Training Day
A client has been receiving inhalation desmopressin (DDAVP) therapy for hypothalamic diabetes insipidus (DI). What will the nurse evaluate to determine the therapeutic response to this medication?
1. Urine specific gravity
2. Blood glucose
3. Vital signs
4. Oxygen saturation levels
Correct Answer: 1
Rationale:
DDAVP alleviates polyuria by acting as antidiuretic hormone (ADH). In the case of DI, urine specific gravity should return to a normal level of 1.010 to 1.030. There is no effect on blood glucose or oxygen saturation levels. One adverse effect (not considered therapeutic for DDAVP) is the possibility of a change in vital signs related to peripheral vascular resistance (vasoconstriction). Another reason the vital signs may be affected is water intoxication, which is also a side effect of DDAVP.
The nurse is performing an assessment on a client who has been receiving long-term steroid therapy. What would the nurse expect to find during the assessment?
1.
Jaundice
2.
Flank pain
3.
Bulging eyes
4.
Central obesity
Correct Answer: 4
Rationale:
Cushing's syndrome develops because of an excess of cortisol, in this case from prolonged exogenous steroid administration. This syndrome may be characterized by truncal (central) obesity, hypertension, weakness, hirsutism, abdominal striae (stretch marks), edema, and hypokalemia. Flank pain is associated with kidney problems. Bulging eyes are found in hyperthyroidism. Jaundice is associated with liver and gallbladder problems. (Lewis, et al., 9 ed., p. 1208.)
The nurse is monitoring the fluid replacement during treatment of a client in an adrenal crisis. The nurse would question which of the following IV orders?
1.
D5/0.45% NS
2.
Isotonic saline solution
3.
Hydrocortisone
4.
D5W
Correct Answer: 4
Rationale:
A client in adrenal, or addisonian, crisis has hyponatremia. It would be inappropriate to administer a sodium-free IV solution such as D5W. Isotonic saline solution (normal saline), half strength (0.45%) saline with dextrose, and hydrocortisone are used in the treatment of adrenal crisis (addisonian crisis).
The physician orders hydrocortisone daily for a client with Addison disease. The nurse explains to the client that the dosage may need to be adjusted because of which concern?
1.
Increased food intake
2.
An increase in blood glucose levels
3.
Increased stress levels
4.
Stomach discomfort
Correct Answer: 3
Rationale:
Stress levels in the body will cause utilization of increased amounts of cortisol. With the lack of steroids caused by adrenal insufficiency associated with Addison disease, it would be important to maintain the level of cortisone in the body to keep the body functioning appropriately.
The nurse is caring for a client in diabetic ketoacidosis (DKA). An order exists for insulin to be added to the current infusing IV. What type of insulin will the nurse use?
1.
Insulin detemir
2.
Regular insulin
3.
NPH insulin
4.
Insulin glargine
Correct Answer: 2
Rationale:
Regular insulin is the only forms of insulin recommended for IV use. The rapid- and slower-acting insulins are clear. All the other insulins are for subQ injection or are cloudy.
Which symptom is most likely experienced by a client with an acute episode of diabetes insipidus?
1.
Low serum albumin
2.
Urine specific gravity of 1.003
3.
Pulse oximeter reading of 84%
4.
A1C of 9%
Correct Answer: 2
Rationale:
Diabetes insipidus (DI) causes a pronounced loss of intravascular volume as evidenced by 5 to 20 L of urine output per day. This would lead to dilute urine (very low specific gravity) and concentrated blood (as evidenced by hypernatremia). Nutrition (low albumin), gas exchange (poor oxygen saturation), and a high A1C (as is seen in diabetes mellitus) are not related to DI.
What is important to teach a client with adrenal insufficiency who has a prescription for prednisone?
1.
Be sure to include foods that are low in potassium in the diet.
2.
Slowly change positions to avoid dizziness and fainting.
3.
Watch for signs of low blood sugar: headache, shakiness, and diaphoresis.
4.
Signs of fluid retention may occur while taking this drug
Correct Answer: 4
Rationale:
Report any excessive weight gain or swelling to the health care provider because either one may indicate an adverse effect of the medication. The client taking prednisone needs to consume a high-potassium diet, because prednisone causes hypokalemia. Hypertension, not orthostatic hypotension, is a side effect of taking glucocorticoids. Hyperglycemia can occur with prednisone use, not hypoglycemia.
A young child weighing 17 kg with a history of type 1 diabetes is admitted with ketoacidosis. The nurse would question which of the following admission orders?
