Endocrine Health Problems NCLEX Questions with Rationale

Endocrine Health Problems NCLEX Questions with Rationale

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NCLEX Endocrine Health Problems Questions

Endocrine Health Problems NCLEX Practice Questions

Question 1.
The nurse is completing a health assessment of a 42-year-old female with suspected Graves’ disease. When conducting a focused assessment, what should the nurse assess the client for?
(a) anorexia
(b) tachycardia
(c) weight gain
(d) cold skin
Answer:
(b) tachycardia

Explanation:
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.

Question 2.
When conducting a health history with a female client with thyrotoxicosis, the nurse should ask about which changes in the menstrual cycle?
(a) dysmenorrhea
(b) metrorrhagia
(c) oligomenorrhea
(d) menorrhagia
Answer:
(c) oligomenorrhea

Explanation:
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.

Question 3.    
A 34-year-old female is diagnosed with hypo-thyroidism. What information should the nurse obtain from conducting a focused assessment? Select all that apply.
(a) rapid pulse
(b) decreased energy and fatigue
(c) weight gain of 10 lb (4.5 kg)
(d) fine, thin hair with hair loss
(e) constipation
(f) menorrhagia
Answer:
(b) decreased energy and fatigue
(c) weight gain of 10 lb (4.5 kg)
(e) constipation
(f) menorrhagia

Explanation:
(b), (c), (e), (f). 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.

Question 4.
Propylthiouracil (PTU) is prescribed for a client with Graves’ disease. Which symptom should the nurse teach the client to report?
(a) sore throat
(b) excessive menstruation
(c) constipation
(d) increased urine output
Answer:
(a) sore throat

Explanation:
The most serious adverse effects of PTU are leukopenia and agranulocytosis, which usually occur within the first 3 months of treatment. The client should be taught to promptly report to the health care provider (HCP) signs and symptoms of infection, such as a sore throat and fever. Clients having a sore throat and fever should have an immediate white blood cell count and differential performed, and the drug must be withheld until the results are obtained. Painful menstruation, constipation, and increased urine output are not associated with PTU therapy.
 
Question 5.
A client with thyrotoxicosis says to the nurse, “I’m so irritable. I’m having problems at work because I lose my temper very easily.” Which response by the nurse would give the client the most accurate explanation of this behavior?
“You are experiencing:
(a) temporary confusion brought on by your illness.”
(b) excess thyroid hormone in your system.”
(c) worry about the seriousness of your illness.”
(d) stress of trying to manage a career and cope with illness.”
Answer:
(b) excess thyroid hormone in your system.”

Explanation:
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.

Question 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 statement from the client indicates the drug is effective?
(a) “I have excess energy throughout the day.”
(b) “I'm able to sleep and rest at night.”
(c) “I’ve lost weight since taking this medication.”
(d) “I do perspire throughout the entire day.”
Answer:
(b) “I'm able to sleep and rest at night.”

Explanation:
PTU is a prototype of thioamide antithyroid drugs. It inhibits the production of thyroid hormones and 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.

Question 7.
A client with hyperthyroidism is to have a thyroidectomy. The health care provider (HCP) has prescribed propranolol. In reviewing the client’s history, the nurse notes that the client has asthma. What should the nurse do next?
(a) Take the client’s pulse and withhold the propranolol if the pulse is <100 beats per minute.
(b) Count the client’s respirations and withhold the propranolol if the respirations are <20 breaths per minute.
(c) Contact the HCP and discuss the prescription for propranolol because of the client’s history of having asthma.
(d) Instruct the client to make position changes slowly.
Answer:
(c) Contact the HCP and discuss the prescription for propranolol because of the client’s history of having asthma.

A client with hyperthyroidism is to have a thyroidectomy. the health care provider (hcp) has prescribed propranolol

Explanation:
Propranolol hydrochloride is a nonselective beta-blocker of both cardiac and bronchial adrenoreceptors, which competes with epinephrine and norepinephrine for available beta-receptor sites. Propranolol blocks the cardiac effects of beta-adrenergic stimulation; as a result, it reduces heart rate; a hypertensive effect is associated with decreased cardiac output. A contraindication of propranolol is bronchial asthma; propranolol can cause bronchio- lar constriction even in normal clients. The nurse takes the apical pulse and BP before administering propranolol. The medication is withheld if the heart rate is <60 beats per minute or the systolic blood pressure is <90 mm Hg.

Question 8.
A client with Graves’ disease has exophthalmos. What should the nurse teach the client to do to prevent corneal irritation?
(a) Massage the eyes every 4 hours.
(b) Instill an ophthalmic anesthetic as prescribed.
(c) Wear dark-colored glasses when awake.
(d) Cover both eyes with moistened gauze pads at night.
Answer:
(c) Wear dark-colored glasses when awake.

Explanation:
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.

Question 9.    
A client with hyperthyroidism is to be treated with radioactive iodine (RAI, I-131). Following treatment, what should the nurse should teach the client to do?
(a) Monitor for signs and symptoms of hyperthyroidism.
(b) Rest for 1 week to prevent complications of the medication.
(c) Take thyroxine replacement for the remainder of the client’s life.
(d) Assess for hypertension and tachycardia resulting from altered thyroid activity.
Answer:
(c) Take thyroxine replacement for the remainder of the client’s life.

Explanation:
The client needs to be educated about the need for lifelong thyroid hormone replacement. Permanent hypothyroidism is the major complication of radioactive iodine 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.

Question 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. What should the nurse explain to the client about the expected outcome of using this drug? The drug helps:
(a) slow progression of exophthalmos.
(b) reduce the vascularity of the thyroid gland.
(c) decrease the body’s ability to store thyroxine.
(d) increase the body’s ability to excrete thyroxine.
Answer:
(b) reduce the vascularity of the thyroid gland.

Explanation:
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.

Question 11.    
A client with hyperthyroidism is to take saturated solution of potassium iodide (SSKI). What should the nurse do when administering this drug?
(a) Pour the solution over ice chips.
(b) Mix the solution with an antacid.
(c) Dilute the solution with water, milk, or fruit juice and have the client drink it with a straw.
(d) Disguise the solution in a pureed fruit or vegetable.
Answer:
(c) Dilute the solution with water, milk, or fruit juice and have the client drink it with a straw.

Explanation:
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 the 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.

Question 12.
Following a subtotal thyroidectomy, the nurse asks the client to speak immediately upon regaining consciousness. The client is not able to make a sound. The nurse determines that the client is experiencing which complication of the surgery?
(a) internal hemorrhage
(b) decreasing level of consciousness
(c) laryngeal nerve damage
(d) upper airway obstruction
Answer:
(c) laryngeal nerve damage

Explanation:
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 health care provider (HCP) 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.

Question 13.
Immediately following a thyroidectomy, the nurse asks the client to say “hello.” The client moves the lips, but is not able to speak the word. What should the nurse do next?
(a) Give the client a sip of water.
(b) Have the client take a deep breath and cough.
(c) Notify the surgeon.
(d) Check client’s pupillary response.
Answer:
(c) Notify the surgeon.

Explanation:
The nurse first should notify the surgeon; inability to speak may indicate laryngeal nerve damage. The client should not receive water until fully recovered from anesthesia. Coughing now will irritate the throat. The client is responsive, so the immediate action is not to do a pupillary check.

Question 14. 
One day following a subtotal thyroidectomy, a client begins to have tingling in the fingers and toes. What should the nurse do first?
(a) Encourage the client to flex and extend the fingers and toes.
(b) Notify the health care provider (HCP).
(c) Assess the client for thrombophlebitis.
(d) Ask the client to speak.
Answer:
(b) Notify the health care provider (HCP).

