MSN Endocrine Quiz 1

1. A clinic nurse is evaluating a client with type 1 diabetes who intends to enroll in a tennis class. Which statement made by the client indicates that the client understands the effects of exercise on insulin demand?

“I will carry a high-fat, high-calorie food, such as a cookie.”

“I will administer 1 unit of lispro insulin prior to playing tennis.”

“I will eat a 15-gram carbohydrate snack before playing tennis.”

“I will decrease the meal prior to the class by 15-grams of carbohydrates.”

Excessive exercise without sufficient carbohydrates can result in unexpected hypoglycemia. The food should be a simple sugar food because the fat content of a high-fat food will delay the absorption of the glucose in the food. Taking insulin or decreasing the carbohydrate intake prior to activity will lower the blood glucose level such that hypoglycemia can occur.

Explanation

Excessive exercise without sufficient carbohydrates can result in unexpected hypoglycemia. The food should be a simple sugar food because the fat content of a high-fat food will delay the absorption of the glucose in the food. Taking insulin or decreasing the carbohydrate intake prior to activity will lower the blood glucose level such that hypoglycemia can occur.

2. Two hours after taking a regular morning dose of Insulin Regular (Humulin R®), a client presents to a clinic with diaphoresis, tremors, palpitations, and tachycardia. Which nursing action is most appropriate for this client?

Check pulse oximetry and administer oxygen at 2 L per nasal cannula.

Administer a baby aspirin, one sublingual nitroglycerin tablet, and obtain an electrocardiogram (ECG).

Check blood glucose level and provide carbohydrates if less than 70 mg/dL (3.8 mmol/L).

Check vital signs and administer atenolol (Tenormin®) 25 mg orally if heart rate is greater than 120 beats per minute.

Humulin R is regular insulin that peaks in 2 to 4 hours after administration. The client’s symptoms suggest hypoglycemia, so a blood glucose level should be checked. The symptoms do not suggest a respiratory problem (option 1). Though diaphoresis, palpitations, and tachycardia are symptoms of both hypoglycemia and cardiac problems, the client had taken insulin 2 hours earlier. Treating the low blood sugar first will likely

resolve the client’s symptoms.

Explanation

Humulin R is regular insulin that peaks in 2 to 4 hours after administration. The client’s symptoms suggest hypoglycemia, so a blood glucose level should be checked. The symptoms do not suggest a respiratory problem (option 1). Though diaphoresis, palpitations, and tachycardia are symptoms of both hypoglycemia and cardiac problems, the client had taken insulin 2 hours earlier. Treating the low blood sugar first will likely

resolve the client’s symptoms.

3. A nurse is caring for a client with type 2 diabeteson a telemetry unit. The client is scheduled for cardiac rehabilitation exercises (cardiac rehab). The nurse notes that the client's blood glucose level is 300 mg/dL and the urine is positive for ketones. Which nursing action should be included in the nurse's plan of care?

Send the client to cardiac rehab because exercise will lower the client’s blood glucose level.

Administer insulin and then send the client tocardiac rehab with a 15-gram carbohydrate snack.

Delay the cardiac rehab because blood glucose levels will decrease too much with exercise.

Cancel the cardiac rehab because blood glucose levels will increase further with exercise.

Exercising with blood glucose levels exceeding 250 mg/dL and ketonuria increases the secretion of glucagon, growth hormone, and catecholamines, causing the liver to release more glucose. Exercise in the

presence of hyperglycemia does not lower the blood glucose level (options 1 and 3). Administering insulin may be an option, but the blood glucose level should be known before sending the client to cardiac rehab (option 2).

Explanation

Exercising with blood glucose levels exceeding 250 mg/dL and ketonuria increases the secretion of glucagon, growth hormone, and catecholamines, causing the liver to release more glucose. Exercise in the

presence of hyperglycemia does not lower the blood glucose level (options 1 and 3). Administering insulin may be an option, but the blood glucose level should be known before sending the client to cardiac rehab (option 2).