1. Rehydrate slowly over 48 hours.
2. Weigh on admission and daily.
3. Administer IV regular insulin via pump at 2 units/kg/hr after a hydration bolus.
4. Start an IV of D5/0.45% normal saline with 20 mEq KCl.
Correct Answer: 4
Rationale:
The order to question is the IV D5/0.45% normal saline with KCl. No indication is given regarding the child's urine output, and 0.9% normal saline would be indicated on admission for rehydration, not dextrose in the IV until the blood sugar and acidosis are corrected. Rehydration is accomplished slowly over a 48-hour period to reduce the risk of cerebral edema that may occur with rapid fluid replacement. Also, potassium would not be given until the child is rehydrated after the acidosis problem. An admission weight is an important baseline for determining the dosage of insulin to administer. The rest of the options would all be appropriate nursing interventions.
A client is being treated for Addisonian crisis and 0.9% saline solution is being administered. What nursing observation would indicate this intervention may not be achieving the desired response?
1. Ankle edema
2. Serum potassium of 4.1 mEq/L (4.1 mmol/L)
3. Decreasing blood pressure (BP)
4. Heart rate of 78 beats/min
Correct Answer: 3
Rationale:
The purpose of the infusion of large volumes of saline is to reverse/prevent hypotension. Edema would not be expected, because this is associated with Cushing's syndrome. Hyperkalemia is associated with Addison disease. Sodium polystyrene sulfonate may be administered to clients experiencing higher-than-normal ranges of potassium levels in which bradycardia and irregular pulse are clinical findings. Decreasing BP may be considered a late sign of cardiac decompensation with decreased atrial and ventricular output. Pedal edema would not be associated in clients experiencing hyperkalemia because it is related to sodium retention.
A client admitted with a pheochromocytoma returns from the operating room after adrenalectomy. What should the nurse carefully assess in this client?
1.
Hypoglycemia
2.
Hypokalemia
3.
Changes in blood pressure (BP)
4.
Increased sodium and water retention
Correct Answer: 3
Rationale:
Pheochromocytoma is a tumor in the adrenal medulla that produces excess catecholamines (epinephrine and norepinephrine). An excess of these catecholamines can cause severe hypertension. Surgery (i.e., an adrenalectomy) alleviates the elevated BP most of the time. In 10% to 30% of clients, hypertension remains and must be monitored and treated. Electrolyte imbalances and blood sugar are not typically affected.
A client is receiving treatment for Cushing's syndrome. Which laboratory measurement would provide an indication that treatment is successful?
1. A decreased serum potassium level
2. An increased urinary calcium level
3. An increased serum sodium level
4. A decreased serum glucose level
Correct Answer: 4
Rationale:
Cushing's syndrome is characterized by hyperglycemia, hypokalemia, hypernatremia, and hypercalciuria. A drop-in serum potassium and an increase in urinary calcium levels would not indicate improvement; however, a drop in serum glucose would indicate improvement.
For a client with hypercortisolism, which finding requires a need to call the provider?
1.
Upset stomach
2.
Rapid weight gain
3.
Striae on the abdominal skin
4.
Development of a buffalo hump
Correct Answer: 2
Rationale:
Rapid weight gain, which is a sign of fluid retention, must be reported to the health care provider because it may indicate excess steroids in the body, which will lead to symptoms of Cushing's syndrome. Gastric irritation and upset stomach are results of the steroid medication irritating the stomach and can be minimized with food ingestion before taking the medication. Striae are noted in the diagnosis of hypercortisolism because high levels of cortisol degrade collagen, but they do not need to be reported; neither does the buffalo hump.
A nurse assessing a client with syndrome of inappropriate antidiuretic hormone (SIADH) would expect to find which laboratory values?
1.
Serum sodium = 150 mEq/L (150 mmol/L) and low urine osmolality
2.
Serum potassium = 5 mEq/L (5 mmol/L) and low serum osmolality
3.
Serum sodium = 120 mEq/L (120 mmol/L) and low serum osmolality
4.
Serum potassium = 3 mEq/L (3 mmol/L) and high serum osmolality
Correct Answer: 3
Rationale:
SIADH occurs when excessive antidiuretic hormone (ADH) is released, even when the plasma (serum) osmolality is normal. The excess ADH increases the permeability of the renal tubules, causing reabsorption of water into the circulation. As a result of extracellular fluid expansion, serum osmolality decreases. Also, sodium levels decline (as a result of being diluted), leading to hyponatremia.
What is a priority assessment for a client with a pheochromocytoma?
1.
Breath sounds
2.
Blood pressure
3.
Daily weight
4.
