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A nurse cares for a patient with a deficiency of aldosterone. Which assessment finding would the nurse correlate with this deficiency?
a. Increased urine output
b. Vasoconstriction
c. Blood glucose of 98 mg/dL (5.4 mmol/L)
d. Serum sodium of 144 mEq/L (144 mmol/L)
ANS: A
Aldosterone, the major mineralocorticoid, maintains extracellular fluid volume. It promotes sodium and water reabsorption and potassium excretion in the kidney tubules. A patient with an aldosterone deficiency will have increased urine output. Vasoconstriction is not related. These sodium and glucose levels are normal; in aldosterone deficiency, the patient would have hyponatremia and hyperkalemia.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Endocrine system | assessment/diagnostic examination
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse cares for a patient who is prescribed a serum catecholamine test. What action would the nurse take when obtaining the sample?
a. Discard the first sample and then begin the collection.
b. Draw the blood sample after the patient eats breakfast.
c. Place the sample on ice and send to the laboratory immediately.
d. Add preservatives before sending the sample to the laboratory.
ANS: C
A blood sample for catecholamine must be placed on ice and taken to the laboratory immediately. This sample is not urine, and therefore the first sample would not be discarded nor would preservatives be added to the sample. The nurse would use the appropriate tube and obtain the sample based on which drugs are administered, not dietary schedules.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Endocrine system | assessment/diagnostic examination
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
After teaching a patient who has diabetes mellitus and proliferative retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the patient’s understanding. Which statement made by the patient indicates a correct understanding of the teaching?
a. “I have so many complications; exercising is not recommended.”
b. “I will exercise more frequently because I have so many complications.”
c. “I used to run for exercise; I will start training for a marathon.”
d. “I should look into swimming or water aerobics to get my exercise.”
ANS: D
Exercise is not contraindicated for this patient, although modifications based on existing pathology are necessary to prevent further injury. Swimming or water aerobics will give the patient exercise without the worry of having the correct shoes or developing a foot injury. The patient should not exercise too vigorously.
PTS: 1 DIF: Cognitive Level: Evaluating KEY: Diabetes mellitus | exercise
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Health Promotion and Maintenance
Which clinical manifestation would the nurse expect to find in a patient with hyperaldosteronism?
a. hypertension
b. hyperkalemia
c. hypotension
d. dehydration
ANS: A
A nurse teaches a patient with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement would the nurse include in this patient’s teaching to prevent injury?
a. “Examine your feet using a mirror every day.”
b. “Rotate your insulin injection sites every week.”
c. “Check your blood glucose level before each meal.”
d. “Use a bath thermometer to test the water temperature.”
ANS: D
Patients with diminished sensory perception can easily experience a burn injury when bathwater is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and checking blood glucose levels will not prevent injury.
PTS: 1 DIF: Cognitive Level: Understanding KEY: Diabetes mellitus | foot care
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A nurse reviews the medication list of a patient with a 20-year history of diabetes mellitus. The patient holds up the bottle of prescribed duloxetine (Cymbalta) and states, “My cousin has depression and is taking this drug. Do you think I’m depressed?” How would the nurse respond?
a. “Many people with long-term diabetes become depressed after a while.”
b. “It’s for peripheral neuropathy. Do you have burning pain in your feet or hands?”
c. “This antidepressant also has anti-inflammatory properties for diabetic pain.”
d. “No. Many medications can be used for several different disorders.”
ANS: B
Damage along nerves causes peripheral neuropathy and leads to burning pain along the nerves. Many drugs, including duloxetine (Cymbalta), can be used to treat peripheral neuropathy. The nurse would assess the patient for this condition and then would provide an explanation of why this drug is being used. This medication, although it is used for depression, is not being used for that reason in this case. Duloxetine does not have anti-inflammatory properties. Telling the patient that many medications are used for different disorders does not provide the patient with enough information to be useful.
PTS: 1 DIF: Cognitive Level: Applying KEY: Diabetes mellitus | neuropathy
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse assesses a patient who is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted?
a. Serum potassium level has increased.
b. Blood osmolarity has decreased.
c. Glasgow Coma Scale score is unchanged.
d. Urine remains negative for ketone bodies.
ANS: C
A slow but steady improvement in central nervous system functioning is the best indicator of therapy effectiveness for HHS. Lack of improvement in the level of consciousness may indicate inadequate rates of fluid replacement. The Glasgow Coma Scale assesses the patient’s state of consciousness against criteria of a scale including best eye, verbal, and motor responses. An increase in serum potassium, decreased blood osmolality, and urine negative for ketone bodies do not indicate adequacy of treatment.