Explanation:
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 HCP. 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.

Question 15.
Which medication should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy?
(a) sodium phosphate
(b) calcium gluconate
(c) echothiophate iodide
(d) sodium bicarbonate
Answer:
(b) calcium gluconate

Explanation:
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.

Question 16. 
A 60-year-old female is diagnosed with hypothyroidism. What additional information should the nurse obtain when conducting a focused assessment?
(a) tachycardia
(b) weight gain
(c) diarrhea
(d) nausea
Answer:
(b) weight gain

Explanation:
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.

Question 17.    
A client is being evaluated for hypothyroidism. To plan care, the nurse should ask the client about which sign or symptom?
(a) corneal abrasion
(b) weight loss
(c) diarrhea
(d) fatigue
Answer:
(d) fatigue

Explanation:
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.

Question 18.    
A client with hypothyroidism has started to take thyroid hormone replacement therapy and asks the nurse about the reason for feeling sad and depressed. What should the nurse tell the client?
“The feelings of sadness and depression are caused by:
(a) the side effects of thyroid hormone replace ment therapy and will diminish over time.”
(b) a condition unrelated to hypothyroidism and require follow-up.”
(c) having a chronic illness and are normal.”
(d) low thyroid hormone levels and will improve with replacement therapy.”
Answer:
(d) low thyroid hormone levels and will improve with replacement therapy.”

Explanation:
Hypothyroidism may contribute to sadness and depression. This client needs to know that these feelings may be related to 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.”

Question 19.    
The nurse is instructing the client with hypothyroidism who takes levothyroxine 100 meg, digoxin, and simvastatin. The nurse judges that the teaching regarding the use of these medications is effective if the client will take:
(a) the levothyroxine with breakfast and the other medications after breakfast.
(b) the levothyroxine before breakfast and the other medications 4 hours later.
(c) all medications together 1 hour after eating breakfast.
(d) all medications before going to bed. The Client with Diabetes Mellitus
Answer:
(b) the levothyroxine before breakfast and the other medications 4 hours later.

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

Question 20.    
The nurse is coaching a diabetic client using an empowerment approach. The nurse should initiate teaching by asking which question?
(a) “How much does your family need to be involved in learning about your condition?”
(b) “What is required for your family to manage your symptoms?”
(c) “What activities are most important for you to be able to maintain control of your diabetes?”
(d) “What do you know about your medications and condition?”
Answer:
(c) “What activities are most important for you to be able to maintain control of your diabetes?”

Explanation:
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.

Question 21.    
The nurse is obtaining a health history from a client with diabetes mellitus who has been taking insulin for 20 years. Currently, the client reports having periods of hypoglycemia followed by periods of hyperglycemia. What should the nurse ask about the client’s current management plan?
Is the client:
(a) eating snacks between meals?
(b) using an insulin pump?
(c) injecting insulin at a site of lipodystrophy?
(d) adjusting insulin according to blood glucose levels?
Answer:
(c) injecting insulin at a site of lipodystrophy?

Explanation:
Lipodystrophy, specifically lipohyper- trophy, 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.

Question 22. 
A nurse is participating in a diabetes screening program. Which clients are at risk for developing type 2 diabetes? Select all that apply.
(a) a 32-year-old female who gave birth to a 9.5-lb (4,300-g) infant
(b) a 44-year-old Native American (First Nations) who has a body mass index (BMI) of 32
(c) an 18-year-old immigrant from Mexico who jogs four times a week
(d) a 55-year-old Asian who has hypertension and two siblings with type 2 diabetes
(e) a 12-year-old who is overweight 
Answer:
(a) a 32-year-old female who gave birth to a 9.5-lb (4,300-g) infant
(b) a 44-year-old Native American (First Nations) who has a body mass index (BMI) of 32
(d) a 55-year-old Asian who has hypertension and two siblings with type 2 diabetes
(e) a 12-year-old who is overweight 

Explanation:
(a), (b), (d), (e). The risk factors for developing type 2 diabetes include giving birth to an infant weighing >9 lb (4,100 g); obesity (BMI over 30); ethnicity of Asian, African, Native American, or First Nations; age >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.

Question 23. 
An adult with type 2 diabetes mellitus has been NPO since 2200 in preparation for having a nephrectomy the next day. At 0600 on the day of surgery, the nurse reviews the client’s medical record and laboratory results. Which finding should the nurse report to the health care provider?
(a) urine output of 350 mL in 8 hours
(b) urine specific gravity of 1.015
(c) potassium of 4.0 mEq (4 mmol/L)
(d) blood glucose of 140 mg/dL (7.8 mmol/L)
Answer:
(d) blood glucose of 140 mg/dL (7.8 mmol/L)

Explanation:
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.

Question 24. 
The nurse is checking the laboratory results of an adult client with type 1 diabetes (see chart). What laboratory result indicates a problem that should be managed?
Laboratory Results

Test

Result

Blood glucose

192 mg/dL (10.7 mmol/L)

Total cholesterol

250 mg/dL (6.5 mmol/L)

Hemoglobin

12.3 mg/dL (123 g/L)

Low-density lipoprotein cholesterol

125 mg/dL (3.2 mmol/L)

(a) blood glucose
(b) total cholesterol
(c) hemoglobin
(d) low-density lipoprotein (LDL) cholesterol
Answer:
(a) blood glucose

Explanation:
The normal range for blood glucose is 70 to 100 mg/dL (3.9 to 5.6 mmol/L); 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 prescriptions for the hyperglycemia or notify the health care provider (HCP). 

Question 25.
A client with type 1 diabetes mellitus has diabetic ketoacidosis. Which finding has the greatest effect on fluid loss?
(a) hypotension
(b) decreased serum potassium level
(c) rapid, deep respirations
(d) warm, dry skin
Answer:
(c) rapid, deep respirations

Explanation:
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.

Question 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 >200 mg/dL (11.1 mmol/L). How should the nurse administer the insulins?
(a) 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.
(b) Roll the glargine insulin vial, and then roll the aspart insulin vial. Draw up the longer- acting glargine insulin first.
(c) Shake both vials of insulin before drawing up e ch dose in separate insulin syringes.
(d) 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:
(d) 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.

Explanation:
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.

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

Explanation:
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.

Question 28.    
An adult with type 2 diabetes is taking metformin 1,000 mg two times every day. The client asks the nurse about having an alcoholic drink. Which statement indicates the client understands the interaction of alcohol and metformin?
(a) “If I know I’ll be having alcohol, I shouldn’t take metformin.”
(b) “If my health care provider approves, I may drink alcohol with my metformin.”
(c) “Adverse effects I should watch for are feeling excessively energetic, unusual muscle stiffness, low back pain, and a rapid heartbeat.”
(d) “If I feel bloated, I should call my health care provider.”
Answer:
(a) “If I know I’ll be having alcohol, I shouldn’t take metformin.”

Explanation:
Lactic acidosis is a rare but serious adverse effect of metformin when combined with alcohol use; 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.

Question 29.    
Before supper, an adult client who has type 2 diabetes and requires insulin tells the nurse about having tremors and being weak and anxious. What should the nurse do next?
(a) Tell the client to lie down for 30 minutes.
(b) Have the client drink a glass of milk or orange juice.
(c) Contact the client’s health care provider (HCP) to decrease the insulin dose.
(d) Administer the next dose of insulin.
Answer:
(b) Have the client drink a glass of milk or orange juice.

