is a serious adverse effect and needs to be reported
to the primary health care provider after stopping the drug. If weight gain and cold intolerance
occurs, then the client may need a lower dose of the drug. The drug should not cause GI
distress or a metallic taste in his or her mouth.
53
A nurse plans care for a client with hyperparathyroidism. Which intervention does the nurse
include in this client’s plan of care?
a. Use a lift sheet to assist the client with position changes in bed.
b. Ask the client to ambulate in the hallway twice a day.
c. Provide the client with a soft-bristled toothbrush for oral care.
d. Instruct the assistive personnel to strain the patient’s urine for stones.
ANS: A
Hyperparathyroidism causes increased resorption of calcium from the bones, increasing the
risk for pathologic fractures. Using a lift sheet when moving or positioning the client, instead
of pulling on the client, reduces the risk of bone injury. Hyperparathyroidism can cause
kidney stones, but not every client will need to have urine strained. The priority is preventing
injury. Ambulating in the hall and using a soft toothbrush are not specific interventions for
this patient.
54
While assessing a client with Graves disease, the nurse notes that the client’s temperature has
risen 1° F (1° C). What does the nurse do first?
a. Turn the lights down and shut the patient’s door.
b. Call for an immediate electrocardiogram (ECG).
c. Calculate the client’s apical-radial pulse deficit.
d. Administer a dose of acetaminophen.
ANS: A
A temperature increase of 1° F (5/9° C) may indicate the development of thyroid storm, and
the primary health care provider or RRT needs to be notified. But before notifying the
provider, the nurse should first take measures to reduce environmental stimuli that increase
the risk of cardiac complications. The nurse can then call for an ECG. The apical-radial pulse
deficit would not be necessary, and acetaminophen is not needed because the temperature
increase is due to thyroid activity.
55
```
The nurse is caring for a client who has possible hypothyroidism. What possible risk factors
can cause this health problem? (Select all that apply.)
a. Lithium drug therapy
b. Thyroid cancer
c. Autoimmune thyroid disease
d. Iodine deficiency
e. Laryngitis
f. Pituitary tumors
```
ANS: A, B, C, D, F
All of these factors place a client at risk for hypothyroidism except for laryngitis which is an
inflammation of the larynx.
56
A nurse is caring for a client with elevated triiodothyronine and thyroxine, and normal
thyroid-stimulating hormone levels. What actions does the nurse take? (Select all that apply.)
a. Administer levothyroxine.
b. Administer propranolol.
c. Monitor the apical pulse.
d. Assess for Trousseau sign.
e. Initiate telemetry monitoring.
ANS: C, E
The client’s laboratory findings suggest that the client is experiencing hyperthyroidism. The
increased metabolic rate can cause an increase in the client’s heart rate, and the client should
be monitored for the development of dysrhythmias. Placing the client on a telemetry monitor
might also be a precaution. Levothyroxine is given for hypothyroidism. Propranolol is a beta
blocker often used to lower sympathetic nervous system activity in hyperthyroidism.
Trousseau sign is a test for hypocalcemia.
57
A nurse teaches a client with hyperthyroidism. Which dietary modifications should the nurse
include in this client’s health teaching? (Select all that apply.)
a. Increased carbohydrates
b. Decreased fats
c. Increased calorie intake
d. Supplemental vitamins
e. Increased proteins
ANS: A, C, E
The client is hypermetabolic and has an increased need for carbohydrates, calories, and
proteins. Proteins are especially important because the client is at risk for a negative nitrogen
balance. There is no need to decrease fat intake or take supplemental vitamins.
58
A nurse is teaching a client with diabetes mellitus who asks, “Why is it necessary to maintain
my blood glucose levels no lower than about 60 mg/dL (3.3 mmol/L)?” How would the nurse
respond?
a. “Glucose is the only fuel used by the body to produce the energy that it needs.”
b. “Your brain needs a constant supply of glucose because it cannot store it.”
c. “Without a minimum level of glucose, your body does not make red blood cells.”
d. “Glucose in the blood prevents the formation of lactic acid and prevents acidosis.”
ANS: B
Because the brain cannot synthesize or store significant amounts of glucose, a continuous
supply from the body’s circulation is needed to meet the fuel demands of the central nervous
system. The nurse would want to educate the patient to prevent hypoglycemia. The body can
use other sources of fuel, including fat and protein, and glucose is not involved in the
production of red blood cells. Glucose in the blood will encourage glucose metabolism but is
not directly responsible for lactic acid formation.