PTS: 1 DIF: Cognitive Level: Applying KEY: Diabetes mellitus | hyperglycemia
MSC: Integrated Process: Nursing Process/Evaluation
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse cares for a patient who possibly has syndrome of inappropriate antidiuretic hormone (SIADH). The patient’s serum sodium level is 114 mEq/L (114 mmol/L). What action would the nurse take first?
a. Consult with the dietitian about increased dietary sodium.
b. Restrict the patient’s fluid intake to 600 mL/day.
c. Handle the patient gently by using turn sheets for repositioning.
d. Instruct unlicensed assistive personnel to measure intake and output.
ANS: B
With SIADH, patients often have dilutional hyponatremia. The patient needs a fluid restriction, sometimes to as little as 500 to 600 mL/24 hr. Adding sodium to the patient’s diet will not help if he or she is retaining fluid and diluting the sodium. The patient is not at increased risk for fracture, so gentle handling is not an issue. The patient would be on intake and output; however, this will monitor only the patient’s intake, so it is not the best answer. Reducing intake will help increase the patient’s sodium.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Pituitary disorder | electrolyte imbalance
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse cares for a patient who has excessive catecholamine release. Catecholamines are responsible for what response?
a. Flight-or-fight response
b. Fight-or-flight response
c. Decreased heart rate response
d. Increased respirations
B. Fight-or flight stress response
Catecholamines are responsible for the fight-or-flight stress response. Activation of the sympathetic nervous system leads to tachycardia. All of the others are incorrect.
A nurse cares for a patient who has excessive catecholamine release. Which assessment finding would the nurse correlate with this condition?
a. Decreased blood pressure
b. Increased pulse
c. Decreased respiratory rate
d. Increased urine output
ANS: B
Catecholamines are responsible for the fight-or-flight stress response. Activation of the sympathetic nervous system can be correlated with tachycardia. Catecholamines do not decrease blood pressure or respiratory rate, nor do they increase urine output.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Endocrine system | assessment/diagnostic examination
MSC: Integrated Process: Nursing Process/Evaluation
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
After teaching a patient with acromegaly who is scheduled for a hypophysectomy, the nurse assesses the patient’s understanding. Which statement made by the patient indicates a need for additional teaching?
a. “I will no longer need to limit my fluid intake after surgery.”
b. “I am glad no visible incision will result from this surgery.”
c. “I hope I can go back to wearing size 8 shoes instead of size 12.”
d. “I will wear slip-on shoes after surgery to limit bending over.”
ANS: C
Although removal of the tissue that is oversecreting hormones can relieve many symptoms of hyperpituitarism, skeletal changes and organ enlargement are not reversible. It will be appropriate for the patient to drink as needed postoperatively and avoid bending over. The patient can be reassured that the incision will not be visible.
PTS: 1 DIF: Cognitive Level: Evaluating
KEY: Pituitary disorder | preoperative nursing
MSC: Integrated Process: Nursing Process/Evaluation
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse cares for a patient with chronic hypercortisolism. What action would the nurse take?
a. Wash hands when entering the room.
b. Keep the patient in airborne isolation.
c. Observe the patient for signs of infection.
d. Assess the patient’s daily chest x-ray.
ANS: A
Excess cortisol reduces the number of circulating lymphocytes, inhibits maturation of macrophages, reduces antibody synthesis, and inhibits production of cytokines and inflammatory chemicals. As a result, these patients are at greater risk of infection and may not have the expected inflammatory manifestations when an infection is present. The nurse needs to take precautions to decrease the patient’s risk. It is not necessary to keep the patient in isolation. The patient does not need a daily chest x-ray.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Adrenal gland disorder | infection control
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A nurse assesses a patient who takes lithium. Which assessment finding should alert the nurse to a side effect of this therapy?
a. Increased heat intolerance and weight loss
b. Bradycardia and loss of eyebrow hair
c. Positive Chvostek’s and Trousseau’s sign
d. Loss of bone density and recent fractures
ANS: B
Lithium causes decreased synthesis of thyroid hormone, so the nurse assesses for signs of hypothyroidism including bradycardia and loss of eyebrow hair. Heat intolerance and weight loss indicate hyperthyroidism. Chvostek’s and Trousseau’s signs are indicative of hypocalcemia and hypoparathyroidism. Fractures and decreased bone density can indicate hyperparathyroidism.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Thyroid gland disorder | medication safety
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse teaches a patient who is diagnosed with diabetes mellitus. Which statement would the nurse include in this patient’s plan of care to delay the onset of microvascular and macrovascular complications?
a. “Maintain tight glycemic control and prevent hyperglycemia.”
b. “Restrict your fluid intake to no more than 2 L a day.”
c. “Prevent hypoglycemia by eating a bedtime snack.”
d. “Limit your intake of protein to prevent ketoacidosis.”