Explanation:
Hypoglycemia is a blood glucose level below 70 mg/dL (3.9 mmol/L). The signs and symptoms of hypoglycemia include confusion, irritability, diaphoresis, tremors, hunger, weakness, and visual disturbances. Untreated hypoglycemia can progress to loss of consciousness, seizures, coma, and death. With effective treatment, hypoglycemia can usually be quickly reversed. If the client has manifestations of hypoglycemia and monitoring equipment is not available, hypoglycemia is assumed, and treatment is initiated. 

Hypoglycemia is treated by ingesting 10 to 15 g of simple (fast-acting) carbohydrates, such as 4 to 8 oz of fruit juice or regular (nondiet) soft drink or 8 oz of low-fat milk. The nurse can tell the client to eat the regularly scheduled meal or a snack that has protein, such as cheese or peanut butter, to prevent hypoglycemia from recurring. Without treating the possible hypoglycemia, the blood glucose level will go down even lower and the client may lose consciousness, develop seizures, or go into a coma. Contacting the HCP would delay treating the possible hypoglycemia. Decreasing the insulin dose or increasing the meal plan may prevent episodes of hypoglycemia in the future. Administering insulin would cause the blood sugar to go even lower.

Question 30.    
The health care provider (HCP) has prescribed insulin detemir for a client with type 2 diabetes requiring insulin. What should the nurse teach the client about this insulin?
(a) “You may increase the carbohydrates in your diet when using this insulin.”
(b) “You do not need to rotate injection sites with this insulin.”
(c) “You do not mix insulin detemir; the solution is clear.”
(d) “You may refill the Detemir insulin pen.” 
Answer:
(c) “You do not mix insulin detemir; the solution is clear.”

The health care provider (hcp) has prescribed insulin detemir for a client with type 2 diabetes requiring insulin

Explanation:
Insulin detemir is used only if the solution appears clear and colorless with no visible particles. Insulin detemir is not diluted or mixed with any other insulin preparations. As with any insulin therapy, lipodystrophy may occur at the injection site and delay insulin absorption. Continuous rotation of the injection site within a given area may help to reduce or prevent this reaction. The client should continue to follow the prescribed diet and monitor glucose levels when taking insulin detemir. Insulin detemir is available in a prefilled insulin pen. When the insulin pen is empty, it may not be refilled; instead, the pen is discarded.

Question 31.
When evaluating teaching a client how to administer insulin, which action indicates that additional teaching is necessary?
The client:
(a) draws up the regular insulin first and then the NPH.
(b) rotates sites from legs to arms.
(c) identifies that the syringe is U-100.
(d) waits 30 minutes to eat breakfast after injecting rapid-acting insulin.
Answer:
(d) waits 30 minutes to eat breakfast after injecting rapid-acting insulin.

Explanation:
The nurse instructs the client to not wait any longer than 5 to 15 minutes to eat after injecting rapid-acting insulin, which has an onset action of 5 minutes and a duration of 1 hour. The client is using the proper technique for mixing the insulins, rotating sites, and using the U-100 syringe.

Question 32.
A client with newly diagnosed type 1 diabetes is scheduled to receive regular insulin 10 units and NPH insulin 20 units every morning. When should the nurse schedule the administration of these medications?
(a) regular insulin with breakfast; NPH after breakfast
(b) both insulins 0.5 hours before breakfast
(c) in two separate syringes with breakfast
(d) NPH 1 hour before and regular 0.5 hours before breakfast
 Answer:
(b) both insulins 0.5 hours before breakfast

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

Question 33. 
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.
(a) A major risk factor for complications is obesity and central abdominal obesity.
(b) Supplemental insulin is mandatory for controlling the disease.
(c) Exercise increases insulin resistance.
(d) The primary nutritional source requiring monitoring in the diet is carbohydrates.
(e) Annual eye and foot examinations are recommended by the American and Canadian Diabetes Associations.
Answer:
(a) A major risk factor for complications is obesity and central abdominal obesity.
(e) Annual eye and foot examinations are recommended by the American and Canadian Diabetes Associations.

Explanation:
(a), (e). 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.

Question 34.    
When teaching the diabetic client about foot care, what should the nurse instruct the client to do?
(a) Avoid going barefoot.
(b) Buy shoes a half size larger.
(c) Cut toenails at angles.
(d) Use heating pads for sore feet.
Answer:
(a) Avoid going barefoot.

Explanation:
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 prevent injury. 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.

Question 35.    
A client with diabetes mellitus asks the nurse to recommend something to remove corns from the toes. What should the nurse advise the client to do?
(a) Apply a high-quality corn plaster to the area.
(b) Consult a health care provider (HCP) about removing the corns.
(c) Apply iodine to the corns before peeling them off.
(d) Soak the feet in borax solution to peel off the corns.
Answer:
(b) Consult a health care provider (HCP) about removing the corns.

Explanation:
A client with diabetes should be advised to consult an HCP or a 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 an HCP or a podiatrist.

Question 36.    
A client with diabetes mellitus presents 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 response by the nurse would be most appropriate?
(a) “Wash all wounds in isopropyl alcohol.”
(b) “Keep all cuts clean and covered.”
(c) “Could you have your children do the cooking and ironing?”
(d) “You really should be fine as long as you take your daily medication.”
Answer:
(b) “Keep all cuts clean and covered.”

Explanation:
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.

Question 37. 
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 nutrients?
(a) carbohydrates only
(b) fats and carbohydrates only
(c) protein and carbohydrates only
(d) proteins, fats, and carbohydrates
Answer:
(d) proteins, fats, and carbohydrates

Explanation:
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.

Question 38.    
A client with type 1 diabetes mellitus is admitted to the emergency department. Which respiratory pattern in a client with diabetes mellitus requires immediate action?
(a) deep, rapid respirations with long expirations
(b) shallow respirations alternating with long  expirations
(c) regular depth of respirations with frequentpauses
(d) short expirations and inspirations
Answer:
(a) deep, rapid respirations with long expirations

Explanation:
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.

Question 39.    
The client has been recently diagnosed with type 2 diabetes and is taking metformin 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. What should the nurse do? Select all that apply.
(a) Discontinue the metformin.
(b) Administer glargine insulin rather than the metformin.
(c) Inform the client that the adverse effects of diarrhea, nausea, and upset stomach gradually subside over time.
(d) Assess the client’s renal function.
(e) Monitor the client’s glucose value prior to each meal.
Answer:
(c) Inform the client that the adverse effects of diarrhea, nausea, and upset stomach gradually subside over time.
(d) Assess the client’s renal function.
(e) Monitor the client’s glucose value prior to each meal.

Explanation:
(c), (d), (e). The nurse may not discontinue a medication without a health care provider’s (HCP’s) prescription, and the nurse may not substitute one medication for another. Maximum doses ma}? 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.

Question 40.    
A client with type 2 diabetes has just started to take dulaglutide. The client reports having severe nausea. What should the nurse instruct the client to do to manage the nausea? Select all that apply.
(a) Eat small meals more frequently.
(b) Increase the fat content in the diet.
(c) Drink ginger tea.
(d) Stop using the drug.
(e) Avoid fried foods.
Answer:
(a) Eat small meals more frequently.
(c) Drink ginger tea.
(e) Avoid fried foods.

Explanation:
(a), (c), (e). Nausea is a common side effect when clients first start taking dulaglutide. To manage the nausea the nurse can suggest that the client eat smaller meals more frequently, drink beverages with ginger in them, and avoid fried foods. The client should decrease the fat content in the diet. The client should not stop using the drug unless pre-scribed by the health care provider.