59
```
The nurse is assessing a client for risk of developing metabolic syndrome. Which risk factor is
associated with this health condition?
a. Hypotension
b. Hyperthyroidism
c. Abdominal obesity
d. Hypoglycemia
```
ANS: C
The client at risk for metabolic syndrome typically has hypertension, abdominal obesity,
hyperlipidemia, and hyperglycemia.
60
After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the
nurse assesses the client’s understanding. Which statement made by the client indicates a
correct understanding of the need for eye examinations?
a. “At my age, I should continue seeing the ophthalmologist as I usually do.”
b. “I will see the eye doctor when I have a vision problem and yearly after age 40.”
c. “My vision will change quickly. I should see the ophthalmologist twice a year.”
d. “Diabetes can cause blindness, so I should see the ophthalmologist yearly.”
ANS:D
Diabetic retinopathy is a leading cause of blindness in North America. All clients with
diabetes, regardless of age, should be examined by an ophthalmologist (rather than an
optometrist or optician) at diagnosis and at least yearly thereafter.
61
A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile
sensation in both feet. What action would the nurse take first?
a. Document the finding in the client’s chart.
b. Assess tactile sensation in the client’s hands.
c. Examine the client’s feet for signs of injury.
d. Notify the primary health care provider.
ANS: C
Diabetic neuropathy is common when the disease is of long duration. The client is at great risk
for injury in any area with decreased sensation because he or she is less able to feel injurious
events. Feet are common locations for neuropathy and injury, so the nurse would inspect them
for any signs of injury. After assessment, the nurse would document findings in the client’s
chart. Testing sensory perception in the hands may or may not be needed. The primary health
care provider can be notified after assessment and documentation have been completed.
62
A nurse cares for a client who has a family history of diabetes mellitus. The client states, “My
father has type 1 diabetes mellitus. Will I develop this disease as well?” How would the nurse
respond?
a. “Your risk of diabetes is higher than the general population, but it may not occur.”
b. “No genetic risk is associated with the development of type 1 diabetes mellitus.”
c. “The risk for becoming a diabetic is 50% because of how it is inherited.”
d. “Female children do not inherit diabetes mellitus, but male children will.”
ANS: A
Risk for type 1 diabetes is determined by inheritance of genes coding for HLA-DR and
HLA-DQ tissue types. Clients who have one parent with type 1 diabetes are at increased risk
for its development. Diabetes (type 1) seems to require interaction between inherited risk and
environmental factors, so not everyone with these genes develops diabetes. The other
statements are not accurate.
63
A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement would the
nurse include in this client’s plan of care to delay the onset of microvascular and
macrovascular complications?
a. “Maintain tight glycemic control and prevent hyperglycemia.”
b. “Restrict your fluid intake to no more than 2 L a day.”
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c. “Prevent hypoglycemia by eating a bedtime snack.”
d. “Limit your intake of protein to prevent ketoacidosis.”
ANS: A
Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications.
Maintaining tight glycemic control will help delay the onset of complications. Restricting
fluid intake is not part of the treatment plan for patients with diabetes. Preventing
hypoglycemia and ketosis, although important, is not as important as maintaining daily
glycemic control.
64
A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk?
a. A 19-year-old Caucasian
b. A 22-year-old African American
c. A 44-year-old Asian American
d. A 58-year-old American Indian
ANS: D
Diabetes is a particular problem among African Americans, Hispanics, and American Indians.
The incidence of diabetes increases in all races and ethnic groups with age. Being both an
American Indian and middle age places this patient at highest risk.
65
A nurse teaches a patient about self-monitoring of blood glucose levels. Which statement
would the nurse include in this client’s teaching to prevent bloodborne infections?
a. “Wash your hands after completing each test.”
b. “Do not share your monitoring equipment.”
c. “Blot excess blood from the strip with a cotton ball.”
d. “Use gloves when monitoring your blood glucose.”
ANS: B
Small particles of blood can adhere to the monitoring device, and infection can be transported
from one user to another. Hepatitis B in particular can survive in a dried state for about a
week. The client would be taught to avoid sharing any equipment, including the lancet holder.
The client would also be taught to wash his or her hands before testing. He or she would not
need to blot excess blood away from the strip or wear gloves.
66
A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol).