4. A nurse administers 15 units of glargine (Lantus®) insulin at 2100 hours to a Hispanic client when the client's fingerstick blood glucose reading was 110 mg/dL. At 2300 hours, a nursing assistant reports to the nurse that an evening snack was not given because the client was sleeping. Which instruction by the nurse is most appropriate?

“The next time the client wakes up, check a blood glucose level and then give a snack.”

The onset of glargine is 1 hour, it has no peak, and it lasts for 24 hours. Glargine lowers the blood glucose by increasing transport into cells and promoting the conversion of glucose to glycogen. Because it is peakless, a bedtime snack is unnecessary. Options 1 and 3 are unnecessary and option 4 is incorrect. Glargine is administered once daily, the same time each day, to maintain relatively constant concentrations over 24 hours.

Explanation

The onset of glargine is 1 hour, it has no peak, and it lasts for 24 hours. Glargine lowers the blood glucose by increasing transport into cells and promoting the conversion of glucose to glycogen. Because it is peakless, a bedtime snack is unnecessary. Options 1 and 3 are unnecessary and option 4 is incorrect. Glargine is administered once daily, the same time each day, to maintain relatively constant concentrations over 24 hours.

5. A nurse is teaching a client who has been newly diagnosed with type 2 diabetes mellitus (DM). Which teaching point should the nurse emphasize?

Use the arm when self-administering NPH insulin.

Exercise for 30 minutes daily, preferably after a meal.

Consume 30% of the daily calorie intake from protein foods.

Eat a 30-gram carbohydrate snack prior to strenuous activity.

Exercise increases insulin receptor sites in the tissue and can have a direct effect on lowering blood glucose levels. Exercise also contributes to weight loss, which also decreases insulin resistance. Usually type 2 DM is controlled with oral hypoglycemic agents. If insulin is needed, sites should be rotated. For those with DM, protein should contribute less than 10% of the total energy consumed. Strenuous activity can be perceived by the body as a stressor, causing a release of counterregulatory hormones that subsequently increases blood glucose. Hyperglycemia can result from the combination of strenuous activity and extra carbohydrates.

Explanation

Exercise increases insulin receptor sites in the tissue and can have a direct effect on lowering blood glucose levels. Exercise also contributes to weight loss, which also decreases insulin resistance. Usually type 2 DM is controlled with oral hypoglycemic agents. If insulin is needed, sites should be rotated. For those with DM, protein should contribute less than 10% of the total energy consumed. Strenuous activity can be perceived by the body as a stressor, causing a release of counterregulatory hormones that subsequently increases blood glucose. Hyperglycemia can result from the combination of strenuous activity and extra carbohydrates.

6. A nurse is evaluating a client's outcome. The client's nursing care plan includes the nursing diagnosis of fluid volume deficit related to hyperosmolar hyperglycemic nonketotic syndrome (HHNS) secondary to severe hyperglycemia. The nurse knows that the client has a positive outcome when which serum laboratory value has decreased to a normal range?

Glucose

Sodium

Osmolality

Potassium

Extreme hyperglycemia produces severe osmotic diuresis; loss of sodium, potassium, and phosphorous; and profound dehydration. Consequently, hyperosmolality occurs. A normalizing of the serum osmolality indicates that the fluid volume deficit is resolving. A decrease in serum glucose indicates that the hyperglycemia is resolving, but not the fluid volume deficit. Serum sodium and potassium values should increase, not decrease, with treatment.

Explanation

Extreme hyperglycemia produces severe osmotic diuresis; loss of sodium, potassium, and phosphorous; and profound dehydration. Consequently, hyperosmolality occurs. A normalizing of the serum osmolality indicates that the fluid volume deficit is resolving. A decrease in serum glucose indicates that the hyperglycemia is resolving, but not the fluid volume deficit. Serum sodium and potassium values should increase, not decrease, with treatment.

7. A client with type 1 diabetes mellitus is scheduled for a total hip replacement. In reviewing the client's orders the evening prior to surgery, a nurse notes that the physician did not write an order to change the client's daily insulin dose. Which nursing action is most appropriate?

Notify the physician who wrote the insulin order in the client’s medical record.

Write an order to decrease the morning insulin dose by one-half of the prescribed morning dose.