Question 41.    
A client is to use an insulin pen. Which action indicates the client is using the pen correctly? Select all that apply.
(a) stores the unopened pens in the refrigerator
(b) injects the insulin in sites around the abdomen
(c) primes the pen by expelling any air
(d) massages the site after injection
(e) saves needle for reuse
Answer:
(a) stores the unopened pens in the refrigerator
(b) injects the insulin in sites around the abdomen
(c) primes the pen by expelling any air

Explanation:
(a), (b), (c). Insulin pens should be stored in the refrigerator before use; once opened they can be stored at a cool room temperature. The pen needs to be primed by expelling air before injecting the insulin. After the injection, the site can be patted, but not massaged. Needles cannot be reused; the client should remove the needle and place in a hard plastic container for disposal.

Question 42.    
A client with type 2 insulin-requiring diabetes has the flu with nausea, body aches, and lack of appetite. The client’s blood sugar is
180 mg/dL (10 mmol/L). The vital signs are temperature 101°F (38.3°C), pulse 88 bmp, and respirations 20 breaths/min. What should the nurse instruct the client to do? Select all that apply.
(a) Stop taking insulin.
(b) Check blood sugar every 4 hours.
(c) Drink 240 mL fluids every hour.
(d) Check urine for ketones.
(e) Take two 325 mg aspirin.
Answer:
(b) Check blood sugar every 4 hours.
(c) Drink 240 mL fluids every hour.

Explanation:
(b), (c). The nurse should instruct the client with insulin-requiring diabetes who has the flu to check the blood sugar every 4 hours. The client should try to drink 240 mL of fluid every hour. If the blood sugar levels become low, the client should drink liquids with sugar in them. The client should continue to take insulin. It is not necessary to check for ketones until the blood glucose level is above 240 mg/dL. The nurse cannot prescribe aspirin for this client. If the symptoms of the flu continue, the nurse should instruct the client to contact the health care provider.

Question 43.    
A client who uses an insulin pen asks the nurse how to dispose of the needles. The client’s job requires frequent travel by airplane. What information should the nurse include in the teaching plan? Select all that apply.
(a) At home, dispose of needles in a sharps con tainer or solid plastic container.
(b) Put % full sharps containers in recycling bins for home waste management pick-up.
(c) Carry a travel size disposal container and dispose of needles in the hotel recycling bin.
(d) Check with the Transportation Safety Agency (TSA) for guidelines for labeling medications and safe disposal.
(e) Wipe the needle with alcohol, wrap in tissue, and discard in a recycling container.
Answer:
(a) At home, dispose of needles in a sharps con tainer or solid plastic container.
(c) Carry a travel size disposal container and dispose of needles in the hotel recycling bin.

Explanation:
(a), (c). Used needles must be disposed of safely; local community, state, and home waste management services have different regulations about needle disposal. The nurse should instruct the client when at home to discard the needles in a sharps container or other plastic container and contact the local community or waste management services about where the containers used
at home should be disposed. 

When traveling, the client should carry a travel size disposable container, bring it home, and discard it according to home disposal procedures. The client should not place the used needles in a hotel recycling bin unless they are approved containers. When traveling with insulin pens and needles, the client should follow TSA-approved procedures for labeling medications. The client should not touch the needle or wipe it with alcohol. All needles should be placed immediately in sharps containers.

Question 44.    
A client is prescribed exenatide. What should the nurse instruct the client to do? Select all that apply.
(a) Review the one-time setup for each new pen.
(b) Inject in the thigh, abdomen, or upper arm.
(c) Administer the drug within 60 minutes before morning and evening meals.
(d) Understand that there is a low incidence of hypoglycemia when exenatide is taken with insulin.
(e) Take the dose of exenatide as soon as the client remembers a dose has been missed.
Answer:
(a) Review the one-time setup for each new pen.
(b) Inject in the thigh, abdomen, or upper arm.
(c) Administer the drug within 60 minutes before morning and evening meals.

Explanation:
(a), (b), (c). Client teaching includes reviewing proper use and storage of the exenatide dosage pen, particularly the onetime setup 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.

Question 45. 
The nurse is administering the initial dose of a rapid-acting insulin to a client with type 1 diabetes. At what time should the nurse assess the client for hypoglycemia?
(a) 0.5 hours
(b) 1 hour
(c) 2 hours
(d) 3 hours
Answer:
(b) 1 hour

Explanation:
(b). 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.

Question 46.    
The nurse notes grapefruit juice on the breakfast tray of a client who is taking repaglinide. What should the nurse do next?
(a) Contact the manager of the Food and Nutrition Department.
(b) Request that the dietitian discuss the drug-food interaction between repaglinide and grapefruit juice with the client.
(c) Substitute a half grapefruit in place of the grapefruit juice.
(d) Remove the grapefruit juice from the client’stray and bring another juice of the client’s preference.
Answer:
(d) Remove the grapefruit juice from the client’stray and bring another juice of the client’s preference.

Explanation:
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.

Question 47.    
Which finding should the nurse report to the client’s health care provider for a client with unstable type 1 diabetes mellitus? Select all that apply.
(a) systolic blood pressure, 145 mm Hg
(b) diastolic blood pressure, 87 mm Hg
(c) high-density lipoprotein (HDL), 30 mg/dL (1.7 mmol/L)
(d) glycosylated hemoglobin (HbAlc), 10.2% (0.1)
(e) triglycerides, 425 mg/dL (23.6 mmol/L)
(f) urine ketones, negative
Answer:
(a) systolic blood pressure, 145 mm Hg
(b) diastolic blood pressure, 87 mm Hg
(c) high-density lipoprotein (HDL), 30 mg/dL (1.7 mmol/L)
(d) glycosylated hemoglobin (HbAlc), 10.2% (0.1)
(e) triglycerides, 425 mg/dL (23.6 mmol/L)

Explanation:
(a), (b), (c), (d), (e). 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 <130/80 mm Hg. Therefore, the nurse would need to report any findings >130/80 mm Hg. The goal of HbA10 (. is <7% (0.07); thus, a level of 10.2% (0.1) must be reported. HDL <40 mg/dL (2.2 mmol/L) and triglycerides >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.

Question 48.    
To reduce the risk of developing type 2 diabetes mellitus, what should the nurse instruct the client to do?
(a) Stop smoking cigarettes.
(b) Obtain a high-cholesterol diet.
(c) Maintain weight in normal limits.
(d) Prevent hypertension.
Answer:

Explanation:
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

Question 49.    
The nurse is teaching the client about home blood glucose monitoring. Which blood glucose measurement indicates hypoglycemia?
(a) 59 mg/dL (3.3 mmol/L)
(b) 75 mg/dL (4.2 mmol/L)
(c) 108 mg/dL (6 mmol/L)
(d) 119 mg/dL (6.6 mmol/L)
Answer:
(a) 59 mg/dL (3.3 mmol/L)

Explanation:
Although some individual variation exists, when the blood glucose level decreases to <70 mg/dL (3.9 mmol/L), the client experiences or is at risk for hypoglycemia. Hypoglycemia can occur 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.

Question 50.    
The client with type 1 diabetes mellitus is taught to take isophane insulin suspension NPH at 1700 each day. The client should be instructed that the greatest risk of hypoglycemia will occur at about what time?
(a) 1100, shortly before lunch
(b) 1300, shortly after lunch
(c) 1800, shortly after dinner
(d) 0100, while sleeping
Answer:
(d) 0100, while sleeping

Explanation:
The client with diabetes mellitus who is taking NPH insulin 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.

Question 51.    
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?
(a) arms
(b) legs
(c) abdomen
(d) iliac crest
Answer:
(c) abdomen

Explanation:
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.