Which statement would the nurse include in this client’s teaching?
a. “Change positions slowly when you get out of bed.”
b. “Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs).”
c. “If you miss a dose of this drug, you can double the next dose.”
d. “Discontinue the medication if you develop a urinary infection.”
ANS: B
NSAIDs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a
sulfonylurea. The other statements are not applicable to glipizide.
67
After teaching a patient with type 2 diabetes mellitus who is prescribed nateglinide, the nurse
assesses the client’s understanding. Which statement made by the patient indicates a correct
understanding of the prescribed therapy?
a. “I’ll take this medicine during each of my meals.”
b. “I must take this medicine in the morning when I wake.”
c. “I will take this medicine before I go to bed.”
d. “I will take this medicine immediately before I eat.”
ANS: D
Nateglinide is an insulin secretagogue that is designed to increase meal-related insulin
secretion. It should be taken immediately before each meal. The medication should not be
taken without eating as it will decrease the client’s blood glucose levels causing
hypoglycemia. The medication should be taken before meals instead of during meals.
68
A nurse cares for a patient who is prescribed pioglitazone. After 6 months of therapy, the
client reports that he has a new onset of ankle edema. What assessment question would the
nurse take?
a. “Have you gained unexpected weight this week?”
b. “Has your urinary output declined recently?”
c. “Have you had fever and achiness this week?”
d. “Have you had abdominal pain recently?”
ANS: A
Thiazolidinediones (including pioglitazone) can cause cardiovascular adverse effects
including health failure which is manifested by peripheral edema and unintentional weight
gain. The client should have been taught to weigh every week and report sudden increases in
weight.
69
A nurse cares for a client with diabetes mellitus who asks, “Why do I need to administer more
than one injection of insulin each day?” How would the nurse respond?
a. “You need to start with multiple injections until you become more proficient at
self-injection.”
b. “A single dose of insulin each day would not match your blood insulin levels and
your food intake patterns.”
c. “A regimen of a single dose of insulin injected each day would require that you eat
fewer carbohydrates.”
d. “A single dose of insulin would be too large to be absorbed, predictably putting
you at risk for insulin shock.”
ANS: B
Even when a single injection of insulin contains a combined dose of different-acting insulin
types, the timing of the actions and the timing of food intake may not match well enough to
prevent wide variations in blood glucose levels. One dose of insulin would not be appropriate
even if the patient decreased carbohydrate intake. Additional injections are not required to
allow the client practice with injections, nor will one dose increase the client’s risk of insulin
shock.
70
After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the client’s
understanding. Which statement made by the client indicates a need for further teaching?
a. “The lower abdomen is the best location because it is closest to the pancreas.”
b. “I can reach my thigh the best, so I will use the different areas of my thighs.”
c. “By rotating the sites in one area, my chance of having a reaction is decreased.”
d. “Changing injection sites from the thigh to the arm will change absorption rates.”
ANS: A
The abdominal site has the fastest rate of absorption because of blood vessels in the area, not
because of its proximity to the pancreas. The other statements are accurate assessments of
insulin administration.
71
A nurse reviews the laboratory test values for a client with a new diagnosis of diabetes
mellitus type 2. Which A1C value would the nurse expect?
a. 5.0%
b. 5.7%
c. 6.2%
d. 7.4%
ANS: D
A client is diagnosed with diabetes if the client’s A1C is 6.5% or greater. All listed values are
below that level except for 7.4%.
72
The nurse is planning teaching for a client who is starting exenatide extended release (ER) for
diabetes mellitus type 2. Which statement will the nurse include in the teaching?
a. “Be sure to take the drug once a day before breakfast.”
b. “Take the drug every evening before bedtime.”
c. “Give your drug injection the same day every week.”
d. “Take the drug with dinner at the same time each day.”
ANS: C
Exenatide ER is an incretin mimetic (GLP-1 agonist) that works with insulin to lower blood
glucose levels by reducing pancreatic glucagon secretion, reducing liver glucose production,
and delaying gastric emptying. As an extended-release drug, it is given only once a week by
injection.
73
The nurse is planning teaching for a client who is starting acarbose for diabetes mellitus type
2. Which statement will the nurse include in the teaching?
a. “Be sure to take the drug with each meal.”
b. “Take the drug every evening before bedtime.”
c. “Take the drug on an empty stomach in the morning.”
d. “Decide on the best day of the week to take the drug.”
ANS: A
Acarbose is an alpha-glucosidase inhibitor that works in the intestinal tract to prevent
enzymes from breaking down starches into glucose. However, it must be taken with food at
each meal, usually 3 times a day, to allow the drug to work as intended.
74
After teaching a client who has diabetes mellitus with retinopathy, nephropathy, and
peripheral neuropathy, the nurse assesses the client’s understanding. Which statement made
by the client indicates a correct understanding of the teaching?
a. “I have so many complications; exercising is not recommended.”
b. “I will exercise more frequently because I have so many complications.”
c. “I used to run for exercise; I will start training for a marathon.”
d. “I should look into swimming or water aerobics to get my exercise.”
ANS: D
Exercise is not contraindicated for this client, although modifications based on existing
pathology are necessary to prevent further injury. Swimming or water aerobics will give the
client exercise without the worry of having the correct shoes or developing a foot injury. The
client should not exercise too vigorously.
75
The nurse assesses a client with diabetic ketoacidosis. Which assessment finding would the
nurse correlate with this condition?
a. Increased rate and depth of respiration
b. Extremity tremors followed by seizure activity
c. Oral temperature of 102° F (38.9° C)
d. Severe orthostatic hypotension
ANS: A
Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the
brain to buffer the effects of increasing acidosis. The rate and depth of respiration are
increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation. Tremors,
elevated temperature, and orthostatic hypotension are not associated with ketoacidosis.
76
A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values would the
nurse identify as potential ketoacidosis in this client?
a. pH 7.38, HCO3 22 mEq/L (22 mmol/L), PCO2 38 mm Hg, PO2 98 mm Hg
b. pH 7.28, HCO3 18 mEq/L (18 mmol/L), PCO2 28 mm Hg, PO2 98 mm Hg
c. pH 7.48, HCO3 28 mEq/L (28 mmol/L), PCO2 38 mm Hg, PO2 98 mm Hg
d. pH 7.32, HCO3 22 mEq/L (22 mmol/L), PCO2 58 mm Hg, PO2 88 mm Hg
ANS: B
When the lungs can no longer offset acidosis, the pH decreases to below normal. A client who
has diabetic ketoacidosis would present with arterial blood gas values that show primary
metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis
with decreased carbon dioxide levels.
77
A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul
respirations. What action would the nurse take?
a. Administration of oxygen via facemask
b. Intravenous administration of 10% glucose
c. Implementation of seizure precautions
d. Administration of intravenous insulin
ANS: D
The rapid, deep respiratory efforts of Kussmaul respirations are the body’s attempt to reduce
the acids produced by using fat rather than glucose for fuel. Only the administration of insulin
will reduce this type of respiration by assisting glucose to move into cells and to be used for
fuel instead of fat. The patient who is in ketoacidosis may not experience any respiratory
impairment and therefore does not need additional oxygen. Giving the patient glucose would
be contraindicated. The patient does not require seizure precautions.
78
A nurse teaches a client with type 1 diabetes mellitus. Which statement would the nurse
include in this client’s teaching to decrease the client’s insulin needs?
a. “Limit your fluid intake to 2 L a day.”
b. “Animal organ meat is high in insulin.”
c. “Limit your carbohydrate intake to 80 g a day.”
d. “Walk at a moderate pace for 1 mile daily.”
ANS: D
Moderate exercise such as walking helps regulate blood glucose levels on a daily basis and
results in lowered insulin requirements for patients with type 1 diabetes mellitus. Restricting
fluids and eating organ meats will not reduce insulin needs. People with diabetes need at least
130 g of carbohydrates each day.
79
After teaching a client who is recovering from pancreas transplantation, the nurse assesses the
client’s understanding. Which statement made by the client indicates a need for further
teaching?
a. “If I develop an infection, I should stop taking my corticosteroid.”
b. “If I have pain over the transplant site, I will call the surgeon immediately.”
c. “I should avoid people who are ill or who have an infection.”
d. “I should take my cyclosporine exactly the way I was taught.”
ANS: A
Immunosuppressive agents should not be stopped without the consultation of the
transplantation physician, even if an infection is present. Stopping immunosuppressive
therapy endangers the transplanted organ. The other statements are correct. Pain over the graft
site may indicate rejection. Antirejection drugs cause immunosuppression, and the patient
should avoid crowds and people who are ill. Changing the routine of antirejection medications
may cause them to not work optimally.
80
A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced
sensation. Which statement would the nurse include in this client’s teaching to prevent
injury?
a. “Examine your feet using a mirror every day.”
b. “Rotate your insulin injection sites every week.”
c. “Check your blood glucose level before each meal.”
d. “Use a bath thermometer to test the water temperature.”
