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44: Endocrine System
PRACTICE QUESTIONS
1. A nurse is caring for a client following hypophysectomy. The nurse notices clear nasal drainage from the client’s nostril. The appropriate nursing action would be to: 1. Continue to observe drainage. 2. Test the drainage for glucose. 3. Lower the head of the bed. 4. Obtain a culture of the drainage. Answer: 2 Rationale: Following hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid (CSF) leak. If this occurs, the drainage should be collected and tested for the presence of CSF. The head of the bed should not be lowered to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication. Test-Taking Strategy: Use the process of elimination. Option 3 can be eliminated first. Option 4 can be eliminated because the drainage is clear. Because an action is required, eliminate option 1. Review the complications following hypophysectomy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1234. Linton, A. & Maebius, N. (2003) Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 861. 2. Following several diagnostic tests, a client is diagnosed with diabetes insipidus. The nurse understands that which symptom is indicative of this disorder? 1. Diarrhea 2. Polydipsia 3. Weight gain 4. Fatigue Answer: 2 Rationale: Polydipsia and polyuria are classic symptoms of diabetes insipidus. The urine is pale in color and its specific gravity is low. Anorexia and weight loss occur. Test-Taking Strategy: Use the process of elimination. Eliminate option 4 first because this symptom is rather vague and occurs in many conditions. Knowledge of the manifestations of diabetes insipidus will assist in eliminating options 1 and 3. If you had difficulty with this question, review the clinical manifestations associated with diabetes insipidus. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection

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Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 864. 3. A nurse caring for a client with Addison’s disease would expect to note which of the following? 1. Obesity 2. Edema 3. Hypotension 4. Hirsutism Answer: 3 Rationale: Common manifestations of Addison’s disease include postural hypotension from fluid loss, syncope, muscle weakness, anorexia, nausea and vomiting, abdominal cramps, weight loss, depression, and irritability. Test-Taking Strategy: Knowledge regarding the clinical manifestations associated with Addison’s disease is required to answer this question. Remember that hypotension occurs in Addison’s disease. If you had difficulty with this question, review this endocrine disorder. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 870. 4. A client with Cushing’s syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. The nurse makes which statement to the client? 1. “This is permanent, but looks are deceiving and not that important.” 2. “Don’t be concerned; this problem can be covered with clothing.” 3. “Try not to worry about it. There are other things to be concerned about.” 4. “Usually, these physical changes slowly improve following treatment.” Answer: 4 Rationale: The client with Cushing’s syndrome should be reassured that most physical changes resolve with treatment. Options 1, 2, and 3 are not therapeutic responses. Test-Taking Strategy: Use knowledge regarding the physical changes that occur in Cushing’s syndrome and therapeutic communication techniques to answer this question. Options 1, 2, and 3 are not therapeutic responses to a client. Review this disorder and therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 876. 5. A nurse assists in developing a plan of care for a client with Graves’ disease. Which of the

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following would the nurse include in the plan of care? 1. Provide three small meals a day. 2. Provide the client with extra blankets. 3. Provide a high-fiber diet. 4. Provide a restful environment. Answer: 4 Rationale: Because of the hypermetabolic state, the client with Graves’ disease needs to be provided with an environment that is restful both physically and mentally. Six full meals a day that are well balanced and high in calories are required because of the accelerated metabolic rate. Foods that increase peristalsis, such as high-fiber foods, need to be avoided. These clients suffer from heat intolerance and require a cool environment. Test-Taking Strategy: The key concept to bear in mind when answering this question is that clients with Graves’ disease experience an accelerated metabolic rate. This concept should assist in eliminating options 1, 2, and 3. Review care of the client with Graves’ disease if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 883; 890. 6. A nurse is caring for a client following thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to: 1. Treat thyroid storm. 2. Prevent cardiac irritability. 3. Stimulate the release of parathyroid hormone. 4. Treat hypocalcemic tetany. Answer: 4 Rationale: Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips or toes, muscle spasms, or twitching, the physician is notified immediately. Calcium gluconate should be kept at the bedside. Test-Taking Strategy: Noting the name of the medication (calcium gluconate) should easily direct you to option 4. Calcium is given if hypocalcemic tetany occurs. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 886. 7. A nurse is collecting data on the client following a thyroidectomy and notes that the client has