Question 52.    
A client with diabetes is taking insulin lispro injections. At what time should the nurse advise the client to eat?
(a) within 10 to 15 minutes after the injection
(b)1 hour after the injection
(c) at any time because timing of meals with lispro injections is unnecessary
(d) 2 hours before the injection
Answer:
(a) within 10 to 15 minutes after the injection

Explanation:
Insulin lispro begins to act within 10 to 15 minutes and lasts approximately 4 hours. A major advantage of lispro 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.

Question 53.
The nurse has instructed a client newly diagnosed with diabetes how to self-inject insulin. Which is the best indicator that the client has learned how to give an insulin self-injection correctly?
The client can:
(a) perform the procedure safely and correctly.
(b) critique the nurse’s performance of the procedure.
(c) explain all steps of the procedure correctly.
(d) obtain 100% correct answers on a posttest.
Answer:
(a) perform the procedure safely and correctly.

Explanation:
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 or she 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. 

Question 54.    
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? Record your answer using a whole number ......................... units.
Answer:
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.

Question 55.    
The nurse should teach the diabetic client that which symptom is most indicative of hypoglycemia?
(a) nervousness
(b) anorexia
(c) Kussmaul’s respirations
(d) bradycardia
Answer:
(a) nervousness

Explanation:
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.

Low Sugar Fruits & Vegetables

Question 56.    
The nurse is assessing the client’s understanding of the use of medications. Which medication may cause a complication with the treatment plan of a client with diabetes?
(a) aspirin
(b) steroids
(c) sulfonylureas
(d) angiotensin-converting enzyme (ACE) inhibitors
Answer:
(b) steroids

Explanation:
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.

Question 57. 
A client with type 1 diabetes mellitus has influenza. What should the nurse instruct the client to do?
(a) Increase the frequency of self-monitoring (blood glucose testing).
(b) Reduce food intake to diminish nausea.
(c) Discontinue that dose of insulin if unable to eat.
(d) Take half of the normal dose of insulin.
Answer:
(a) Increase the frequency of self-monitoring (blood glucose testing).

Explanation:
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. The nurse can encourage the client to drink clear fluids, juices, and electrolyte drinks. Not taking insulin when sick, or taking half the normal dose, may cause the client to develop ketoacidosis.

Question 58.    
Which goal is a priority for the diabetic client who is taking insulin and has nausea and vomiting from a viral illness or influenza?
(a) obtaining adequate food intake
(b) managing own health
(c) relieving pain
(d) increasing activity
Answer:
(a) obtaining adequate food intake

Explanation:
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 carbohydrates or food equal to 200 cal. every 3 to 4 hours. If the client cannot eat the carbohydrates or take fluids, the health care provider (HCP) should be called or the client should go to the emergency department. The diabetic client is in danger of complications with dehydration, electrolyte imbalance, and ketoacidosis. Increasing the client’s health management skills is important to lifestyle behaviors, but it is not a priority during this acute illness of influenza. Pain relief may be a need for this client, but it is not the priority at this time; neither is increasing activity during the illness.

Question 59.    
A client with diabetes begins to cry and says, “I just can’t stand the thought of having to give myself a shot every day.” What would be the best response by the nurse?
(a) “If you don’t give yourself your insulin shots, you’ll be at greater risk for complications.”
(b) “We can teach a family member to give the shots so you won’t have to do it.”
(c) “I can arrange to have a home care nurse give you the shots every day.”
(d) “What is it about giving yourself the insulin shots that bothers you?”
Answer:
(d) “What is it about giving yourself the insulin shots that bothers you?”

A client with diabetes begins to cry and says, “i just can’t stand the thought of having to give myself a shot every day. what would be the best response by the nurse

Explanation:
The best response is to allow the client to verbalize fears about performing self-injection. Tactics that increase fear such as threatening the client about complications are not effective in changing behavior. If possible, the client needs to be responsible for self-care, including giving self-injections. A nurse for home care visits is not justified if the client is capable of self-administration.

Question 60.    
A client is to have a transsphenoidal hypophysectomy to remove a large, invasive pituitary tumor. Where should the nurse tell the client the surgical incision will be made?
(a) back of the mouth
(b) high in the nares
(c) sinus channel below the right eye
(d) upper gingival mucosa in the space between the upper gums and lip
Answer:
(d) upper gingival mucosa in the space between the upper gums and lip

Explanation:
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.

Question 61.    
A client is to have a hypophysectomy. To minimize the risk of postoperative respiratory complications, what should the nurse instruct the client to do?
(a) Limit use of pain medications.
(b) Turn the head from side to side.
(c) Take deep breaths.
(d) Clear the throat and cough.
Answer:
(c) Take deep breaths.

Explanation:
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. The client should receive sufficient medication to control postoperative pain. 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.

Question 62.
Following a transsphenoidal hypophysectomy, the nurse should assess the client for which sign of a potential complication?
(a) cerebrospinal fluid (CSF) leak
(b) fluctuating blood glucose levels
(c) Cushing’s syndrome
(d) cardiac arrhythmias
Answer:
(a) cerebrospinal fluid (CSF) leak

Explanation:
A major focus of nursing care after transs-phenoidal 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.

Question 63.
A male client expresses concern about how a hypophysectomy will affect his sexual function. Which statement provides the most accurate information about the physiologic effects of hypophysectomy in a male?
(a) Removing the source of excess hormone should restore the client’s libido, erectile function, and fertility.
(b) Potency will be restored, but the client will remain infertile.
(c) Fertility will be restored, but impotence and decreased libido will persist.
(d) Exogenous hormones will be needed to restore erectile function after the adenoma is removed.
Answer:
(a) Removing the source of excess hormone should restore the client’s libido, erectile function, and fertility.

Explanation:
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.

Question 64.    
Following a transsphenoidal hypophysectomy, a client has a cerebrospinal fluid leak. The nurse should prepare the client for which treatment of the leak?
(a) packing the nose with pressure dressings
(b) returning the client to surgery to close the leak
(c) maintaining bed rest with the head of the bed elevated to 30 degrees
(d) administering high-dose corticosteroid therapy
Answer:
(c) maintaining bed rest with the head of the bed elevated to 30 degrees

Explanation:
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.

Question 65.    
To provide oral hygiene for a client recovering from transsphenoidal hypophysectomy, what should the nurse instruct the client to do?
(a) Rinse the mouth with saline.
(b) Perform frequent toothbrushing.
(c) Clean the teeth with an electric toothbrush.
(d) Floss the teeth thoroughly.
Answer:
(a) Rinse the mouth with saline.

Explanation:
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 oral swabs. Frequent or vigorous toothbrushing or flossing is contraindicated because it may disturb or cause tension on the suture line.

Question 66.    
A client has had an hypophysectomy. What signs of a potential complication should the nurse teach the client to report?
(a) acromegaly
(b) Cushing’s disease
(c) diabetes mellitus
(d) hypopituitarism
Answer:
(d) hypopituitarism

Explanation:
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.

Question 67.    
After pituitary surgery, which laboratory finding should the nurse report to the health care provider?
(a) urine specific gravity <1.010
(b) urine output between 1 and 2 L/day
(c) blood glucose level higher than 300 mg/dL (16.7 mmol/L)
(d) absence of glucose and ketones in the urine 
Answer:
(a) urine specific gravity <1.010

Explanation:
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.

Question 68.    
A client with diabetes insipidus is receiving vasopressin. Which sign indicates that the drug is having the intended effect?
(a) lower blood pressure
(b) concentration of urine
(c) normal insulin levels
(d) improved glucose metabolism
Answer:
(b) concentration of urine

Explanation:
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 lower blood pressure or affect insulin production or glucose metabolism.