ANS: A
Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications. Maintaining tight glycemic control will help delay the onset of complications. Restricting fluid intake is not part of the treatment plan for patients with diabetes. Preventing hypoglycemia and ketosis, although important, is not as important as maintaining daily glycemic control.
PTS: 1 DIF: Cognitive Level: Applying KEY: Diabetes mellitus | hyperglycemia
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
An emergency department nurse assesses a patient with ketoacidosis. Which clinical manifestation would the nurse correlate with this condition?
a. Increased rate and depth of respiration
b. Extremity tremors followed by seizure activity
c. Oral temperature of 102° F (38.9° C)
d. Severe orthostatic hypotension
ANS: A
Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation. Tremors, elevated temperature, and orthostatic hypotension are not associated with ketoacidosis.
PTS: 1 DIF: Cognitive Level: Remembering KEY: Diabetes mellitus | hyperglycemia
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse assesses a patient who has diabetes mellitus. Which arterial blood gas values would the nurse identify as potential ketoacidosis in this patient?
a. pH 7.38, HCO 22 mEq/L (22 mmol/L), PCO2 38 mm Hg, PO2 98 mm Hg
b. pH 7.28, HCO 18 mEq/L (18 mmol/L), PCO2 28 mm Hg, PO2 98 mm Hg
c. pH 7.48, HCO 28 mEq/L (28 mmol/L), PCO2 38 mm Hg, PO2 98 mm Hg
d. pH 7.32, HCO 22 mEq/L (22 mmol/L), PCO2 58 mm Hg, PO2 88 mm Hg
ANS: B
When the lungs can no longer offset acidosis, the pH decreases to below normal. A patient who has diabetic ketoacidosis would present with arterial blood gas values that show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels.
PTS: 1 DIF: Cognitive Level: Analyzing KEY: Diabetes mellitus | hyperglycemia
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse cares for a patient experiencing diabetic ketoacidosis who presents with Kussmaul respirations. What action would the nurse take?
a. Administration of oxygen via face mask
b. Intravenous administration of 10% glucose
c. Implementation of seizure precautions
d. Administration of intravenous insulin
ANS: D
The rapid, deep respiratory efforts of Kussmaul respirations are the body’s attempt to reduce the acids produced by using fat rather than glucose for fuel. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. The patient who is in ketoacidosis may not experience any respiratory impairment and therefore does not need additional oxygen. Giving the patient glucose would be contraindicated. The patient does not require seizure precautions.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Diabetes mellitus | hyperglycemia | respiratory distress/failure
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse assesses a patient with diabetes mellitus. Which clinical manifestation would alert the nurse to decreased kidney function in this patient?
a. Urine specific gravity of 1.033
b. Presence of protein in the urine
c. Elevated capillary blood glucose level
d. Presence of ketone bodies in the urine
ANS: B
Renal dysfunction often occurs in the patient with diabetes. Proteinuria is a result of renal dysfunction. Specific gravity is elevated with dehydration. Elevated capillary blood glucose levels and ketones in the urine are consistent with diabetes mellitus but are not specific to renal function.
PTS: 1 DIF: Cognitive Level: Applying KEY: Diabetes mellitus | renal failure
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse teaches a patient with diabetes mellitus about sick-day management. Which statement would the nurse include in this patient’s teaching?
a. “When ill, avoid eating or drinking to reduce vomiting and diarrhea.”
b. “Monitor your blood glucose levels at least every 4 hours while sick.”
c. “If vomiting, do not use insulin or take your oral antidiabetic agent.”
d. “Try to continue your prescribed exercise regimen even if you are sick.”
ANS: B
When ill, the patient should monitor his or her blood glucose at least every 4 hours. The patient should continue taking the medication regimen while ill. The patient should continue to eat and drink as tolerated but should not exercise while sick.