Abdominal girth
Correct Answer: 2
Rationale:
Hypertension is the principal clinical finding with pheochromocytoma. It is related to the release of catecholamines, primarily norepinephrine, and requires frequent assessment of the client's BP. Rapid elevations in BP should be reported to the physician because they may cause a complication, such as a stroke. Weight and abdominal girth are associated with fluid overload and conditions that contribute to fluid imbalance, such as congestive heart failure and liver problems. Assessing breath sounds is part of a routine pulmonary assessment.
The nurse is providing education to a client diagnosed with Addison disease. Which statement by the client would indicate that more education is needed?
1.
"I will make sure I carry my medical identification card wherever I go."
2.
"I am just glad I do not have to take steroids for the rest of my life."
3.
"If I have any stomach problems, I'll let the doctor know."
4.
"If I get an infection or injured, the doctor might have to give me more steroids."
Correct Answer: 2
Rationale:
Addison disease is caused by a decrease in secretion of adrenal cortex hormones. For a client diagnosed with Addison disease, lifelong steroid therapy is necessary. The client should carry a medical identification card that identifies his or her condition in case of an emergency. Gastric distress should be reported because it may be an indication of ulcer formation caused by steroids. An increase in steroid medication may be needed for an infection or injury.
What is the nurse's priority concern for a client admitted to the hospital with a diagnosis of diabetes insipidus (DI)?
1.
Sleep disturbance caused by nocturia
2.
Decreased physical mobility caused by muscular cramping
3.
Fluid volume excess caused by water retention
4.
Skin breakdown caused by generalized edema
Correct Answer: 1
Rationale:
DI is associated with a decrease (or deficiency) in the secretion of ADH. Lack of ADH leads to increased urinary output (as much as 5 to 20 L/day). Clients with DI become very fatigued from nocturia. Fluid volume deficit can occur as a result of the excess urine output. There is no edema or muscle weakness. (Lewis, et al., 9 ed., p. 1195.)
A client has a diagnosis of diabetes insipidus (DI). What are appropriate nursing interventions for this client? Select all that apply.
1.
Monitor urine for specific gravity.
2.
Reduce IV fluids and electrolytes.
3.
Administer lispro.
4.
Monitor for increase in weight gain.
5.
Provide a sodium-restricted diet.
Correct Answer(s): 1,5
Rationale:
Urine specific gravity will be low (1.001 to 1.005) and dilute, so it should be monitored. One of the characteristics of DI is a decrease in antidiuretic hormone (ADH), which leads to decreased urine output and electrolyte depletion. Vasopressin is administered, not lispro. Because of the excessive urine volume, dehydration occurs, not weight gain. Limiting sodium intake to no more than 3 g/day is thought to help decrease the urine output.
An adolescent with type 1 diabetes mellitus is experiencing a problem with diabetic ketoacidosis (DKA). Which laboratory results reflect this condition?
1. Hematocrit of 37%
2. Serum glucose level of 150 mg/dL (8.3 mmol/L)
3. Blood pH of 7.28
4. Serum creatinine level of 5.6 mg/dL (495 μmol/L)
Correct Answer: 3
Rationale:
DKA is reflected in the decreased pH (7.28), which indicates metabolic acidosis. This often is accompanied by an increased temperature and urine output, dry mouth, abdominal pain, flushing, decreased energy, and an elevated blood glucose level greater than 300 mg/dL (16.7 mmol/L). The hematocrit is within normal range. The serum glucose is not high enough for DKA (usually the value is greater than 250 mg/dL [13.9 mmol/L]). Creatinine is elevated to three times more than normal, but this would not necessarily reflect DKA, because it is associated more with diabetic nephropathy.
A client has a diagnosis of adrenocortical insufficiency. What would be an appropriate task to delegate to the certified nursing assistant (CNA)? Select all that apply.
1. Revise the client's nursing care.
2. Remind the client to change positions slowly.
3. Assist the client out of bed.
4. Evaluate the client for fatigue and muscle weakness.
5. Explain to the client how to collect a 24-hour urine sample.
6. Teach the client's spouse the importance of diet.
Correct Answer(s): 2,3
Rationale:
Clients with adrenocortical insufficiency have neuromuscular weakness and hypotension, so assigning the CNA to assist the client out of bed and to remind the client to change positions slowly would be a safe nursing measure, especially after the nurse has initially explained to the client these nursing measures. Any type of assessment, teaching, or care planning is the function of the licensed professional nurse.
The nurse would note which findings on the physical assessment of a client with a diagnosis of Cushing's disease? Select all that apply.
1. Buffalo hump
2. Thinning hair
3. Acne
4. Hirsutism
5. Gynecomastia
6. Bulging eyes
Correct Answer(s): 1,2,3,4,5
Rationale:
Typical clinical findings of Cushing's disease include thinning hair, hirsutism in women, gynecomastia in men, moon face, buffalo hump, abdominal striae, weight gain, truncal obesity, thin limbs, acne, hypertension, and mood changes. This may be due to externally administered steroids or excessive production of steroids by the adrenal glands. Bulging eyes are associated with hyperthyroidism.
