Endocrine System

1. A child with diabetic ketoacidosis has a potassium level of 3 mEq/L. What must the nurse do before giving this client the supplemental potassium ordered by the physician?
   • 1   –   Check the client’s respiratory rate.
   • 2   –   Order another potassium level test.
   • 3   –   Check the nasogastric (NG) tube drainage.
   • 4   –   Check urine output.

   RATIONALE: Before administering potassium to a client, the nurse should assess the urine output because potassium is excreted by the kidneys. The respiratory rate is of no concern when administering potassium. A follow-up potassium level should be drawn after the potassium is administered. NG tube drainage need not be checked before administering potassium.
   NURSING PROCESS STEP: Planning
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
   COGNITIVE LEVEL: Application

2. A client has a subtotal thyroidectomy and is returned from the postanesthesia care unit. Immediate postoperative care would include assessing which of the following conditions to identify a major complication of this procedure?
   • 1   –   Wound for drainage
   • 2   –   Quality of muscle tone
   • 3   –   Client’s position in bed
   • 4   –   Quality of the client’s voice

   RATIONALE: One of the major complications of thyroid surgery is damage to the laryngeal nerve, and the best way to assess for this complication is to evaluate the quality of the client’s voice. Assessing the wound drainage, muscle tone, and client position wouldn’t yield information about a major complication.
   NURSING PROCESS STEP: Assessment
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
   COGNITIVE LEVEL: Knowledge

3. A client is being returned to the room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client’s bedside?
   • 1   –   Indwelling urinary catheter kit
   • 2   –   Tracheostomy set
   • 3   –   Cardiac monitor
   • 4   –   Humidifier

   RATIONALE: After a subtotal thyroidectomy, swelling of the surgical site (the tracheal area) may obstruct the airway. Therefore, the nurse should keep a tracheostomy set at the client’s bedside in case of a respiratory emergency. Although an indwelling urinary catheter and a cardiac monitor may be used for a client after a thyroidectomy, the tracheostomy set is more important. This client doesn’t need a humidifier.
   NURSING PROCESS STEP: Planning
   CLIENT NEEDS CATEGORY: Safe, effective care environment
   CLIENT NEEDS SUBCATEGORY: Safety and infection control
   COGNITIVE LEVEL: Knowledge

4. A client is diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will prescribe diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn’t comply with treatment, which complication may arise?

   • 1   –   Cerebral edema
   • 2   –   Hypovolemic shock
   • 3   –   Severe hyperkalemia
   • 4   –   Tetany

   RATIONALE: Noncompliance with treatment for SIADH may lead to water intoxication from fluid retention caused by excessive antidiuretic hormone. This, in turn, limits water excretion and increases the risk of cerebral edema. Hypovolemic shock results from severe fluid volume deficit; in contrast, SIADH causes excessive fluid volume. The major electrolyte disturbance in SIADH is dilutional hyponatremia, not hyperkalemia. Because SIADH doesn’t alter renal function, potassium excretion remains normal; therefore, severe hyperkalemia doesn’t occur. Tetany results from hypocalcemia, an electrolyte disturbance not associated with SIADH.
   NURSING PROCESS STEP: Evaluation
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
   COGNITIVE LEVEL: Comprehension

5. A client is evaluated for type 1 (insulin-dependent) diabetes mellitus. Which client comment correlates best with this disorder?

   • 1   –   “I’m thirsty all the time. I just can’t get enough to drink.”
   • 2   –   “It seems like I have no appetite. I have to make myself eat.”
   • 3   –   “I have a cough and cold that just won’t go away.”
   • 4   –   “I notice pain when I urinate.”

   RATIONALE: Classic signs and symptoms of diabetes mellitus are polydipsia (excessive thirst), polyuria (excessive urination), and polyphagia (excessive appetite). Decreased appetite, lingering cough and cold, and pain on urination aren’t related to diabetes. Decreased appetite reflects a GI disorder; cough and cold indicate an upper respiratory problem; and pain on urination suggests a urinary tract infection.
   NURSING PROCESS STEP: Assessment
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
   COGNITIVE LEVEL: Analysis

6. A client visits the physician’s office complaining of agitation, restlessness, and weight loss. The physical examination reveals exophthalmos, a classic sign of Graves’ disease. Based on the client’s history and physical findings, the nurse suspects hyperthyroidism. Exophthalmos is characterized by:
   • 1   –   dry, waxy swelling and abnormal mucin deposits in the skin.
   • 2   –   protruding eyes and a fixed stare.
   • 3   –   wide, staggering gait.
   • 4   –   more than 10 beats/minute difference between the apical and radial pulse rates.