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developed hoarseness and a weak voice. Which of the following nursing actions is appropriate? 1. Notify the physician immediately. 2. Reassure the client that this is usually a temporary condition. 3. Check for signs of bleeding. 4. Administer calcium gluconate. Answer: 2 Rationale: Weakness and hoarseness of the voice can occur as a result of trauma of the laryngeal nerve. If this develops, the client should be reassured that the problem will subside in a few days. Unnecessary talking should be discouraged. It is not necessary to notify the physician. These signs do not indicate bleeding or the need to administer calcium gluconate. Test-Taking Strategy: Use the process of elimination. Options 3 and 4 can easily be eliminated, because they are unrelated to the signs presented in the question. There are data presented requiring physician notification. Review the expected findings following thyroidectomy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1203. 8. A client is admitted to the emergency room and a diagnosis of myxedema coma is made. Which nursing action would the nurse prepare to carry out initially? 1. Warm the client. 2. Administer fluids. 3. Maintain a patent airway. 4. Administer thyroid hormone. Answer: 3 Rationale: The initial nursing action would be to maintain a patent airway. Oxygen would be administered, followed by fluid replacement, keeping the client warm, monitoring vital signs, and administering thyroid hormones. Test-Taking Strategy: Note the key words, carry out initially. All the options are appropriate interventions, but use of the ABCs—airway, breathing, and circulation—will direct you to option 3. Review care of the client with myxedema coma if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1196. 9. A client is taking NPH insulin daily every morning. The nurse instructs the client that the most likely time for a hypoglycemic reaction to occur is: 1. 2 to 4 hours after administration 2. 6 to 14 hours after administration

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3. 16 to 18 hours after administration 4. 18 to 24 hours after administration Answer: 2 Rationale: NPH is an intermediate-acting insulin. The onset of action is 1 to 3 hours, it peaks in 6 to 14 hours, and its duration of action is 20 hours. Hypoglycemic reactions most likely occur during peak time. Test-Taking Strategy: Knowledge regarding the onset, peak, and duration of action for NPH insulin is required to answer this question. Remember, hypoglycemic reactions most likely occur during peak time. Review the characteristics of NPH insulin if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology References: Linton, A., & Maebius, N. (2003) Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 908. McKenry, L. & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 864. 10. A nurse is assisting in preparing a teaching plan for the client with diabetes mellitus regarding proper foot care. Which of the following instructions should be included in the plan? 1. Soak feet in hot water. 2. Apply a moisturizing lotion to dry feet. but not between the toes. 3. Always have a podiatrist cut your toenails; never cut them yourself. 4. Avoid using a mild soap on the feet. Answer: 2 Rationale: The client should use a moisturizing lotion on his or her feet and avoid applying lotion between the toes. The client should also be instructed not to soak the feet and to avoid hot water to prevent burns. The client may cut toenails straight and even with the toe itself, and would consult a podiatrist if the toenails were thick, hard to cut, or if vision is poor. The client should be instructed to wash the feet daily using a mild soap. Test-Taking Strategy: Use the process of elimination. Eliminate option 3 first because of the word “always” and option 1 because of the word “hot.” From the remaining options, recalling the concern related to skin infection will assist in eliminating option 4. Review diabetic foot care instructions if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine References: Linton, A., & Maebius, N. (2003) Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 904. Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 968. 11. A nurse provides dietary instructions to a client with diabetes mellitus regarding the

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prescribed diabetic diet. Which statement, if made by the client, indicates a need for further teaching? 1. “I need to drink diet soft drinks.” 2. “I'll eat a balanced meal plan.” 3. “I need to buy special dietetic foods.” 4. “I'll snack on fruit instead of cake.” Answer: 3 Rationale: It is important to emphasize to the client and family that they are not eating a diabetic diet but rather following a balanced meal plan. Adherence to nutrition principles is an important component of diabetic management, and an individualized meal plan should be developed for the client. It is not necessary for the client to purchase special dietetic foods. Test-Taking Strategy: Note the key words, indicates a need for further teaching. These words indicate a false response question and that you need to select the incorrect client statement. Basic principles related to the diabetic diet will direct you to option 3. Review these principles if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 906. 12. An external insulin pump is prescribed for a client with diabetes mellitus and the client asks the nurse about the functioning of the pump. The nurse plans to base the response on the information that the pump: 1. Gives a small continuous dose of regular insulin subcutaneously, and the client can bolus self with an additional dose from the pump prior to each meal 2. Is timed to release programmed doses of regular or NPH insulin into the bloodstream at specific intervals 3. Is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream 4. Continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels Answer: 1 Rationale: An insulin pump provides a small continuous dose of regular insulin subcutaneously throughout the day and night, and the client can self-administer an additional dose from the pump prior to each meal as needed. Regular insulin is used in an insulin pump. An external pump is not surgically attached to the pancreas. Test-Taking Strategy: Use the process of elimination. Recalling that regular insulin is used in an insulin pump will assist in eliminating options 2 and 4. Careful reading of the question, noting the word “external,” will assist in eliminating option 3. Review the use of the insulin pump if you are unfamiliar with it. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning

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Content Area: Adult Health/Endocrine Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, pp. 1276-1277. 13. A client newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. The nurse assists in preparing a discharge teaching plan regarding the insulin and includes which of the following concepts? 1. Increase the amount of insulin prior to unusual exercise. 2. Acetone in the urine will signify a need for less insulin. 3. Always keep insulin vials refrigerated. 4. Systematically rotate insulin injection sites. Answer: 4 Rationale: Insulin dosages should not be adjusted nor increased prior to unusual exercise. If acetone is found in the urine, it may possibly indicate the need for additional insulin. To minimize the discomfort associated with insulin injections, insulin should be administered at room temperature. Injection sites should be systematically rotated from one area to another. The client should be instructed to give injections in one area, about 1 inch apart, until the whole area has been used, and then change to another site. This prevents dramatic changes in daily insulin absorption. Test-Taking Strategy: Use the process of elimination. Eliminate option 3 first because of the word “always.” Knowledge regarding insulin administration and the significance of acetone in the urine will assist in eliminating options 1 and 2. If you had difficulty with this question, review insulin management. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Planning Content Area: Pharmacology Reference: McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 863. 14. A nurse reinforces teaching with a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that glucose will be taken if which of the following symptoms develop? 1. Fruity breath odor 2. Shakiness 3. Blurred vision 4. Polyuria Answer: 2 Rationale: Shakiness is a sign of hypoglycemia and would indicate the need for food or glucose. A fruity breath odor, blurred vision, and polyuria are signs of hyperglycemia. Test-Taking Strategy: Knowledge regarding the signs and symptoms of hypoglycemia and hyperglycemia is required to answer this question. If you are unfamiliar with these signs, be sure to learn them. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance

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Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 921. 15. A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. The appropriate intervention to decrease the client’s anxiety would be to: 1. Administer a sedative. 2. Make sure the client knows all the correct medical terms so that he or she can understand what is happening. 3. Ignore the signs and symptoms of anxiety so that they will soon disappear. 4. Convey empathy, trust, and respect toward the client. Answer: 4 Rationale: The appropriate intervention is to address the client’s feelings related to the anxiety. Administering a sedative is not the most appropriate intervention. The nurse should not ignore the client’s anxious feelings. A client will not relate to medical terms, particularly when anxiety exists. Test-Taking Strategy: Use therapeutic communication techniques to answer the question. Remember that client’s feelings come first. Keeping this in mind will direct you to option 4. Review these techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Adult Health/Endocrine Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 437-440. 16. A nurse reinforces instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse determines accurate understanding of measures to prevent diabetic ketoacidosis (DKA) when the client says: 1. “I will stop taking my insulin if I’m too sick to eat.” 2. “I will decrease my insulin dose during times of illness.” 3. “I will notify my physician if my blood glucose level is higher than 250 mg/dL.” 4. “I will adjust my insulin dose according to the level of glucose in my urine.” Answer: 3 Rationale: During illness, the client should monitor the blood glucose level and should notify the physician if the level is higher than 250 mg/dL. Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the physician’s advice. Test-Taking Strategy: Use the process of elimination. Note that options 1, 2, and 4 all relate to adjustment of insulin doses. Therefore, eliminate these options. Review diabetic management during illness if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance

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Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 905. 17. A physician prescribes levothyroxine (Synthroid), 0.15 mg orally daily, for a client with hypothyroidism. The nurse prepares to administer this medication: 1. Three times a day in equal doses of 0.5 mg each to ensure consistent serum drug levels 2. In the morning to prevent sleeplessness 3. Only when the client complains of fatigue and cold intolerance 4. At various times of the day to prevent tolerance from occurring Answer: 2 Rationale: Levothyroxine is a synthetic thyroid hormone that increases cellular metabolism. It should be given in the morning in a single dose to prevent sleeplessness and should be given at the same time each day to maintain a drug level. Test-Taking Strategy: Use the process of elimination. Options 1 and 3 can be eliminated, because the nurse cannot change or alter a physician’s order. From the remaining options, use principles related to medication administration to direct you to option 2. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine References: McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, pp. 842-844. Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 903. 18. A nurse is monitoring a client receiving chlorpropamide (Diabinese). The nurse understands that which of the following is an ineffective therapeutic outcome indicating poor glycemic control? 1. A decrease in polyuria 2. A blood glucose level of 110 mg/dL 3. A decrease in polyphagia 4. A glycosylated hemoglobin level of 18% Answer: 4 Rationale: Chlorpropamide is an oral hypoglycemic agent administered to decrease the serum glucose level and the signs and symptoms of hyperglycemia. Therefore, a decrease in both polyuria and polyphagia would indicate a therapeutic response. Laboratory values are also used to assess a client’s response to treatment. A blood glucose level of 110 mg/dL is within normal limits. However, a glycosylated hemoglobin of 18% indicates poor glycemic control. Test-Taking Strategy: Note the key words, ineffective therapeutic outcome. Recalling that chlorpropamide is an oral hypoglycemic agent tells you to look for an option that would indicate hyperglycemia (lack of response to the medication). Options 1 and 3 are similar and are eliminated first. Next, eliminate option 2 because it is a normal blood glucose level. Review this