ANS: D
Clients with diminished sensory perception can easily experience a burn injury when
bathwater is too hot. Instead of checking the temperature of the water by feeling it, they
should use a thermometer. Examining the feet daily does not prevent injury, although daily
foot examinations are important to find problems so they can be addressed. Rotating insulin
and checking blood glucose levels will not prevent injury.
81
A nurse assesses a client with diabetes mellitus. Which assessment finding would alert the
nurse to decreased kidney function in this client?
a. Urine specific gravity of 1.033
b. Presence of protein in the urine
c. Elevated capillary blood glucose level
d. Presence of ketone bodies in the urine
ANS: B
Renal dysfunction often occurs in the client with diabetes. Proteinuria is a result of renal
dysfunction. Specific gravity is elevated with dehydration. Elevated capillary blood glucose
levels and ketones in the urine are consistent with diabetes mellitus but are not specific to
renal function.
82
A nurse develops a dietary plan for a client with diabetes mellitus and new-onset
microalbuminuria. Which component of the client’s diet would the nurse decrease?
a. Carbohydrates
b. Proteins
c. Fats
d. Total calories
ANS: B
Restriction of dietary protein is recommended for clients with microalbuminuria to delay
progression to renal failure. The client’s diet does not need to be decreased in carbohydrates,
fats, or total calories.
83
A nurse assesses a client who has diabetes mellitus and notes that the client is awake and alert,
but shaky, diaphoretic, and weak. Five minutes after administering a half-cup (120 mL) of
orange juice, the client’s signs and symptoms have not changed. What action would the nurse
take next?
a. Administer another half-cup (120 mL) of orange juice.
b. Administer a half-ampule of dextrose 50% intravenously.
c. Administer 10 units of regular insulin subcutaneously.
d. Administer 1 mg of glucagon intramuscularly.
ANS: A
This patient is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, the
nurse would administer oral glucose in the form of orange juice. If the symptoms do not
resolve immediately, the treatment would be repeated. The patient does not need intravenous
dextrose, insulin, or glucagon.
84
A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which
would alert the nurse to intervene immediately?
a. Serum chloride level of 98 mEq/L (98 mmol/L)
b. Serum calcium level of 8.8 mg/dL (2.2 mmol/L)
c. Serum sodium level of 132 mEq (132 mmol/L)
d. Serum potassium level of 2.5 mEq/L (2.5 mmol/L)
ANS: D
Insulin activates the sodium–potassium ATPase pump, increasing the movement of potassium
from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In
hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The
chloride level is normal. The calcium and sodium levels are slightly low, but this would not be
related to hyperglycemia and insulin administration.
85
A nurse teaches a client with diabetes mellitus about sick-day management. Which statement
would the nurse include in this client’s teaching?
a. “When ill, avoid eating or drinking to reduce vomiting and diarrhea.”
b. “Monitor your blood glucose levels at least every 4 hours while sick.”
c. “If vomiting, do not use insulin or take your oral antidiabetic agent.”
d. “Try to continue your prescribed exercise regimen even if you are sick.”
ANS: B
When ill, the client should monitor his or her blood glucose at least every 4 hours. The client
should continue taking the medication regimen while ill. The client should continue to eat and
drink as tolerated but should not exercise while sick.
86
The nurse is caring for a client who has diabetes mellitus. The nurse administers 6 units of
regular insulin and 10 units of NPH insulin at 7:00 a.m. (0700). At which time would the
nurse assess the client for potential hypoglycemia related to the NPH insulin?
a. 8:00 a.m. (0800)
b. 4:00 p.m. (1600)
c. 8:00 p.m. (2000)
d. 11:00 p.m. (2300)
ANS: B
Neutral protamine Hagedorn (NPH) is an intermediate-acting insulin with an onset of 1.5
hours, peak of 4 to 12 hours, and duration of action of 22 hours. Checking the client at 0800
would be too soon. Checking the patient at 2000 and 2300 would be too late. The nurse would
check the patient at 1600 (4:00 p.m.).
87
When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, “I
will never be able to stick myself with a needle.” How would the nurse respond?
a. “I can give your injections to you while you are here in the hospital.”
b. “Everyone gets used to giving themselves injections. It really does not hurt.”
c. “Your disease will not be managed properly if you refuse to administer the shots.”
d. “Tell me what it is about the injections that are concerning you.”