   RATIONALE: Exophthalmos is characterized by protruding eyes and a fixed stare. Dry, waxy swelling and abnormal mucin deposits in the skin typify myxedema, a condition resulting from advanced hypothyroidism. A wide, staggering gait and a differential between the apical and radial pulse rates aren’t signs of thyroid dysfunction.
   NURSING PROCESS STEP: Assessment
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
   COGNITIVE LEVEL: Knowledge

7. A client who was diagnosed with insulin-dependent diabetes mellitus 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client’s blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level?
   • 1   –   Cool, moist skin
   • 2   –   Rapid, thready pulse
   • 3   –   Arm and leg trembling
   • 4   –   Slow, shallow respirations

   RATIONALE: This client’s abnormally high blood glucose level indicates hyperglycemia, which typically causes polyuria, polyphagia, and polydipsia. Because polyuria leads to fluid loss, the nurse should expect to assess signs of a fluid volume deficit, such as decreased blood pressure, rapid respirations, and a rapid, thready pulse. Cool, moist skin and arm and leg trembling are associated with hypoglycemia. Rapid respirations – not slow, shallow ones – are associated with hyperglycemia.
   NURSING PROCESS STEP: Assessment
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Physiological adaptation
   COGNITIVE LEVEL: Analysis

8. A client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which “related-to” phrase should the nurse add?

   • 1   –   Related to bone demineralization resulting in pathologic fractures
   • 2   –   Related to exhaustion secondary to an accelerated metabolic rate
   • 3   –   Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces
   • 4   –   Related to tetany secondary to a decreased serum calcium level

   RATIONALE: Poorly controlled hyperparathyroidism may cause an elevated serum calcium level. This, in turn, may diminish calcium stores in the bone, causing bone demineralization and setting the stage for pathologic fractures and a risk for injury. Hyperparathyroidism doesn’t accelerate the metabolic rate. A decreased thyroid hormone level, not an increased parathyroid hormone level, may cause edema and dry skin secondary to fluid infiltration into the interstitial spaces. Hyperparathyroidism causes hypercalcemia, not hypocalcemia; therefore, it isn’t associated with tetany.
   NURSING PROCESS STEP: Planning
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
   COGNITIVE LEVEL: Analysis

9. A client with Addison’s disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of:
   • 1   –   calcium and phosphorus abnormalities.
   • 2   –   chloride and magnesium abnormalities.
   • 3   –   sodium and chloride abnormalities.
   • 4   –   sodium and potassium abnormalities.

   RATIONALE: In Addison’s disease, a form of adrenocortical hypofunction, aldosterone secretion is reduced. Aldosterone promotes sodium conservation and potassium excretion. Therefore, aldosterone deficiency increases sodium excretion, predisposing the client to hyponatremia, and inhibits potassium excretion, predisposing the client to hyperkalemia. Because aldosterone doesn’t regulate calcium, phosphorus, chloride, or magnesium, an aldosterone deficiency doesn’t affect levels of these electrolytes directly.
   NURSING PROCESS STEP: Assessment
   CLIENT NEEDS CATEGORY: Physiological integrity
   CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
   COGNITIVE LEVEL: Analysis

10. A client with diabetes mellitus has just been prescribed insulin. When teaching the client about hypoglycemia, which of the following effects should the nurse warn the client to expect?
    • 1   –   Polyuria, fatigue, and headache
    • 2   –   Nervousness, diaphoresis, and confusion
    • 3   –   Polydipsia, pallor, and irritability
    • 4   –   Polyphagia and flushed, dry skin

    RATIONALE: Signs and symptoms of hypoglycemia include nervousness, diaphoresis, and confusion. Headache, dizziness, irritability, weakness, pallor, seizures, and coma may also occur. Polyuria, polydipsia, polyphagia, and weight loss are classic manifestations of hyperglycemia, not hypoglycemia. Other signs and symptoms of hyperglycemia include mental status changes, fatigue, blurred vision, and flushed, dry skin.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

11. A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. The client’s urine output suddenly rises above 200 ml/hour 36 hours later, leading the nurse to suspect diabetes insipidus. Which of the following laboratory findings support the nurse’s suspicion of diabetes insipidus?
    • 1   –   Above-normal urine and serum osmolality levels
    • 2   –   Below-normal urine and serum osmolality levels
    • 3   –   Above-normal urine osmolality level, below-normal serum osmolality level
    • 4   –   Below-normal urine osmolality level, above-normal serum osmolality level

    RATIONALE: In diabetes insipidus, polyuria causes dilute urine, resulting in a below-normal urine osmolality level. At the same time, polyuria depletes the body of water, causing dehydration that leads to an above-normal serum osmolality level. For the same reasons, diabetes insipidus doesn’t cause above-normal urine osmolality or below-normal serum osmolality levels.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

12. A client with type 1 (insulin-dependent) diabetes mellitus has just learned she’s pregnant. The nurse is teaching her about insulin requirements during pregnancy. Which of the following guidelines should the nurse provide?
    • 1   –   “Insulin requirements don’t change during pregnancy. Continue your current regimen.”
    • 2   –   “Insulin requirements usually decrease during the last two trimesters.”
    • 3   –   “Insulin requirements usually decrease during the first trimester.”
    • 4   –   “Insulin requirements increase greatly during labor.”

    RATIONALE: Maternal insulin requirements usually decrease during the first trimester because of rapid fetal growth and maternal metabolic changes. This decrease necessitates adjustment of the client’s insulin dosage. Maternal insulin requirements continue to fluctuate throughout the pregnancy. After decreasing during the first trimester, they rise again during the second and third trimesters when fetal growth slows. During labor, insulin requirements diminish because of the extreme maternal energy expenditure.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Comprehension

13. A client with type 1 (insulin-dependent) diabetes mellitus is admitted to an acute care facility with diabetic ketoacidosis (DKA). To correct this acute diabetic emergency, which measure should the health care team take first?

    • 1   –   Initiate fluid replacement therapy.
    • 2   –   Administer insulin.
    • 3   –   Correct DKA.
    • 4   –   Determine the cause of DKA.

    RATIONALE: The health care team initiates fluid replacement therapy first to prevent or treat circulatory collapse caused by severe dehydration. Although DKA results from insulin deficiency, the client must have an adequate fluid volume before insulin can be administered; otherwise, the drug won’t circulate throughout the body effectively. Therefore, insulin administration follows fluid replacement therapy. Determining and correcting the cause of DKA are important steps, but the client’s condition must be stabilized first to prevent life-threatening complications.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

14. A nurse is caring for a client with Addison’s disease. Which nursing diagnosis is most appropriate for this client?

    • 1   –   Risk for infection
    • 2   –   Excess fluid volume
    • 3   –   Urinary retention
    • 4   –   Hypothermia

    RATIONALE: Addison’s disease decreases the production of all adrenal hormones, compromising the body’s normal stress response and increasing the risk for infection. Other appropriate nursing diagnoses for a client with Addison’s disease include Deficient fluid volume and Hyperthermia. Urinary retention isn’t appropriate because Addison’s disease causes polyuria.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Analysis

15. After a physical examination, a 50-year-old client is tentatively diagnosed with Addison’s disease. Which of the following tests would confirm or refute this diagnosis?

    • 1   –   Plasma and urinary cortisol levels
    • 2   –   Blood urea nitrogen and creatinine levels
    • 3   –   Electrolytes and complete blood count
    • 4   –   Chest X-ray and urinalysis

    RATIONALE: Adrenal function is evaluated by examining cortisol levels in plasma and urine. The other diagnostic tests would be part of a general physical examination to assess renal, respiratory, and hematologic status.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

16. An incoherent client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, the nurse prepares to take emergency action to prevent the potential complication of:
    • 1   –   thyroid storm.
    • 2   –   cretinism.
    • 3   –   myxedema coma.
    • 4   –   Hashimoto’s thyroiditis.

    RATIONALE: Severe hypothyroidism may result in myxedema coma, in which a drastic drop in the metabolic rate causes decreased vital signs, hypoventilation (possibly leading to respiratory acidosis), and nonpitting edema. Thyroid storm is an acute complication of hyperthyroidism. Cretinism is a form of hypothyroidism that occurs in infants. Hashimoto’s thyroiditis is a common chronic inflammatory disease of the thyroid gland in which autoimmune factors play a prominent role.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Comprehension

17. During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands secrete parathyroid hormone (PTH). PTH maintains the balance between calcium and:
    • 1   –   sodium.
    • 2   –   potassium.
    • 3   –   magnesium.
    • 4   –   phosphorus.