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medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Endocrine Reference: Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 612. 19. A nurse is monitoring a client newly diagnosed with diabetes mellitus for sign of complications. Which of the following, if exhibited in the client, would indicate hyperglycemia and warrant physician notification? 1. Hypertension 2. Diaphoresis 3. Polyuria 4. Increased pulse rate Answer: 3 Rationale: The classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Options 1, 2, and 4 are not signs of hyperglycemia. Test-Taking Strategy: Focus on the issue, hyperglycemia. Remember the 3 Ps—polyuria, polydipsia, polyphagia. Review the signs of hyperglycemia if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003) Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 900. 20. A nurse is reinforcing instructions with a client with diabetes mellitus recovering from diabetic ketoacidosis (DKA) in measures to prevent a recurrence. The nurse tells the client to: 1. Eat six small meals daily. 2. Receive appropriate follow-up health care. 3. Monitor blood glucose levels frequently. 4. Test urine for ketone levels. Answer: 3 Rationale: Client education following DKA should emphasize the need for home glucose monitoring two to four times per day. It is also important to instruct the client to notify the health care provider when illness occurs. The presence of urinary ketones indicates that DKA has already occurred. The client should eat well-balanced meals with snacks as prescribed. Test-Taking Strategy: Focus on the issue, preventing DKA. Recall that the treatment of DKA focuses on maintenance of an appropriate blood glucose level. Option 1 is not an accurate component of diabetic care. Option 2 will not prevent DKA, and option 4 does not prevent DKA but actually confirms the diagnosis. Review this complication of diabetes mellitus if you had difficulty with this question. Level of Cognitive Ability: Application

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Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 906. 21. A nurse is collecting data from a client with type 2 diabetes mellitus. Which statement by the client indicates an understanding of the medication regimen? 1. “I am taking oral insulin instead of insulin shots.” 2. “The medication that I am taking helps release the insulin I already make.” 3. “By taking these medications, I am able to eat more.” 4. “When I become ill, I need to increase the number of pills I take.” Answer: 2 Rationale: Clients with type 2 diabetes mellitus have decreased or impaired insulin secretion. Oral hypoglycemic agents are given to these clients to facilitate glucose utilization. Insulin injections may be given during times of stress-induced hyperglycemia. Oral insulin is not available or effective because of the breakdown of the insulin by digestion. Test-Taking Strategy: Focus on the issue, type 2 diabetes mellitus. Eliminate option 1 because there is no “oral insulin.” Next, eliminate options 3 and 4 because they are not accepted treatment for diabetes mellitus. Review the treatment for diabetes mellitus if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003) Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 912. 22. A client with type 1 diabetes mellitus is having trouble remembering the type, duration, and onset of the action of insulin and the client’s family members have not been supportive. The nurse should make which statement to the client? 1. “You can’t always depend on your family to help.” 2. “Let me go over the types of insulin with you again.” 3. “It’s not really necessary for you to remember this.” 4. “What is it you don’t understand?” Answer: 2 Rationale: Reinforcement of knowledge and behaviors is vital to the success of the client’s selfcare. Option 1 may devalue a client’s family. Option 3 places the issue on hold, and option 4 requests an explanation by the client. Option 2 clarifies previous information. Test-Taking Strategy: Focus on the data in the question. Use therapeutic communication techniques to answer the question. This will direct you to option 2. Review these techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation

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Content Area: Adult Health/Endocrine Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 437-440. 23. A nurse is doing discharge teaching with a client who has Cushing’s syndrome. Which of the following statements by the client indicate that the instructions related to dietary management were understood? 1. “I am fortunate that I do not need to follow any special diet.” 2. “I will need to limit the amount of protein in my diet.” 3. “I am fortunate that I can eat all the salty foods I enjoy.” 4. “I can eat foods that have a lot of potassium in them.” Answer: 4 Rationale: A diet low in calories, carbohydrates, and sodium, but ample in protein and potassium content, is encouraged for a client with Cushing’s syndrome. Such a diet promotes weight loss, reduction of edema and hypertension, control of hypokalemia, and rebuilding of wasted tissue. Test-Taking Strategy: Note the key words, instructions related to dietary management were understood. Eliminate option 1 because it indicates that no dietary change is necessary. Eliminate option 2 next, because protein is usually only limited with renal disorders. Excess sodium is not healthy in general, so eliminate option 4. Review dietary management of Cushing’s syndrome if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 877. 24. A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia. Which statement by the client indicates an inadequate understanding of NPH insulin and exercise? 1. “The best time for me to exercise is late afternoon.” 2. “The best time for me to exercise is after lunch.” 3. “The best time for me to exercise is after breakfast.” 4. “The best time for me to exercise is before bedtime.” Answer: 1 Rationale: A hypoglycemic reaction may occur in response to increased exercise. Clients should avoid exercise during the peak time of insulin. NPH insulin peaks at 6 to 14 hours; therefore, late afternoon exercise will occur during the peak of the medication. Test-Taking Strategy: Use the process of elimination and note the key words, inadequate understanding. Recalling the peak time of insulin will direct you to option 1. Review the measures to prevent hypoglycemia if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Endocrine

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References: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, pp. 1282-1283. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 913. 25. A nurse is collecting data from an older client who is being admitted to the hospital for a diagnostic workup for primary hyperparathyroidism. The nurse understands that which client complaint would be characteristic of this disorder? 1. Diarrhea 2. Polyuria 3. Polyphagia 4. Weight gain Answer: 2 Rationale: Hypercalcemia is the hallmark of hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis (polyuria). This diuresis lead to dehydration and the client would lose weight. Both options 1 and 3 are gastrointestinal (GI) symptoms but are not associated with the common GI symptoms typical of hyperparathyroidism (nausea, vomiting, anorexia, constipation). Test-Taking Strategy: Use the process of elimination. Note that options 1, 3, and 4 are similar and are all GI symptoms. Review the characteristics of hyperparathyroidism if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 894. 26. A nurse is caring for a postoperative parathyroidectomy client. Which client complaint would indicate that a serious life-threatening complication may be developing that requires immediate notification of the physician? 1. Difficulty voiding 2. Abdominal cramps 3. Laryngeal stridor 4. Mild to moderate incisional pain Answer: 3 Rationale: During the postoperative period, the nurse carefully observes the client for signs of hemorrhage, which cause swelling and compression of adjacent tissue. Laryngeal stridor is a harsh, high-pitched sound heard on inspiration and expiration caused by compression of the trachea leading to respiratory distress. It is an acute emergency situation that requires immediate attention to avoid complete obstruction of the airway. Test-Taking Strategy: Consider the anatomical location of the surgical procedure and use the ABCs—airway, breathing, and circulation—to select the correct option. Options 1, 2, and 4 are usual postoperative problems that are not life-threatening. Option 3 addresses the airway. Review care of the client following parathyroidectomy if you had difficulty with this question.

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Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1213. 27. A nurse is preparing to discharge a client who has had a parathyroidectomy. The nurse teaches the client about the prescribed oral calcium supplements and tells the client to: 1. Store the calcium in the refrigerator to maintain potency. 2. Check the pulse daily, and not to take the calcium if it is below 60 beats per minute. 3. Take the calcium 30 to 60 minutes following a meal. 4. Avoid sunlight because it can cause skin color change. Answer: 3 Rationale: Oral calcium supplements need to be taken 30 to 60 minutes after meals to enhance their absorption and decrease gastrointestinal irritation. All the other options are unrelated to oral calcium therapy. Test-Taking Strategy: Knowledge regarding the administration of calcium is required to answer this question. Eliminate those options that seem unusual. Checking the pulse is usually done for cardiac medications. Avoidance of sunlight and refrigeration of tablets are required for some medications, but is not a common intervention. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Endocrine Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 155. 28. A nurse notes that a client with type 1 diabetes mellitus has lipodystrophy on both upper thighs. The nurse would most appropriately inquire if the client: 1. Cleanses the skin with alcohol before each injection 2. Rotates sites for injection 3. Aspirates for blood prior to injection into the subcutaneous tissue 4. Administers the insulin at a 45-degree angle Answer: 2 Rationale: Lipodystrophy (hypertrophy of subcutaneous tissue at the injection site) occurs in some diabetic clients when the same injection sites are used for prolonged periods of time. Thus, clients are instructed to adhere to a rotating injection site plan to avoid tissue changes. Cleansing with alcohol, aspiration, and angle of insulin administration does not produce tissue damage. Test-Taking Strategy: Recalling the definition of lipodystrophy will direct you to the correct option. If you are unfamiliar with this complication of insulin therapy, review this component of diabetic teaching. Level of Cognitive Ability: Application Client Needs: Physiological Integrity