Do nothing because the physician would want the client to receive the usual insulin dose prior to surgery.

Inform the day shift nurse to check the client’s fingerstick glucose before surgery and hold the morning dose of insulin.

nurse must ensure that the usual insulin dosage has been changed to prevent hypoglycemia. The change may include eliminating the rapidacting insulin and giving a decreased amount of intermediate-acting NPH or Lente insulin. A registered nurse is unable to prescribe medications. The nurse could write the order based on standing orders, but this is not noted in the option. Doing nothing could cause a hypoglycemic reaction because the client will be NPO for surgery. Holding the morning dose of insulin can cause hyperglycemia leading to diabetic ketoacidosis. Even without food, glucose levels increase from hepatic glucose production. Clients with type 1 diabetes require insulin 24 hours a day.

Explanation

nurse must ensure that the usual insulin dosage has been changed to prevent hypoglycemia. The change may include eliminating the rapidacting insulin and giving a decreased amount of intermediate-acting NPH or Lente insulin. A registered nurse is unable to prescribe medications. The nurse could write the order based on standing orders, but this is not noted in the option. Doing nothing could cause a hypoglycemic reaction because the client will be NPO for surgery. Holding the morning dose of insulin can cause hyperglycemia leading to diabetic ketoacidosis. Even without food, glucose levels increase from hepatic glucose production. Clients with type 1 diabetes require insulin 24 hours a day.

8. A nurse administers a usual morning dose of 4 units of regular insulin and 8 units of NPH insulin at 7:30 a.m. to a client with a blood glucose level of 110 mg/dL. Which statements regarding the client's insulin are correct?

The onset of the regular insulin will be at 7:45 a.m. and the peak at 1:00 p.m.

The onset of the regular insulin will be at 8:00 a.m. and the peak at 10:00 a.m.

The onset of the NPH insulin will be at 8:00 a.m. and the peak at 10:00 a.m.

The onset of the NPH insulin will be at 12:30 p.m. and the peak at 11:30 p.m.

The onset of regular insulin (short-acting) is one-half to 1 hour, and the peak is 2 to 3 hours. The onset of NPH insulin (intermediate acting) is 2 to 4 hours, and the peak is 4 to 12 hours. All other options have incorrect medication onset and peak times.

Explanation

The onset of regular insulin (short-acting) is one-half to 1 hour, and the peak is 2 to 3 hours. The onset of NPH insulin (intermediate acting) is 2 to 4 hours, and the peak is 4 to 12 hours. All other options have incorrect medication onset and peak times.

9. A friend brings an older adult homeless client to a free health-screening clinic because the friend is unable to continue administering the client's morning and evening insulin for type 1 diabetes mellitus. When advocating for this client, which action by the nurse is most appropriate?

Notify Adult Protective Services about the client’s condition and living situation.

Ask where the client lives and if someone else can administer the insulin.

Contact the unit social worker to arrange for someone to give the client’s insulin at a local homeless shelter.

Have the client return to the screening clinic mornings and evenings to receive the insulin injections.

In DKA, the blood glucose level is above 300 mg/dL. Additional glucose will only increase the glucose level. Initially 0.45% or 0.9% sodium chloride (NaCl) is administered for fluid resuscitation. Glucose may be added when blood glucose levels approach 250 mg/dL. Insulin will drive potassium into the cells, so potassium chloride (KCL) is administered to prevent life-threatening hypokalemia. Normal pH is 7.35 to 7.45. Sodium bicarbonate will reverse the severe acidosis. Intravenous (IV) insulin will correct the hyperglycemia and hyperketonemia. Tight glucose control can be maintained by hourly glucose checks and adjusting the insulin infusion dose.

Explanation

In DKA, the blood glucose level is above 300 mg/dL. Additional glucose will only increase the glucose level. Initially 0.45% or 0.9% sodium chloride (NaCl) is administered for fluid resuscitation. Glucose may be added when blood glucose levels approach 250 mg/dL. Insulin will drive potassium into the cells, so potassium chloride (KCL) is administered to prevent life-threatening hypokalemia. Normal pH is 7.35 to 7.45. Sodium bicarbonate will reverse the severe acidosis. Intravenous (IV) insulin will correct the hyperglycemia and hyperketonemia. Tight glucose control can be maintained by hourly glucose checks and adjusting the insulin infusion dose.