Question 69.    
Which statement indicates that the client with diabetes insipidus understands how to manage care?
The client will:
(a) maintain normal fluid and electrolyte balance.
(b) select a diabetic diet correctly.
(c) state dietary restrictions.
(d) exhibit serum glucose level within normal range.
Answer:
(a) maintain normal fluid and electrolyte balance.

Explanation:
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.

Question 70.    
The nurse is instructing a college student with Addison’s disease how to adjust the dose of glucocorticoids. The nurse should explain that the client may need an increased dosage of glucocorticoids in which situation?
(a) completing course work.
(b) gaining 4 lb (1.8 kg)
(c) becoming engaged
(d) having wisdom teeth extracted
Answer:
(d) having wisdom teeth extracted

Explanation:
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.

Question 71.
Which goal is the priority for a client in addisonian crisis?
(a) controlling hypertension
(b) preventing irreversible shock
(c) preventing infection
(d) relieving anxiety
Answer:
(b) preventing irreversible shock

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

Question 72.
What is an expected finding in a client with adrenal crisis (addisonian crisis)?
(a) fluid retention
(b) pain
(c) peripheral edema
(d) hunger
Answer:
(b) pain

Explanation:
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.

Question 73. 
A client with Addison’s disease is taking corticosteroid replacement therapy. The nurse should instruct the client about which side effects of corticosteroids? Select all that apply.
(a) hyperkalemia
(b) skeletal muscle weakness
(c) mood changes
(d) hypocalcemia
(e) increased susceptibility to infection
(f) hypotension
Answer:
(b) skeletal muscle weakness
(c) mood changes
(d) hypocalcemia
(e) increased susceptibility to infection

Explanation:
(b), (c), (d), (e). The long-term administration of corticosteroids in therapeutic doses often leads to serious complications or side effects. Corticosteroid therapy is not recommended for minor chronic conditions; the potential benefits of treatment must always be weighed against the risks. Hypokalemia may develop; corticosteroids act on the renal tubules to increase sodium reabsorption and enhance potassium and hydrogen excretion. Corticosteroids stimulate the breakdown of protein for gluconeogenesis, which can lead to skeletal muscle wasting. CNS adverse effects are euphoria, headache, insomnia, confusion, and psychosis. 

The nurse watches for changes in mood and behavior, emotional stability, sleep pattern, and psychomotor activity, especially with long-term therapy. Hypocalcemia related to anti-vitamin D effect may occur. Corticosteroids cause atrophy of the lymphoid tissue, suppress the cell-mediated immune responses, and decrease the production of antibodies. The nurse must be alert to the possibility of masked infection and delayed healing (anti-inflammatory and immunosuppressive actions). Retention of sodium (and subsequently water) increases blood volume and, therefore, blood pressure.

Question 74.    
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:
(a) discontinue the infusion.
(b) apply a warm soak to the site.
(c) stop the flow of solution temporarily.
(d) irrigate the needle with normal saline.
Answer:
(a) discontinue the infusion.

Explanation:
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.

Question 75.    
A client with Addison’s disease has fluid and electrolyte loss due to inadequate fluid intake and to fluid loss secondary to inadequate adrenal hormone secretion. As the client’s oral intake increases, which fluids would be most appropriate?
(a) milk and diet soda
(b) water and eggnog
(c) chicken broth and juice
(d) coffee and milkshakes
Answer:
(c) chicken broth and juice

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

Question 76.    
After stabilization of Addison’s disease, the nurse teaches the client about stress management. What should the nurse instruct the client to do?
(a) Remove all sources of stress from daily life.
(b) Use relaxation techniques such as music.
(c) Take antianxiety drugs daily.
(d) Avoid discussing stressful experiences.
Answer:
(b) Use relaxation techniques such as music.

Explanation:
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.

Question 77.    
A client newly diagnosed with primary Addison’s disease asks the nurse about the cause of the disease. What should the nurse tell the client?
“The disease is caused by:
(a) insufficient secretion of growth hormone (GH).”
(b) dysfunction of the hypothalamic pituitary.”
(c) idiopathic atrophy of the adrenal gland.”
(d) oversecretion of the adrenal medulla.”
Answer:
(c) idiopathic atrophy of the adrenal gland.”

Explanation:
Primary Addison’s disease refers to a problem in the gland itself that results from idiopathic atrophy of the glands. The process is believed to be autoimmune in nature. The most common causes of primary adrenocortical insufficiency are autoimmune destruction (70%) and tuberculosis (20%). Insufficient secretion of GH causes dwarfism or growth delay. Hyposecretion of glucocorticoids, aldosterone, and androgens occurs 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.

Question 78.    
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.
(a) Addison’s disease will resolve over a few weeks, requiring no further treatment.
(b) Avoiding stress and maintaining a balanced lifestyle will minimize risk for exacerbations.
(c) Fatigue, weakness, dizziness, and mood changes need to be reported to the health care provider (HCP).
(d) A medical identification bracelet should be worn.
(e) Family members need to be informed about the warning signals of adrenal crisis.
(f) Dental work or surgery will require adjustment of daily medication.
Answer:
(b) Avoiding stress and maintaining a balanced lifestyle will minimize risk for exacerbations.
(c) Fatigue, weakness, dizziness, and mood changes need to be reported to the health care provider (HCP).
(d) A medical identification bracelet should be worn.
(e) Family members need to be informed about the warning signals of adrenal crisis.
(f) Dental work or surgery will require adjustment of daily medication.

Explanation:
(b), (c), (d), (e),(f). 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. 

Question 79.    
A client has been diagnosed with Addison’s disease. The nurse should plan with the client to manage which effect of the disease?
(a) weight gain
(b) hunger
(c) lethargy
(d) muscle spasms
Answer:
(c) lethargy

Explanation:
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.

Question 80.    
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?
(a) the importance of watching for signs of hyperglycemia
(b) the need to adjust the steroid dose based on dietary intake and exercise
(c) to notify the health care provider (HCP) when the blood pressure is suddenly high
(d) how to decrease the dose of the corticosteroids when the client experiences stress
Answer:
(a) the importance of watching for signs of hyperglycemia

Explanation:
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.

Question 81.
The client with Addison’s disease is taking glucocorticoids at home. Which statement indicates that the client understands how to take the medication?
(a) “Various circumstances increase the need for glucocorticoids, so I will need to adjust the dosage.”
(b) “My need for glucocorticoids will stabilize, and I will be able to take a predetermined dose once a day.”
(c) “Glucocorticoids are cumulative, so I will take a dose every third day.”
(d) “I must take a dose every 6 hours to ensure consistent blood levels of glucocorticoids.” 
Answer:
(a) “Various circumstances increase the need for glucocorticoids, so I will need to adjust the dosage.”

Explanation:
The need for glucocorticoids changes with circumstances. The basal dose is established when the client is discharged, but this dose covers only normal daily needs and does not provide for additional stressors. As the manager of the medication schedule, the client needs to know signs and symptoms of excessive and insufficient dosages. Glucocorticoid needs fluctuate. Glucocorticoids are not cumulative and must be taken daily. 

They must never be discontinued suddenly; in the absence of endogenous production, addisonian crisis could result. Two-thirds of the daily dose should be taken at about 0800 and the remainder at about 1600. This schedule approximates the diurnal pattern of normal secretion, with highest levels between 0400 and 0600 and lowest levels in the evening.

Question 82.
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?
(a) Take both drugs three times a day.
(b) Take the entire dose of both drugs first thing in the morning.
(c) Take all the fludrocortisone acetate and two-thirds of the cortisone acetate in the morning, and take the remaining cortisone acetate in the afternoon.
(d) Take half of each drug in the morning and the remaining half of each drug at bedtime.
Answer:
(c) Take all the fludrocortisone acetate and two-thirds of the cortisone acetate in the morning, and take the remaining cortisone acetate in the afternoon.

Explanation:
Fludrocortisone acetate can be administered once a day, but cortisone acetate administration should follow the body’s natural diurnal pattern of secretion, in which greater amounts of cortisol are secreted during the daytime to meet the increased demand of the body. To mimic this pattern, baseline administration of cortisone acetate is typically 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 not meet the needs of the body later in the day and evening.

Question 83.    
When teaching a client about taking oral glucocorticoids, how should the nurse instruct the client to take the medication?
(a) with a full glass of water
(b) on an empty stomach
(c) at bedtime to increase absorption
(d) with meals or with an antacid
Answer:
(d) with meals or with an antacid

Explanation:
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.

Question 84.    
Which indicator is best for determining whether a client with Addison’s disease is receiving the correct amount of glucocorticoid replacement?
(a) skin turgor
(b) temperature
(c) thirst
(d) daily weight
Answer:
(d) daily weight

Explanation:
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.

Question 85.    
Which outcome is a priority for the client with Addison’s disease?
(a) maintenance of medication compliance
(b) avoidance of normal activities with stress
(c) adherence to a 2-g sodium diet
(d) prevention of hypertensive episodes
Answer:
(a) maintenance of medication compliance

Explanation:
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 (HCP) 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.

Question 86.    
The nurse is teaching the client with Addison’s disease to anticipate the need for increased glucocorticoid supplementation. When will the client likely need to increase the dose of glucocorticoids?
(a) returning to work after a weekend
(b) going on vacation
(c) having oral surgery
(d) having a routine medical checkup
Answer:
(c) having oral surgery

Explanation:
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.

Question 87.    
The client with Addison’s disease is concerned about the bronze-color of his skin. What should the nurse tell the client about the cause of the bronze color?
(a) hypersensitivity to sun exposure
(b) increased serum bilirubin level
(c) adverse effects of the glucocorticoid therapy
(d) increased secretion of adrenocorticotropic hormone (ACTH)
Answer:
(d) increased secretion of adrenocorticotropic hormone (ACTH)

Explanation:
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 areas exposed 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.

Question 88.
A client diagnosed with Cushing’s syndrome is admitted to the hospital and scheduled for a dexa- methasone suppression test. What should the nurse do during this test?
(a) Collect a 24-hour urine specimen to measure serum cortisol levels.
(b) Administer 1 mg of dexamethasone orally at night and obtain serum cortisol levels the next morning.
(c) Draw blood samples before and after exercise to evaluate the effect of exercise on serum cortisol levels.
(d) Administer an injection of adrenocorticotropic hormone (ACTH) 30 minutes before drawing blood to measure serum cortisol levels.
Answer:
(b) Administer 1 mg of dexamethasone orally at night and obtain serum cortisol levels the next morning.

Explanation:
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 mmol/L) in adults indicate Cushing’s syndrome. If these results are borderline, a high-dose dexamethasone suppression test is done. The dexa- methasone is given at 2300 to suppress secretion of the corticotrophin-releasing hormone. A plasma cortisol sample is drawn at 0800. Normal cortisol level <5 mcg/dL (140 mmol/L) indicates normal adrenal response.

Question 89.
The nurse should monitor the client with Cushing’s disease for which finding?
(a) postprandial hypoglycemia
(b) hypokalemia
(c) hyponatremia
(d) decreased urine calcium level
Answer:
(b) hypokalemia

Explanation:
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.

Question 90.
A client with Cushing’s disease tells the nurse that the health care provider (HCP) 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 information?
(a) Some clients are very sensitive to the effects of cortisol and develop symptoms even with normal levels.
(b) A single random blood test cannot provide reliable information about endocrine levels.
(c) The excessive cortisol levels seen in Cushing’s disease commonly result from loss of the normal diurnal secretion pattern.
(d) Tumors tend to secrete hormones irregularly, and the hormones are generally not present in the blood.
Answer:
(c) The excessive cortisol levels seen in Cushing’s disease commonly result from loss of the normal diurnal secretion pattern.

Explanation:
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.

Question 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?
(a) Increase calories.
(b) Restrict sodium.
(c) Restrict potassium.
(d) Reduce fat to 10%.
Answer:
(b) Restrict sodium.

Explanation:
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 <20% of total calories is not recommended.

Question 92.
Bone resorption is a possible complication of Cushing’s disease. To help the client prevent this complication, what should the nurse recommend to the client?
(a) Increase the amount of potassium in the diet.
(b) Maintain a regular program of weight-bearing exercise.
(c) Limit dietary vitamin D intake.
(d) Perform isometric exercises.
Answer:
(b) Maintain a regular program of weight-bearing exercise.

Explanation:
Osteoporosis is a serious outcome of prolonged cortisol excess because calcium is resorbed out of the bone. Regular daily weight-bearing exercise (e.g., brisk walking) is an effective way to drive calcium back into the bones. The client should also be instructed to have a dietary or supplemental 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.

Question 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. What should the nurse tell the client to do?
(a) “Sit in an upright position, and take a deep breath.”
(b) “Hold your abdomen firmly with a pillow, and take several deep breaths.”
(c) “Tighten your stomach muscles as you inhale, and breathe normally.”
(d) “Raise your shoulders to expand your chest.” 
Answer:
(b) “Hold your abdomen firmly with a pillow, and take several deep breaths.”

Explanation:
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.

Question 94.    
A client has had an adrenalectomy. What is the priority goal for this client in the first 24 hours after surgery?
(a) beginning oral nutrition
(b) promoting self-care activities
(c) preventing adrenal crisis
(d) ambulating in the hallway
Answer:
(c) preventing adrenal crisis

Explanation:
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.

Question 95.    
A client undergoing a bilateral adrenalectomy has postoperative prescriptions for hydromorphone hydrochloride 2 mg to be administered subcutaneously every 4 hours as needed for pain. Why should the nurse administer hydromorphone in small doses?
A small dose is:
(a) less likely to cause dependency.
(b) less irritating to subcutaneous tissues in small doses.
(c) as potent as morphine in larger doses.
(d) excreted before accumulating in toxic amounts in the body.
Answer:
(c) as potent as morphine in larger doses.

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

Question 96.    
The nurse is caring for a client who is scheduled for an adrenalectomy. Which drug may be included in the preoperative prescriptions to prevent Addison’s crisis following surgery?
(a) prednisone orally
(b) fludrocortisones subcutaneously
(c) spironolactone intramuscularly
(d) methylprednisolone sodium succinate intravenously
Answer:
(d) methylprednisolone sodium succinate intravenously

Explanation:
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.

Question 97.    
Adrenal function is affected by the drug keto- conazole, an antifungal agent used to treat severe fungal infections. How is this effect manifested?
(a) Ketoconazole suppresses adrenal steroidsecretion.
(b) Ketoconazole destroys adrenocortical cells,
resulting in a “medical” adrenalectomy.
(c) Ketoconazole increases adrenocorticotropic hormone (ACTH)-induced corticosteroid serum levels.
(d) Ketoconazole decreases duration of adrenal suppression when administered with corticosteroids.
Answer:
(a) Ketoconazole suppresses adrenal steroidsecretion.

Explanation:
Ketoconazole 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 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.

Question 98.    
In the early postoperative period after a bilateral adrenalectomy, the client has a temperature of 101°F (38.3°C). What should the nurse assess first to determine the cause of the elevated temperature?
(a) dehydration
(b) lung expansion
(c) wound infection
(d) urinary tract infection
Answer:
(b) lung expansion

Explanation:
Poor lung expansion from bed rest, pain, and retained anesthesia is a common cause of postoperative temperature elevation, and the nurse should first assess that the client is taking deep breaths every 1 to 2 hours. The client will have postoperative IV fluid replacement prescribed to prevent dehydration. Wound infections typically appear 4 to 7 days after surgery. Urinary tract infections are not common with this surgery.

Question 99.    
A client who is recovering from a bilateral adrenalectomy has a client-controlled analgesia (PCA) system with morphine sulfate. What should the nurse do to manage safe administration of the morphine?
(a) Observe the client at regular intervals for opi oid addiction.
(b) Encourage the client to reduce analgesic use and tolerate the pain.
(c) Evaluate pain control at least every 2 hours.
(d) Increase the amount of morphine if the client does not administer the medication.
Answer:
(c) Evaluate pain control at least every 2 hours.

Explanation:
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.

Question 100.    
As the nurse assists the postoperative client out of bed, the client reports having gas pains in the abdomen. To reduce this discomfort, what should the nurse do?
(a) Encourage the client to ambulate.
(b) Insert a rectal tube.
(c) Insert a nasogastric (NG) tube.
(d) Encourage the client to drink carbonated liquids.
Answer:
(a) Encourage the client to ambulate.

Explanation:
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 prescription. It is not a preferred treatment for gas postoperatively. Walking should prevent the need for further interventions. Carbonated liquids can increase gas formation.

Question 101.
A client has had a bilateral adrenalectomy. For which potential complication should the nurse assess the client?
(a) postoperative confusion
(b) delayed wound healing
(c) pulmonary emboli
(d) malnutrition
Answer:
(b) delayed wound healing

Explanation:
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.

Question 102.
The client who has undergone a bilateral adrenalectomy is concerned about persistent body changes and unpredictable moods. What should the nurse teach the client about these changes?
(a) The body changes are permanent, and the client will not be the same as before this condition.
(b) The body and mood will gradually return to normal.
(c) The physical changes are permanent, but the mood swings will disappear.
(d) The physical changes are temporary, but the mood swings are permanent.
Answer:
(b) The body and mood will gradually return to normal.

Explanation:
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.

Question 103.    
After a bilateral adrenalectomy for Cushing’s disease, the client will receive periodic testosterone injections. What is the expected outcome of these injections?
(a) balanced reproductive cycle
(b) restored sodium and potassium balance
(c) stimulated protein metabolism
(d) stabilized mood swings
Answer:
(c) stimulated protein metabolism

Explanation:
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.

Question 104.    
Which information should the nurse include in the teaching plan of a female client with bilateral adrenalectomy?
(a) The client will need steroid replacement for the rest of her life.
(b) The client must decrease the dose of steroid medication carefully to prevent crisis.
(c) The client will require steroids only until her body can manufacture sufficient quantities.
(d) The client will need to take steroids whenever her life involves physical or emotional stress.
Answer:
(a) The client will need steroid replacement for the rest of her life.

Explanation:
Bilateral adrenalectomy requires lifelong adrenal hormone replacement therapy. If unilateral surgery is performed, most clients gradually reestablish a normal secretion pattern. The client and family will require extensive teaching and support to maintain self-care management at home. Information on dosing, adverse effects, what to do if a dose is missed, and follow-up examinations is needed in the teaching plan.

Although steroids are tapered when given for an intermittent or onetime 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.

Question 105.    
The nurse is reviewing the postoperative prescriptions (see chart) just written by a health care provider (HCP) 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, what should the nurse do first?
Prescriptions

  • Vital signs every 15 minutes for 4 hours, then every hour for 8 hours.
  • Oxygen 2 L/min per nasal canula.
  • 1,000 ml. NS every 8 hours.
  • 10 mg morphine intramuscularly every 4 hours as needed.
  • 10 U regular insulin stat.

(a) Administer the morphine.
(b) Contact the health care provider (HCP) to rewrite the insulin prescription.
(c) Administer oxygen per nasal cannula at 2 L/min.
(d) Take the vital signs.
Answer:
(b) Contact the health care provider (HCP) to rewrite the insulin prescription.

Explanation:
Insulin is on the list of error-prone medications, and the nurse should ask the HCP to rewrite the prescription to spell out the word “units” and to indicate the route by which the drug is to be administered. The nurse should contact the HCP 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. 

Question 106.
The nurse is receiving results of a blood glucose level from the laboratory over the telephone. What should the nurse do?
(a) Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller.
(b) Repeat the results to the caller from the labo ratory, write the results on scrap paper, and then transfer the results to the medical record.
(c) Indicate to the caller that the nurse cannot receive results from lab tests over the telephone and ask the lab to bring the written results to the nurses’ station.
(d) Request that the laboratory send the results by email to transfer to the client’s medical record.
Answer:
(a) Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller.

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

Question 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 health care provider (HCP) has prescribed 1,000 mL 5% dextrose in water to be infused every 8 hours. What should the nurse do before implementing the HCP’s prescriptions?
Contact the health care provider (HCP) and:
(a) suggest adding potassium to the fluids.
(b) request an increase in the volume of intravenous fluids.
(c) verify the prescription for 5% dextrose in water.
(d) determine if the client should be placed in isolation.
Answer:
(c) verify the prescription for 5% dextrose in water.

Explanation:
The client needs fluid volume replacement due to the dehydration. However, the nurse should verify the prescription for IV dextrose with the HCP ILD 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.

Question 108.
Glulisine 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?
(a) Bring a small glass of juice, and locate the client.
(b) Call the client’s health care provider (HCP).
(c) Check the computerized care plan to deter mine what test was scheduled.
(d) Send the nurse’s assistant to the X-ray department to bring the client back to his room.
Answer:
(c) Check the computerized care plan to deter mine what test was scheduled.

Explanation:
Glulisine 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 HCP 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.

Question 109.    
A client who has been diagnosed with type 1 diabetes has an insulin drip to aid in lowering the serum blood glucose level of 600 mg/dL (33.3 mmol/L). The client is also receiving ciprofloxacin IV. The health care provider (HCP) prescribes discontinuation of the insulin drip. What should the nurse do next?
(a) Discontinue the insulin drip, as prescribed.
(b) Hang the next IV dose of antibiotic before discontinuing the insulin drip.
(c) Inform the HCP that the client has not received any subcutaneous insulin yet.
(d) Add glargine to the insulin drip before discontinuing it.
Answer:
(c) Inform the HCP that the client has not received any subcutaneous insulin yet.

Explanation:
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.

Question 110. 
A nurse has just received report on four clients. Which client should the nurse see first?
(a) A client who underwent a thyroidectomy and has new onset hoarseness.
(b) A client who has Cushing’s syndrome who has been noted to have a blood sugar of 134 mg/dL (7.4 mmol/L).
(c) A client who is in renal failure and a laboratory report noting a creatinine of 3.2 mg/dL (282.3 pmol/L).
(d) A client who was diagnosed with ulcerative colitis and recently passed 100 mL of loose bloody stools.
Answer:
(a) A client who underwent a thyroidectomy and has new onset hoarseness.

Explanation:
New onset of hoarseness following a thy-roidectomy may be a sign of tracheal edema and impending airway obstruction, and the nurse should evaluate this client first. The client with Cushing’s syndrome may have increased blood sugars associated with stress and hospitalization and will need further information to determine whether the blood sugar was obtained when the client was fasting. A client in renal failure would be expected to have an increase in creatinine, and the nurse can later follow up to compare this result with previous results. The client with ulcerative colitis will experience loose, bloody stools and needs to be continuously evaluated for amounts, but this is not the nurse’s first priority.

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