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Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 910. 29. A nurse is caring for a client with type 1 diabetes mellitus. Which of the following client complaints would alert the nurse of a possible hypoglycemic reaction? 1. Hot, dry skin 2. Muscle cramps 3. Anorexia 4. Tremors Answer: 4 Rationale: Decreased blood glucose levels produce automatic nervous system symptoms, which are classically manifested as nervousness, irritability, and tremors. Option 1 is more likely to occur with hyperglycemia. Options 2 and 3 are unrelated to the signs of hypoglycemia. Test-Taking Strategy: Focus on the issue, a hypoglycemic reaction. Recalling the signs associated with this reaction will direct you to option 4. Review this complication if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 921. 30. A male client with type 1 diabetes mellitus tells the nurse that he might lose his job because he has been having frequent hypoglycemic reactions. When these reactions occur, his boss thinks that he is drunk and has been drinking on the job. Which action by the nurse would best assist this client to meet his needs? 1. Contact the local employment office to help him find another job. 2. Ask the client if he indeed has been drinking at work. 3. Examine factors that may be causing frequent hypoglycemic episodes. 4. Ask the client what he does to treat his hypoglycemia. Answer: 3 Rationale: Hypoglycemic reactions present adrenergic symptoms of tremor, shakiness, and nervousness, which are similar to those of alcohol intoxication. The best action to deal with this client’s psychosocial need is to identify and then eliminate those factors that precipitate these types of reactions. Option 1 presumes that the problem is unavoidable and thus the client is at fault. Option 2 is nontherapeutic, because it presumes that the client may be drinking, and option 4 avoids the psychosocial aspects of the client’s problem. Test-Taking Strategy: Use the process of elimination. Note the relationship between the issue, “hypoglycemic reactions,” and option 3. Review the psychosocial issues related to the complications of diabetes mellitus if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity

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Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 921-922. 31. A nurse needs to maintain food and fluid intake to minimize the risk of dehydration in an older client with diabetes mellitus who has gastroenteritis. An appropriate nursing intervention to perform is to: 1. Offer water only until the client is able to tolerate solid foods. 2. Withhold all fluids until vomiting has ceased for at least 4 hours. 3. Encourage the client to take 8 to 12 ounces of fluid every hour while awake. 4. Maintain a clear liquid diet for at least 5 days before advancing the diet to allow inflammation of the bowel to dissipate. Answer: 3 Rationale: Fluids containing both glucose and electrolytes should be offered to the client every hour. Small amounts of fluid may be tolerated, even when vomiting is present. Water alone is insufficient. Withholding all fluids is inappropriate. A clear liquid diet for 5 days is inappropriate. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 because of the words “only” and “all.” The time frame in option 4 seems unreasonable; therefore, select option 2. Review care of the diabetic client during illness if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1286. 32. A client who is currently taking levothyroxine (Synthroid) complains of cold intolerance, constipation, dry skin, weight gain, and puffy eyes. Based on these findings, the nurse would anticipate which of the following physician prescriptions? 1. Increased levothyroxine dosage after checking the T4 level 2. Decreased levothyroxine dosage after checking the T4 level 3. Discontinue the levothyroxine, because the client is having an adverse reaction 4. No change in medication dosage, because these are common side effects that will diminish with time Answer: 1 Rationale: Manifestations of hypothyroidism include cold intolerance, constipation, loss of initiative, thick dry skin, a notably puffy appearance of the skin around the eyes, slowed intellectual function, including retarded speech and apathy, and a low metabolic rate. Levothyroxine is used to correct hypothyroidism. In this situation, the dosage is subtherapeutic and needs to be increased. Test-Taking Strategy: Note the key words, currently taking levothyroxine. Recalling that the signs presented in the question relate to the manifestations associated with hypothyroidism will