    RATIONALE: PTH increases the serum calcium level and decreases the serum phosphate level. PTH doesn’t affect sodium, potassium, or magnesium regulation.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

18. For a client with Graves’ disease, which nursing intervention promotes comfort?
    • 1   –   Restricting intake of oral fluids
    • 2   –   Placing extra blankets on the client’s bed
    • 3   –   Limiting intake of high-carbohydrate foods
    • 4   –   Maintaining room temperature in the low-normal range

    RATIONALE: Graves’ disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client’s room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Analysis

19. On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?

    • 1   –   Hypocalcemia
    • 2   –   Hyponatremia
    • 3   –   Hyperkalemia
    • 4   –   Hypermagnesemia

    RATIONALE: Hypocalcemia may follow thyroid surgery if the parathyroid glands were removed accidentally. Signs and symptoms of hypocalcemia may be delayed for up to 7 days after surgery. Thyroid surgery doesn’t directly cause abnormal serum sodium, potassium, or magnesium levels. Hyponatremia may occur if the client inadvertently received too much fluid; however, the same can happen to any surgical client receiving I.V. fluid therapy, not just one recovering from thyroid surgery. Hyperkalemia and hypermagnesemia are usually associated with reduced renal excretion of potassium and magnesium, not thyroid surgery.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Comprehension

20. The client has suffered a closed head injury in a snowboarding accident. The client’s urinary output has been 2,000 to 4,000 ml/day. A secondary diagnosis of diabetes insipidus has been made. DDAVP, a synthetic vasopressin, has been ordered as part of the treatment. This medication is usually administered:
    • 1   –   rectally.
    • 2   –   intrathecally.
    • 3   –   I.V.
    • 4   –   intranasally.

    RATIONALE: DDAVP is sprayed intranasally several times each day to control symptoms. The other routes of administration are inappropriate.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

21. The mother of a preschooler recently diagnosed with type 1 (insulin-dependent) diabetes mellitus makes an urgent call to the pediatrician’s office. She says her child had an uncontrollable temper tantrum while playing and now is lethargic and hard to arouse. The nurse should instruct the mother to take which action first?
    • 1   –   Obtain a urine sample and measure the glucose level.
    • 2   –   Force the child to drink orange juice.
    • 3   –   Measure the child’s blood glucose level.
    • 4   –   Call 911, because this is an emergency.

    RATIONALE: In a child with type 1 (insulin-dependent) diabetes mellitus, behavioral changes may signal hypoglycemia or hyperglycemia; measuring the blood glucose level is the only way to determine which condition is present. Urine glucose measurement doesn’t accurately reflect the current blood glucose level. Forcing a lethargic child to drink fluids could cause aspiration. After measuring the child’s blood glucose level, the mother may need to take additional emergency measures, such as administering insulin or a simple glucose source. If the child doesn’t respond to these measures, she may need to call for emergency help.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

22. The nurse expects a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) to have an elevated serum glucose level. Which of the following laboratory findings should the nurse also anticipate?
    • 1   –   Elevated serum acetone level
    • 2   –   Serum ketone bodies
    • 3   –   Serum alkalosis
    • 4   –   Decreased serum potassium level

    RATIONALE: A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperglycemic, hyperosmolar state caused by the relative insulin deficiency. An elevated serum acetone level and serum ketone bodies are characteristic of diabetic ketoacidosis. Metabolic acidosis, not serum alkalosis, may occur in HHNS.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

23. The nurse is assessing a client with Cushing’s disease. Which of the following observations should the nurse report to the physician immediately?
    • 1   –   Pitting edema of the legs
    • 2   –   Irregular apical pulse
    • 3   –   Dry mucous membranes
    • 4   –   Frequent urination

    RATIONALE: Because Cushing’s disease causes aldosterone overproduction, which increases urinary potassium loss, the disease may lead to hypokalemia. Therefore, the nurse should report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician immediately. Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. Dry mucous membranes and frequent urination signal dehydration, which isn’t associated with Cushing’s disease.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

24. The nurse is teaching a client with type 1 (insulin-dependent) diabetes mellitus how to manage adverse reactions to insulin. To reverse a hypoglycemic reaction, the client ideally should ingest an oral carbohydrate; however, this treatment isn’t always possible or safe. Therefore, which alternate treatment should the nurse advise the client to keep on hand?
    • 1   –   Epinephrine
    • 2   –   Glucagon
    • 3   –   50% dextrose
    • 4   –   Hydrocortisone

    RATIONALE: During a hypoglycemic reaction, a layperson may administer glucagon, an antihypoglycemic agent, to raise the blood glucose level quickly in a client who can’t ingest an oral carbohydrate. Epinephrine isn’t a treatment for hypoglycemia. Although 50% dextrose is used to treat hypoglycemia, it must be administered I.V. by a skilled health care professional. Hydrocortisone takes a relatively long time to raise the blood glucose level and, therefore, isn’t effective in reversing hypoglycemia.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Application

25. The nurse should expect a client with hypothyroidism to report which of the following health concerns?
    • 1   –   Increased appetite and weight loss
    • 2   –   Puffiness of the face and hands
    • 3   –   Nervousness and tremors
    • 4   –   Enlarged thyroid gland

    RATIONALE: Hypothyroidism (myxedema) causes facial puffiness, extremity edema, and weight gain. Signs and symptoms of hyperthyroidism (Graves’ disease) include an increased appetite, weight loss, nervousness, tremors, and thyroid gland enlargement (goiter).
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Knowledge

26. The parents of a 6-year-old child recently diagnosed with diabetes mellitus are preparing for discharge home. The diabetes resource nurse has been teaching the parents how to administer insulin. To avoid lipodystrophy from occurring, the nurse must teach the parents to:

    • 1   –   rotate injection sites frequently.
    • 2   –   give two separate injections to avoid giving too much in one site.
    • 3   –   let the child select the injection site.
    • 4   –   use the abdomen exclusively.

    RATIONALE: Rotating sites ensures that changes in the subcutaneous fat resulting from insulin administration won’t occur. Giving two injections wouldn’t address the development of lipodystrophy. Letting the child have choices is good, but the parents should give only two options and then have the child choose. Using the abdomen exclusively could cause damage to the subcutaneous layer, thereby altering absorption.
    NURSING PROCESS STEP: Implementation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
    COGNITIVE LEVEL: Application

27. The physician diagnoses type 1 (insulin-dependent) diabetes mellitus in a client who has classic manifestations of the disease and a random blood glucose level of 350 mg/dl. In addition to dietary modifications, the physician prescribes insulin. Initially, most clients receive the least antigenic form of insulin. Therefore, the nurse expects the physician to prescribe which of the following types of insulin?
    • 1   –   Beef insulin
    • 2   –   Fish insulin
    • 3   –   Human insulin
    • 4   –   Pork insulin

    RATIONALE: Human insulin is the least antigenic form of insulin because its composition is identical to that of endogenous insulin. Animal insulins, such as beef, fish, and pork insulins, differ in composition from endogenous insulin and, therefore, are more antigenic.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Comprehension

28. To correct a client’s long-term hypothyroid condition, Synthroid or Cytomel may be ordered. When administering the drug, the nurse should be aware that:
    • 1   –   The larger the dose, the more quickly the client will feel better.
    • 2   –   The client will need to take the drug for 6 months to improve.
    • 3   –   Hypothyroid states should be corrected slowly because the body needs time to adjust.
    • 4   –   The time of administration and the dosage amount aren’t relevant.

    RATIONALE: A hypothyroid state must be corrected slowly because a correction made too rapidly may result in angina, arrhythmias, or myocardial infarction. Large doses don’t necessarily make the client feel better more quickly, and the improvement in symptoms may take 2 to 3 weeks. The dosage amount is relevant to the client response.
    NURSING PROCESS STEP: Analysis
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
    COGNITIVE LEVEL: Knowledge

29. Typical findings in a client with hypothyroidism include: (Select all that apply.)

    • 1   –   Cold intolerance
    • 2   –   Diarrhea
    • 3   –   Dry skin
    • 4   –   Brittle hair
    • 5   –   Tachycardia
    • 6   –   Slowed speech

    RATIONALE: Clinical findings in acquired hypothyroidism include cold intolerance, dry skin, brittle hair, and slowed speech. There are numerous other symptoms, such as constipation, bradycardia, lethargy, fatigue, weight changes, and menstrual disorders; however, diarrhea and tachycardia aren’t among them.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Comprehension