10. A nurse evaluates a client who is being treated for diabetic ketoacidosis (DKA). Which finding indicates that the client is responding to the treatment plan?

Eyes sunken, skin flushed

Skin moist with rapid elastic recoil

Serum potassium level is 3.3 mEq/L

ABG results are pH 7.25, PaCO2 30, HCO3 17

Moist skin and good skin turgor indicate that dehydration secondary to hyperglycemia is resolving. Sunken eyes and flushing are signs of dehydration. Normal serum potassium levels are 3.5 to 5.8 mEq/L. The abnormal ABGs indicate compensating metabolic acidosis.

Explanation

Moist skin and good skin turgor indicate that dehydration secondary to hyperglycemia is resolving. Sunken eyes and flushing are signs of dehydration. Normal serum potassium levels are 3.5 to 5.8 mEq/L. The abnormal ABGs indicate compensating metabolic acidosis.

11. A nurse is documenting nursing diagnoses for a client with elevated growth hormone (GH) levels. Which nursing diagnosis is least likely to be included in the client's plan of care?

Fluid volume deficit related to polyuria

Insomnia related to soft tissue swelling

Impaired communication related to speech difficulties

Disturbed body image related to undersized hands, feet, jaw, and soft body tissue

GH excess causes overgrowth of the bones and soft tissues, resulting in a disturbance in body image. GH excess antagonizes the action of insulin causing hyperglycemia. Thus manifestations of diabetes mellitus occur: polyuria, polydipsia, and polyphagia. Sleep apnea occurs from upper airway narrowing and obstruction from increased amounts of pharyngeal tissue. Enlargement of the tongue may also result in speech difficulties.

Explanation

GH excess causes overgrowth of the bones and soft tissues, resulting in a disturbance in body image. GH excess antagonizes the action of insulin causing hyperglycemia. Thus manifestations of diabetes mellitus occur: polyuria, polydipsia, and polyphagia. Sleep apnea occurs from upper airway narrowing and obstruction from increased amounts of pharyngeal tissue. Enlargement of the tongue may also result in speech difficulties.

12. A client has developed syndrome of inappropriate antidiuretic hormone (SIADH) secondary to a pituitary tumor. The client's symptoms include thirst, weight gain, and fatigue. The client's serum sodium is 127 mEq/L. Which physician order should the nurse anticipate when treating SIADH?

Elevate the head of the bed

Administer vasopressin intravenously (IV)

Fluid restriction of 800 to 1,000 mL per day

0.3% sodium chloride IV infusion

If symptoms are mild and serum sodium is greater than 125 mEq/L (125 mmol/L), treatment includes the restriction of fluid to 800 to 1,000 mL per day and discontinuation of medications that stimulate the release of antidiuretic hormone (ADH). The fluid restriction should result in a progressive rise in serum sodium concentration and osmolality and symptomatic improvement. Normal serum sodium levels are 136 to 146 mEq/L. The bed should be positioned flat or with no more than 10 degrees of elevation to enhance venous return to the heart and increase left atrial filling pressure, reducing ADH release. Vasopressin is an antidiuretic hormone, thus it will aggravate the client’s problem. Hypertonic saline (3% to 5%) should be administered if the hyponatremia is severe (less than 120 mEq/L). Hypertonic solutions cause fluid to be drawn into the vascular system.

Explanation

If symptoms are mild and serum sodium is greater than 125 mEq/L (125 mmol/L), treatment includes the restriction of fluid to 800 to 1,000 mL per day and discontinuation of medications that stimulate the release of antidiuretic hormone (ADH). The fluid restriction should result in a progressive rise in serum sodium concentration and osmolality and symptomatic improvement. Normal serum sodium levels are 136 to 146 mEq/L. The bed should be positioned flat or with no more than 10 degrees of elevation to enhance venous return to the heart and increase left atrial filling pressure, reducing ADH release. Vasopressin is an antidiuretic hormone, thus it will aggravate the client’s problem. Hypertonic saline (3% to 5%) should be administered if the hyponatremia is severe (less than 120 mEq/L). Hypertonic solutions cause fluid to be drawn into the vascular system.