ANS: D
Devote as much teaching time as possible to insulin injection and blood glucose monitoring.
Clients with newly diagnosed diabetes are often fearful of giving themselves injections. If the
client is worried about giving the injections, it is best to try to find out what specifically is
causing the concern, so it can be addressed. Giving the injections for the client does not
promote self-care ability. Telling the client that others give themselves injections may cause
the client to feel bad. Stating that you don’t know another way to manage the disease is
dismissive of the client’s concerns.
88
A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin.
The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin
injection. What action would the nurse take?
a. Apply ice to the site to reduce inflammation.
b. Consult the provider for a new administration route.
c. Assess the client for other signs of cellulitis.
d. Instruct the client to rotate sites for insulin injection.
ANS: D
The client’s tissue has been damaged from continuous use of the same site. The client would
be educated to rotate sites. The damaged tissue is not caused by cellulitis or any type of
infection, and applying ice may cause more damage to the tissue. Insulin can only be
administered subcutaneously and intravenously. It would not be appropriate or practical to
change the administration route.
89
After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse
assesses the client’s understanding. Which statement made by the client indicates a need for
additional teaching?
a. “I should increase my intake of vegetables with higher amounts of dietary fiber.”
b. “My intake of saturated fats should be no more than 10% of my total calorie
intake.”
c. “I should decrease my intake of protein and eliminate carbohydrates from my
diet.”
d. “My intake of water is not restricted by my treatment plan or medication regimen.”
ANS:C
The client should not completely eliminate carbohydrates from the diet, and should reduce
protein if microalbuminuria is present. The client should increase dietary intake of complex
carbohydrates, including vegetables, and decrease intake of fat. Water does not need to be
restricted unless kidney failure is present.
90
A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an
intensified insulin regimen:
• Fasting blood glucose: 75 mg/dL (4.2 mmol/L)
• Postprandial blood glucose: 200 mg/dL (11.1 mmol/L)
• Hemoglobin A1C level: 5.5%
How would the nurse interpret these laboratory findings?
a. Increased risk for developing ketoacidosis
b. Good control of blood glucose
c. Increased risk for developing hyperglycemia
d. Signs of insulin resistance
ANS: B
The client is maintaining blood glucose levels within the defined ranges for goals in an
intensified regimen. Because the client’s glycemic control is good, he or she is not at higher
risk for ketoacidosis or hyperglycemia and is not showing signs of insulin resistance.
91
The nurse is caring for a newly admitted older adult who has a blood glucose of 300 mg/dL
(16.7 mmol/L), a urine output of 185 mL in the past 8 hours, and a blood urea nitrogen (BUN)
of 44 mg/dL (15.7 mmol/L). What diabetic complication does the nurse suspect?
a. Diabetic ketoacidosis (DKA)
b. Severe hypoglycemia
c. Chronic kidney disease (CKD)
d. Hyperglycemic-hyperosmolar state (HHS)
ANS: D
The client most likely has diabetes mellitus type 2 and has a high blood glucose causing
increased blood osmolarity and dehydration, as evidenced by an insufficient urinary output
and increased BUN. Older adults are at the greatest risk for dehydration due to age-related
physiologic changes.
92
The nurse is caring for a newly admitted client who is diagnosed with
hyperglycemic-hyperosmolar state (HHS). What is the nurse’s priority action at this time?
a. Assess the client’s blood glucose level.
b. Monitor the client’s urinary output every hour.
c. Establish intravenous access to provide fluids.
d. Give regular insulin per agency policy
ANS: C
The first priority in caring for a client with HHS is to increase blood volume to prevent shock
or severe hypotension from dehydration. The nurse would monitor vital signs, urinary output,
and blood glucose to determine if interventions were effective. Regular insulin is also
indicated but not as the first priority action.
93
A nurse assesses adults at a health fair. Which adults would the nurse counsel to be tested for
diabetes? (Select all that apply.)
a. A 56-year-old African-American male
b. A 22-year-old female with a 30-lb (13.6 kg) weight gain during pregnancy
c. A 60-year-old male with a history of liver trauma
d. A 48-year-old female with a sedentary lifestyle
e. A 50-year-old male with a body mass index greater than 25 kg/m2
f. A 28-year-old female who gave birth to a baby weighing 9.2 lb (4.2 kg)
ANS: A, D, E, F
Risk factors for type 2 diabetes include certain ethnic/racial groups (African Americans,
American Indians, and Hispanics), obesity and physical inactivity, and giving birth to large
babies. Liver trauma and a 30-lb (13.6 kg) gestational weight gain are not risk factors.