30. When administering insulin, where should the nurse administer it so that it will be absorbed most quickly?

    • 1   –   Abdomen
    • 2   –   Arm
    • 3   –   Leg
    • 4   –   Buttocks

    RATIONALE: Insulin is absorbed most rapidly when administered in the abdomen. It’s absorbed more slowly in the arm and leg unless the client exercises vigorously after administration. Absorption is slowest from the buttocks.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Safe, effective care environment
    CLIENT NEEDS SUBCATEGORY: Management of care
    COGNITIVE LEVEL: Knowledge

31. When assessing a client with pheochromocytoma, the nurse is most likely to detect:
    • 1   –   Blood pressure of 130/70 mm Hg
    • 2   –   Blood glucose level of 130 mg/dl
    • 3   –   Bradycardia
    • 4   –   Blood pressure of 176/88 mm Hg

    RATIONALE: Pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, causes hypertension, tachycardia, hyperglycemia, hypermetabolism, and weight loss. It isn’t associated with the other options.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

32. When assessing a client with syndrome of inappropriate diuretic hormone (SIADH), a nurse should be aware that which of the following signs suggests that the client is experiencing complications?
    • 1   –   Tetanic contractions
    • 2   –   Neck vein distention
    • 3   –   Weight loss
    • 4   –   Polyuria

    RATIONALE: SIADH causes antidiuretic hormone overproduction, which leads to fluid retention. Severe SIADH can cause such complications as vascular fluid overload, signaled by neck vein distention. This syndrome isn’t associated with tetanic contractions. SIADH may cause weight gain and fluid retention (secondary to oliguria).
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Knowledge

33. When assessing a pregnant client with diabetes mellitus, the nurse is alert for signs and symptoms of a vaginal or urinary tract infection. Which of the following conditions makes this client more susceptible to such infections?
    • 1   –   Electrolyte imbalances
    • 2   –   Decreased insulin needs
    • 3   –   Hypoglycemia
    • 4   –   Glycosuria

    RATIONALE: Glycosuria predisposes the pregnant diabetic client to vaginal infections (especially candidiasis) and urinary tract infections because the hormonal changes of pregnancy affect the pH of the vagina and increase the glucose concentration in urine. Electrolyte imbalances and hypoglycemia aren’t associated with vaginal or urinary tract infections. Insulin requirements may decrease in early pregnancy; however, as the client’s food intake improves and maternal and fetal glycogen stores increase, insulin requirements also rise.
    NURSING PROCESS STEP: Assessment
    CLIENT NEEDS CATEGORY: Health promotion and maintenance
    CLIENT NEEDS SUBCATEGORY: None
    COGNITIVE LEVEL: Knowledge

34. Which nursing diagnosis takes highest priority for a client with hyperthyroidism?
    • 1   –   Imbalanced nutrition: More than body requirements related to thyroid hormone excess
    • 2   –   Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing
    • 3   –   Disturbed body image related to weight gain and edema
    • 4   –   Imbalanced nutrition: Less than body requirements related to thyroid hormone excess

    RATIONALE: In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism. These conditions may result in a negative nitrogen balance, increased protein synthesis and breakdown, decreased glucose tolerance, and fat mobilization and depletion. These changes put the client at risk for marked nutrient and calorie deficiency, making Altered nutrition: Less than body requirements the most important nursing diagnosis. The first option would occur with weight gain or obesity, not with weight loss. The second and third options may be appropriate for a client with hypothyroidism, which slows the metabolic rate.
    NURSING PROCESS STEP: Planning
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Basic care and comfort
    COGNITIVE LEVEL: Analysis

35. Which of the following outcomes indicates that treatment of a client with diabetes insipidus has been effective?

    • 1   –   Fluid intake is less than 2,500 ml/24 hours.
    • 2   –   Urine output measures more than 200 ml/hour.
    • 3   –   Blood pressure measures 90/50 mm Hg.
    • 4   –   The heart rate is 126 beats/minute.

    RATIONALE: Diabetes insipidus is characterized by polyuria (up to 8 L/day), constant thirst, and an unusually high oral intake of fluids. Treatment with the appropriate drug should decrease oral fluid intake and urine output. A urine output of 200 ml/hour indicates continuing polyuria. A blood pressure of 90/50 mm Hg and a heart rate of 126 beats/minute indicate compensation for the continued fluid deficit, suggesting that treatment hasn’t been effective.
    NURSING PROCESS STEP: Evaluation
    CLIENT NEEDS CATEGORY: Physiological integrity
    CLIENT NEEDS SUBCATEGORY: Physiological adaptation
    COGNITIVE LEVEL: Analysis