13. Which finding should the nurse anticipate when assessing a client newly diagnosed with diabetes insipidus (DI)?

Polyuria

Weight gain

Hyperglycemia

Profuse sweating and flushed skin

DI is associated with decreased production or secretion of antidiuretic hormone (ADH). This causes increased urine output and increased plasma osmolality. Weight loss is secondary to polyuria. Hyperglycemia is associated with diabetes mellitus, not DI. Profuse sweating and flushed skin are associated with hyperthyroidism.

Explanation

DI is associated with decreased production or secretion of antidiuretic hormone (ADH). This causes increased urine output and increased plasma osmolality. Weight loss is secondary to polyuria. Hyperglycemia is associated with diabetes mellitus, not DI. Profuse sweating and flushed skin are associated with hyperthyroidism.

14. An agitated client is admitted to the emergency department (ED) with tachycardia, dyspnea, and intermittent chest palpitations. The client has a blood pressure of 170/110 mm Hg and heart rate of 130 beats per minute. The client's health history reveals thinning hair, recent 10-lb. weight loss, increased appetite, fine hand and tongue tremors, hyperreflexic tendon reflexes, and smooth moist skin. A physician writes orders for the client. Which order should the nurse implement first?

Obtain 12-lead electrocardiogram (ECG).

Administer propranolol (Inderal®) 2 mg intravenously q10–15min or until symptoms are controlled.

Administer propylthiouracil (PTU) 600 mg oral loading dose followed by 200 mg orally q4h.

Obtain thyroid-stimulating hormone (TSH), free T4, and cardiac enzyme levels.

The nurse should first administer propranolol as ordered by the physician. Propranolol is a beta-adrenergic blocker for symptomatic relief of thyrotoxicosis and decreasing peripheral conversion of T4 to T3. It controls cardiac and psychomotor manifestations within minutes. A beta blocker is also a first-line treatment for a client with acute coronary syndrome. Dysrhythmias can occur from beta-adrenergic receptor stimulation caused by excess thyroid hormone or following an acute coronary syndrome. PTU will inhibit the synthesis of thyroid hormone. Clinical effects may be seen as soon as 1 hour after administration. Decreased TSH and elevated free T4 confirm the diagnosis of hyperthyroidism. Elevated cardiac enzymes confirm the diagnosis of acute coronary syndrome.

Explanation

The nurse should first administer propranolol as ordered by the physician. Propranolol is a beta-adrenergic blocker for symptomatic relief of thyrotoxicosis and decreasing peripheral conversion of T4 to T3. It controls cardiac and psychomotor manifestations within minutes. A beta blocker is also a first-line treatment for a client with acute coronary syndrome. Dysrhythmias can occur from beta-adrenergic receptor stimulation caused by excess thyroid hormone or following an acute coronary syndrome. PTU will inhibit the synthesis of thyroid hormone. Clinical effects may be seen as soon as 1 hour after administration. Decreased TSH and elevated free T4 confirm the diagnosis of hyperthyroidism. Elevated cardiac enzymes confirm the diagnosis of acute coronary syndrome.

15. Which nursing diagnosis should a nurse include when developing a plan of care for a client with hypothyroidism?

Diarrhea related to gastrointestinal hypermotility

Imbalance nutrition: less than body requirements related to calorie intake insufficient for metabolic rate

Activity intolerance related to increased metabolic rate

Anxiety related to forgetfulness, slowed speech, and impaired memory loss

Disturbed thought processes can cause the client to be anxious. Diarrhea, imbalance nutrition related to insufficient calories, and activity intolerance related to increased metabolic rate are nursing diagnoses appropriate for hyperthyroidism.

Explanation

Disturbed thought processes can cause the client to be anxious. Diarrhea, imbalance nutrition related to insufficient calories, and activity intolerance related to increased metabolic rate are nursing diagnoses appropriate for hyperthyroidism.