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direct you to option 1. Review this medication and the signs of hypothyroidism if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, pp. 840-841. 33. A nurse is caring for a client with diabetes insipidus receiving vasopressin (Pitressin). The nurse understands that which of the following is a therapeutic effect of this medication? 1. Decreased gastrointestinal tract smooth muscle tone and contractions 2. Decreased urine output 3. Decreased reabsorption of water by the renal tubules 4. Vasodilation of vascular vessels Answer: 2 Rationale: Vasopressin, an antidiuretic hormone, causes increased gastrointestinal smooth muscle tone and contractions, increased reabsorption of water by the renal tubules, and vasoconstriction with reduced blood flow in coronary, peripheral, cerebral, and pulmonary vessels. Test-Taking Strategy: Note the key word, therapeutic, in the stem of the question. Recalling the pathophysiology related to diabetes insipidus and the associated clinical manifestations will direct you to the correct option. If you had difficulty with this question, review this disorder. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Endocrine Reference: McKenry, L., & Salerno, E. (2003). Mosby’s pharmacology in nursing (21st ed.). St. Louis: Mosby, p. 833. 34. A client is diagnosed with pheochromocytoma. The nurse helping to prepare a nursing care plan for the client understands that pheochromocytoma is a condition that: 1. Causes profound hypotension 2. Causes the release of excessive amounts of catecholamines 3. Is not a curable condition and is treated symptomatically 4. Is manifested by severe hypoglycemia Answer: 2 Rationale: Pheochromocytoma is a catecholamine-producing tumor and causes secretion of excessive amounts of epinephrine and norepinephrine. Hypertension is the principal manifestation, and the client has episodes of a high blood pressure accompanied by pounding headaches. The excessive release of catecholamine also results in excessive conversion of glycogen into glucose in the liver. Consequently, hyperglycemia and glucosuria occur during attacks. Pheochromocytoma is curable. The primary treatment is surgical removal of one or both of the adrenal glands, depending on whether the tumor is unilateral or bilateral. Test-Taking Strategy: Knowledge regarding the pathophysiology associated with

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pheochromocytoma is required to answer this question. Remember pheochromocytoma is a catecholamine-producing tumor and causes secretion of excessive amounts of epinephrine and norepinephrine. Review this disorder if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Endocrine Reference: Linton, A.. & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 877. 35. A nurse is collecting data on a client admitted to the hospital with a diagnosis of pheochromocytoma. The nurse observes for the major symptom associated with pheochromocytoma when the nurse: 1. Tests the client’s urine for glucose 2. Takes the client’s weight 3. Palpates the skin for its temperature 4. Takes the client’s blood pressure Answer: 4 Rationale: Hypertension is the major symptom associated with pheochromocytoma. The blood pressure status is monitored by taking the client’s blood pressure. Glycosuria, weight loss, and diaphoresis are also clinical manifestations of pheochromocytoma, but hypertension is the major symptom. Test-Taking Strategy: Note the key words, major symptom. Use the principles associated with prioritizing and the ABCs—airway, breathing, and circulation. A method of assessing circulation is to take the blood pressure. Review the manifestations of this disorder if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 877. 36. A nurse is caring for a client with pheochromocytoma. The client is scheduled for an adrenalectomy. In the preoperative period, the priority nursing action would be to monitor: 1. Vital signs 2. Urine for glucose and acetone 3. Intake and output 4. Blood urea nitrogen (BUN) level Answer: 1 Rationale: Hypertension is the hallmark of pheochromocytoma. Severe hypertension can precipitate a cerebrovascular accident or sudden blindness. Although all the options are accurate nursing interventions for the client with pheochromocytoma, the priority nursing action is to monitor the vital signs, particularly the blood pressure. Test-Taking Strategy: Note the key words, priority nursing action. Use the ABCs—airway,

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breathing, and circulation. Monitoring vital signs is the nursing action that would assess airway, breathing, and circulation. Also, note that options 2, 3, and 4 all refer to assessment of the renal system. Review care of the client with pheochromocytoma if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 877. 37. A nurse is caring for a client with pheochromocytoma. The client asks for a snack and something warm to drink. The appropriate choice for this client to meet nutritional needs would be which of the following? 1. Graham crackers and warm milk 2. Toast with peanut butter and cocoa 3. Crackers with cheese and tea 4. Vanilla wafers and coffee with cream and sugar Answer: 1 Rationale: The client with pheochromocytoma needs to be provided with a diet high in vitamins, minerals, and calories. Of particular importance is that food or beverages that contain caffeine, such as chocolate, coffee, tea, or cola, are prohibited. Cocoa, tea, and coffee are caffeinecontaining products. Test-Taking Strategy: Use the process of elimination. Eliminate options 2, 3, and 4 because they are similar and include food items that contain caffeine. Review dietary measures for the client with pheochromocytoma if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed) St. Louis: Mosby, p. 474. 38. A nurse is caring for a client with pheochromocytoma. Which of the following data would indicate a potential complication associated with this disorder? 1. A urinary output of 50 mL/hour 2. Congestion heard on auscultation of the lungs 3. A blood urea nitrogen (BUN) level of 20 mg/dL 4. A coagulation time of 5 minutes Answer: 2 Rationale: The complications associated with pheochromocytoma include hypertensive retinopathy and nephropathy, myocarditis, congestive heart failure (CHF), increased platelet aggregation, and cerebrovascular accident (CVA). Death can occur from shock, CVA, renal failure, dysrhythmias, or dissecting aortic aneurysm. Congestion heard on auscultation of the lungs are indicative of CHF. A urinary output of 50 mL/hour is an appropriate output; the nurse