The nurse is caring for a client with Addison disease. Which findings indicate the development of a complication of this condition? Select all that apply.
1. Back and abdominal pain
2. Hyperglycemia
3. Extreme weakness
4. Temperature of 101° F (38.3° C)
5. Increased BP
6. Confusion
Correct Answer(s): 1,3,4,6
Rationale:
Addisonian crisis is an acute episode of adrenal insufficiency, which can be a life-threatening emergency. It is characterized by weakness, often accompanied by pain in the back, abdomen, or legs, along with severe manifestations of glucocorticoid and mineralocorticoid deficiency, including hypotension (particularly postural), tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, hyperpyrexia, and confusion. It is treated by administration of hydrocortisone and fluid replacement.
The nurse is conducting discharge teaching for a client with Addison disease. What would the nurse advise the client to carry at all times? Select all that apply.
1.
Hydrocortisone
2.
Epinephrine
3.
An injectable diuretic agent
4.
The physician's phone number
5.
The client's medication schedule
6.
Documentation of the client's diagnosis
Correct Answer(s): 1,4,5,6
Rationale:
A client with Addison disease should always wear a medical alert ID bracelet and should carry an emergency kit, which should include 100 mg of intramuscular (IM) hydrocortisone and directions for its injection, the physician's phone number, and the client's diagnosis and medication schedule. (Lewis, et al., 9 ed., p. 1213.)
The nurse is caring for a client after a transsphenoidal resection of a pituitary tumor. Which finding(s) must be reported to the surgeon? Select all that apply.
1.
Presence of swelling at suture site
2.
Urine output of 350 mL for past 2 hours
3.
Increased lower lobe crackles
4.
Pulse oximetry of 98%, BP of 138/82 mm Hg
5.
Serum osmolality of 302 mmol/kg
Correct Answer(s): 2,5
Rationale:
After removal of the pituitary, the client may develop diabetes insipidus (DI) as a result of cerebral edema. It will be a priority to monitor urine output and urine specific gravity and to notify the surgeon of an increase in volume and decrease in specific gravity. The other major concern is related to the concentrated serum blood most likely related to hypernatremia. Swelling at the gum site is possible, which would be expected and noted on the chart. Crackles are found with fluid volume overload, not dehydration, which is what this client is at risk of developing. The pulse oximetry is in the normal range, and BP is not critical.
A nurse knows the clinical manifestations of a client with Addison disease include which of the following? Select all that apply.
1.
Nausea
2.
Hypothermia
3.
Hypertension
4.
Hyperpigmentation
5.
Hypotension
6.
Hypernatremia
Correct Answer(s): 1,4,5
Rationale:
Addison disease is due to a hypofunctioning of the adrenal cortex. The clinical manifestations have a very slow onset, and skin hyperpigmentation (melanosis) is a classic sign. This bronze coloring of the skin is seen primarily in those areas exposed to the sun, pressure points, joints, and in skin creases (especially on the palms, knuckles, and elbows). Fatigue, nausea, weight loss, hypotension, hyponatremia, and hyperkalemia are other findings associated with the condition. (Lewis, et al., 9 ed., p. 1211.)
A client is scheduled for transsphenoidal hypophysectomy for treatment of an anterior pituitary tumor. What would be an important preoperative teaching for this client? Select all that apply.
1.
Elevate the head of the bed 30 degrees.
2.
Encourage hourly coughing, deep breathing, and incentive spirometry.
3.
Monitor for symptoms of increasing intracranial pressure.
4.
Monitor urine output for a decrease in volume.
5.
Provide frequent oral hygiene with nonirritating solutions; avoid using a toothbrush.
6.
Take cortisone, thyroid hormones, and antidiuretic hormone (ADH)-regulating medications.
Correct Answer(s): 1,3,5,6
Rationale:
To provide supportive care and preoperative teaching, the nurse would elevate the head of the bed 30 degrees, discourage coughing, sneezing, or straining while defecating to prevent cerebrospinal fluid leak, assess for symptoms of increasing intracranial pressure, evaluate urine for excessive increase in volume (more than 200 mL/hr) or specific gravity less than 1.005 (i.e., development of DI), and provide frequent oral hygiene with nonirritating solutions to avoid disruption of the suture line. The client should avoid brushing the teeth for 10 days after surgery. The client will require medication to support pituitary target organs involved (e.g., pancreas, thyroid, adrenals, gonads), cortisone and thyroid hormone replacement throughout his or her lifetime, and ADH-regulating medications.