94
A nurse assesses a patient who is experiencing diabetic ketoacidosis (DKA). For which
assessment findings would the nurse monitor the client? (Select all that apply.)
a. Deep and fast respirations
b. Decreased urine output
c. Tachycardia
d. Dependent pulmonary crackles
e. Orthostatic hypotension
ANS: A, C, E
DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension.
Usually, patients have Kussmaul respirations, which are fast and deep. Increased urinary
output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and
crackles do not occur.
95
A nurse teaches a client with diabetes mellitus about foot care. Which statements would the
nurse include in this client’s teaching? (Select all that apply.)
a. “Do not walk around barefoot.”
b. “Soak your feet in a tub each evening.”
c. “Trim toenails straight across with a nail clipper.”
d. “Treat any blisters or sores with Epsom salts.”
e. “Wash your feet every other day.”
ANS: A, C
Clients who have diabetes mellitus are at high risk for wounds on the feet secondary to
peripheral neuropathy and poor arterial circulation. The client would be instructed to not walk
around barefoot or wear sandals with open toes. These actions place the client at higher risk
for skin breakdown of the feet. The client would be instructed to trim toenails straight across
with a nail clipper. Feet should be washed daily with lukewarm water and soap, but feet
should not be soaked in the tub. The client should contact the primary health care provider
immediately if blisters or sores appear and should not use home remedies to treat these
wounds.
96
A nurse provides diabetic education at a public health fair. Which disorders would the nurse
include as complications of diabetes mellitus? (Select all that apply.)
a. Stroke
b. Kidney failure
c. Blindness
d. Respiratory failure
e. Cirrhosis
ANS: A, B, C
Complications of diabetes mellitus are caused by macrovascular and microvascular changes.
Macrovascular complications include coronary artery disease, cerebrovascular disease, and
peripheral vascular disease. Microvascular complications include nephropathy, retinopathy,
and neuropathy. Respiratory failure and cirrhosis are not complications of diabetes mellitus.
97
A nurse collaborates with the interprofessional team to develop a plan of care for a client who
is newly diagnosed with diabetes mellitus. Which team members would the nurse include in
this interprofessional team meeting? (Select all that apply.)
a. Registered dietitian nutritionist
b. Clinical pharmacist
c. Occupational therapist
d. Primary health care provider
e. Speech–language pathologist
ANS: A, B, D
When planning care for a client newly diagnosed with diabetes mellitus, the nurse would
collaborate with a registered dietitian nutritionist, clinical pharmacist, and primary health care
provider. The focus of treatment for a newly diagnosed client would be nutrition, medication
therapy, and education. The nurse could also consult with a diabetic educator. There is no
need for occupational therapy or speech therapy at this time.
98
The nurse is caring for a client who has severe hypoglycemia and is experiencing a seizure.
What actions will the nurse take at this time? (Select all that apply.)
a. Administer glucagon 1 mg subcutaneously.
b. Be sure the bed side rails are in the up position.
c. Notify the primary health care provider immediately.
d. Monitor the client’s blood glucose level.
e. Increase the intravenous infusion rate immediately.
ANS: A, B, C, D
The client who has severe hypoglycemia often has a blood sugar of less than 20 mg/dL (1.0
mmol/L) and may be unconscious or seizing. Therefore, the client cannot swallow and needs
glucagon. To keep the client safe during the seizure, the nurse ensures that the side rails are up
to prevent the client from falling out of bed. The nurse would also monitor the client’s blood
sugar to evaluate the effectiveness of the interventions.
99
The nurse is caring for a client who has diabetes mellitus type 1 and is experiencing
hypoglycemia. Which assessment findings will the nurse expect? (Select all that apply.)
a. Warm, dry skin
b. Nervousness
c. Rapid deep respirations
d. Dehydration
e. Ketoacidosis
f. Blurred vision
ANS: B, F
The client who has hypoglycemia is often anxious, nervous, and possibly confused. Due to
lack of glucose, vision may be blurred or the client may report diplopia (double vision).
Clients who have hyperglycemia from diabetes mellitus type 1 have warm skin, Kussmaul
respirations that are rapid and deep, dehydration due to elevated blood glucose, and
ketoacidosis.