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would become concerned if the output were below 30 mL/hour. A BUN level of 20 mg/dL is a normal finding. A coagulation time of 5 minutes is normal. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation. Congestion heard on auscultation of the lungs is associated with airway. Additionally, if you know the normal hourly urinary output and the normal laboratory values for coagulation time and the BUN level, you can determine that option 2 is correct by the process of elimination. Review the complications associated with pheochromocytoma if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed) St. Louis: Mosby, p. 473. 39. A client with pheochromocytoma is scheduled for surgery and says to the nurse, “I’m not sure that surgery is the best thing to do.” The appropriate response by the nurse is which of the following? 1. “You have concerns about the surgical treatment for your condition.” 2. “There is no reason to worry. Your doctor is a wonderful surgeon.” 3. “You are very ill. Your physician has made the correct decision.” 4. “I think you are making the right decision to have the surgery.” Answer: 1 Rationale: Paraphrasing is restating the client’s message in the nurse’s own words. Option 1 addresses the therapeutic communication technique of paraphrasing. The client is reaching out for understanding. In option 2, the nurse is offering a false reassurance and this type of response will block communication. Option 3 also represents a communication block because it reflects a lack of the client’s right to an opinion. In option 4, the nurse is expressing approval, which can be harmful to a nurse-client relationship. Test-Taking Strategy: Use therapeutic communication techniques and always address the client’s concerns and feelings. Option 1 is the only therapeutic option. Review these techniques if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Adult Health/Endocrine Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 437-440. 40. A nurse is caring for a client following thyroidectomy and is monitoring for signs of thyroid storm. The nurse understands that which of the following is a manifestation associated with this disorder? 1. Low-grade fever 2. Bradycardia 3. Hypotension 4. Constipation

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Answer: 3 Rationale: Clinical manifestations associated with thyroid storm include a fever as high as 106° F (41.1° C), severe tachycardia, profuse diarrhea, extreme vasodilation, hypotension, atrial fibrillation, hyperreflexia, abdominal pain, diarrhea, and dehydration. In this disorder, the client’s condition can rapidly progress to coma and cardiovascular collapse. Test-Taking Strategy: Knowledge regarding the manifestations associated with thyroid storm is required to answer the question. Remember, this condition is a rare but potentially fatal hypermetabolic state. If you are unfamiliar with this disorder, review the content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Endocrine Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 312. <AQ>41. A hospitalized client with type 1 diabetes mellitus received NPH and regular insulin 2 hours ago (at 7:30 AM). The client calls the nurse and reports that he is feeling hungry, shaky, and weak. The client ate breakfast at 8 AM and is due to eat lunch at 12:00 noon. List in order of priority the actions that the nurse would take. (Number 1 is the first action.) ____Give the client ½ cup of fruit juice to drink. ____Check the client’s blood glucose level. ____Take the client’s vital signs. ____Give the client a small snack of carbohydrate and protein. ____Document the client’s complaints, actions taken, and outcome. Answer: 21345 Rationale: The client is experiencing symptoms of mild hypoglycemia. If symptoms such as hunger, irritability, shakiness, or weakness occur, the nurse would first check the client’s blood glucose level to verify that the client is experiencing hypoglycemia. Once this is verified, the nurse would give the client 10 to 15 g of a carbohydrate. The nurse would retest the blood glucose in 15 minutes. In the meantime, the nurse would check the client’s vital signs. The nurse would give the client another 10- to 15-g carbohydrate food item if the client’s symptoms do not resolve. Otherwise, the nurse would provide a small snack of carbohydrate and protein if the client’s next scheduled meal is more than an hour away from the time of occurrence of these symptoms. Following treatment and resolution of the hypoglycemic event, the nurse would document the occurrence, actions taken, and outcome. Test-Taking Strategy: Focus on the client’s symptoms. Noting that the client is hospitalized will assist in determining that the first action would be to check the client’s blood glucose level. Once this has been done, it is necessary to treat the hypoglycemia. Recalling that an outcome cannot be determined until treatment has been instituted will assist in selecting the documentation action as the last action. From the remaining two actions, select taking the vital signs as the third action. The nurse would not give the client a carbohydrate and protein food item immediately after giving the client a 10- to 15-g carbohydrate item. Review management of hypoglycemia if you had difficulty with this question. Level of Cognitive Ability: Application

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Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Reference: Ignatavicius, D., ,& Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 1541.

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