PTS: 1 DIF: Cognitive Level: Understanding KEY: Diabetes mellitus | hyperglycemia
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse assesses patients who have endocrine disorders. Which assessment findings are paired correctly with the endocrine disorder? (Select all that apply.)
a. Excessive thyroid-stimulating hormone—increased bone formation
b. Excessive melanocyte-stimulating hormone—darkening of the skin
c. Excessive parathyroid hormone—synthesis and release of corticosteroids
d. Excessive antidiuretic hormone—increased urinary output
e. Excessive adrenocorticotropic hormone—increased bone resorption
ANS: A, B
Thyroid-stimulating hormone targets thyroid tissue and stimulates the formation of bone. Melanocyte-stimulating hormone stimulates melanocytes and promotes pigmentation or the darkening of the skin. Parathyroid hormone stimulates bone resorption. Antidiuretic hormone targets the kidney and promotes water reabsorption, causing a decrease in urinary output. Adrenocorticotropic hormone targets the adrenal cortex and stimulates the synthesis and release of corticosteroids.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Endocrine system | assessment/diagnostic examination
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse teaches a patient with Cushing’s disease. Which dietary requirements would the nurse include in this patient’s teaching? (Select all that apply.)
a. Low calcium
b. Low carbohydrate
c. Low protein
d. Low calories
e. Low sodium
ANS: B, D, E
The patient with Cushing’s disease has weight gain, muscle loss, hyperglycemia, and sodium retention. Dietary modifications need to include reduction of carbohydrates and total calories to prevent or reduce the degree of hyperglycemia. Sodium retention causes water retention and hypertension. Patients are encouraged to restrict their sodium intake moderately. Patients often have bone density loss and need more calcium. Increased protein intake will help decrease muscle loss.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Adrenal gland disorder | laboratory values
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Physiological Integrity: Basic Care and Comfort
A nurse cares for a patient who is prescribed vasopressin (DDAVP) for diabetes insipidus. Which assessment findings indicate a therapeutic response to this therapy? (Select all that apply.)
a. Urine output is increased.
b. Urine output is decreased.
c. Specific gravity is increased.
d. Specific gravity is decreased.
e. Urine osmolality is increased.
f. Urine osmolality is decreased.
ANS: B, C, E
Diabetes insipidus causes urine output to be greatly increased, with a low urine osmolality, as evidenced by a low specific gravity. Effective treatment results in decreased urine output that is more concentrated, as evidenced by an increased specific gravity and increased osmolality.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Pituitary disorder | laboratory values
MSC: Integrated Process: Nursing Process/Evaluation
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse assesses a patient who is experiencing diabetic ketoacidosis (DKA). For which manifestations would the nurse monitor the patient? (Select all that apply.)
a. Deep and fast respirations
b. Decreased urine output
c. Tachycardia
d. Dependent pulmonary crackles
e. Orthostatic hypotension
ANS: A, C, E
DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually, patients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur.
PTS: 1 DIF: Cognitive Level: Applying KEY: Diabetes mellitus | hyperglycemia
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse provides diabetic education at a public health fair. Which disorders would the nurse include as complications of diabetes mellitus? (Select all that apply.)
a. Stroke
b. Kidney failure
c. Blindness
d. Respiratory failure
e. Cirrhosis
ANS: A, B, C
Complications of diabetes mellitus are caused by macrovascular and microvascular changes. Macrovascular complications include coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Microvascular complications include nephropathy, retinopathy, and neuropathy. Respiratory failure and cirrhosis are not complications of diabetes mellitus.
PTS: 1 DIF: Cognitive Level: Understanding KEY: Diabetes mellitus | health screening
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse assesses a patient who potentially has hyperaldosteronism. Which serum laboratory values would the nurse associate with this disorder? (Select all that apply.)
a. Sodium: 150 mEq/L (150 mmol/L)
b. Sodium: 130 mEq/L (130 mmol/L)
c. Potassium: 2.5 mEq/L (2.5 mmol/L)
d. Potassium: 5.0 mEq/L (5.0 mmol/L)
e. pH 7.28
f. pH 7.50
ANS: A, C, F
Aldosterone increases reabsorption of sodium and excretion of potassium. Hyperaldosteronism causes hypernatremia, hypokalemia, and metabolic alkalosis. Hyponatremia, hyperkalemia, and acidosis are manifestations of adrenal insufficiency.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Adrenal gland disorder | laboratory values
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential