1.

An 18 year old female client, 5’4” tall, weighing 113 kg, comes to the clinic for a wound on her
lower leg that has not healed for the last two weeks. Which disease process would the nurse
suspect that the client has developed?
a. Type 1 diabetes
b. Type 2 diabetes
c. Gestational Diabetes
d. Acanthosis nigricans
R: Non healing wounds are a hallmark sign of Type 2 diabetes.

2. The client diagnosed with Type 1 Diabetes Mellitus has a glycosylated hemoglobin (Hb A1C) of
8.1%. Which interpretation should the nurse make based on this result?
a. This result is below normal levels
b. This result is within acceptable levels
c. This result is above recommended levels
d. This result is dangerously high
R: A normal A1C level is below 5.7%. 5.7%-6.4% is prediabetes. 6.5% and above is diabetes.

3. The nurse administered 28 units of Humulin N, an intermediate-acting insulin to a client

diagnosed with type 1 diabetes at 1600. Which intervention should the nurse implement?
a. Ensure the client eats the bedtime snacks
b. Determine how much food the client ate lunch
c. Perform a glucometer reading at 0700
d. Offer the client protein after administering insulin
R: Humulin N peaks in 6-8 hours, making the client at risk for hypoglycemia around midnight.

4. A nurse is evaluating teaching for a client who has diabetes mellitus and is beginning insulin
therapy. Which behavior suggests that the teaching about medications was effective?
a. The nurse showing the client a video that explains the effects of insulin and mechanism
of action
b. The client reading a handout that describes types of insulin
c. The nurse demonstrating the correct procedure for medication from a vial
d. The client withdrawing insulin from the vial and injecting self correctly on second
attempt
R: Client shows great understanding by demonstrating how to administer a maintenance
medication for the condition.

5. The nurse is discussing the importance of exercising with a client diagnosed with type 2 diabetes
mellitus whose diabetes is well controlled with diet and exercise. Which information should the
nurse include in the teaching about diabetes?
a. Eat a simple carbohydrate snack before exercising
b. Carry peanut butter crackers when exercising
c. Encourage the client to walk 20 min three times a week
 d. Perform warm-up and cool-down exercises
R: All clients who exercise should perform warmup and cool-down exercises to help prevent
muscle strain and injury

6. The nurse is assessing the feet of a client with long-term type 2 diabetes mellitus. Which
assessment data warrant immediate intervention by the nurse?
a. The client has crumbling toenails
b. The client has athlete’s foot
c. The client has a necrotic big toe
d. The client has thickened toenails
R: A necrotic big toe indicates “dead” tissue. Increased blood glucose levels decrease the oxygen
supply needed to heal the wound and increase the risk for developing an infection.

7. The home health nurse is completing the admission assessment for a 76 year old client
diagnosed with type 2 diabetes controlled with 70/30 insulin. Which intervention should be
included in the plan of care?
a. Assess the client’s ability to read small print
b. Monitor the client’s serum prothrombin time (PT) level
c. Teach the client how to perform a hemoglobin A1c test daily
d. Instruct the client to check the feet weekly
R: Age-related visual changes and diabetic retinopathy could cause the client to have difficulty in
reading and drawing up insulin dosage accurately.

8. The client with type 2 diabetes controlled with biguanide oral diabetic medication is scheduled
for a computed tomography (CT) scan with contrast of the abdomen to evaluate pancreatic
function. Which intervention should the nurse implement?
a. Provide a high-fat diet 24 hours prior to test
b. Hold the biguanide medication for 48 hours prior to test
c. Obtain an informed consent form for the test
d. Administer pancreatic enzyme prior to the test
R: Biguanide medication must be held for a test with contrast medium because it increases the
risk for lactic acidosis which leads to renal problems

9. The diabetic educator is teaching a class on diabetes type 1 and is discussing sick-day rules.
Which interventions should the diabetes educator include in the discussion? Select all that
apply.
1.Take diabetic medication even if unable to eat the client’s normal diabetic diet
2.If unable to eat, drink liquids equal to the client’s normal caloric intake
3.It is not necessary to notify the health-care provider if ketones are in the urine
4.Test blood glucose levels and test urine ketones once a day and keep a record
5.Call the health-care provider if glucose levels are higher than 180 mg/dL
a. 1,2 b. 3,4 c. 3,4,5 d. 1,2,5
 R: 1) The most important issue to teach clients is to take insulin even if they are unable to eat.
G;ucose levels are increased with illness and stress
2) The client should drink liquids such as regular cola or orange juice, or eat regular gelatin,
which provide enough glucose to prevent hypoglycemia when receiving insulin
5) The HCP should be notified if the blood glucose level is this high. Regular insulin may need
to be prescribed to keep the blood glucose level within acceptable range.

10. The client receives 10 units of Humulin R, a fast acting insulin, at 0700. At 1030 the unlicensed
assistive personnel (UAP) tells the nurse the client has a headache and is really acting “funny”.
Which intervention should the nurse implement first?
a. Instruct the UAP to obtain the blood glucose level
b. Have the client drink eight ounces of orange juice
c. Go to the client’s room and assess the client for hypoglycemia
d. Prepare to administer once ampule 50% dextrose intravenously
R: regular insulin peaks in 2-4 hours. Therefore, the nurse should think about the possibility the
client is having a hypoglycemic reaction and should assess the client. The nurse should not
delegate nursing tasks to a UAP if the client is unstable

11. The nurse at a freestanding healthcare clinic is caring for a 56 year old male client who is homeless
and has type 2 diabetic controlled with insulin. Which action is an example of client advocacy?
A. Ask the client if he has somewhere he can go and live
B. Arrange for someone to give him insulin at a local homeless shelter
C. Notify Adult Protective Services about the client’s situation
D. Ask the HCP to take the client off inulin because he is homeless
R: Client advocacy focuses support on the client’s autonomy. Even if the nurse disagrees with his living on
the street, it is the client’s right. Arranging for someone to give him his insulin provides for his needs and
allows his choices.

12. The nurse is developing a care plan for the client diagnosed with type 1 diabetes. The nurse
identifies the problem ‘’high risk for hyperglycemia related to noncompliance with the medication
regimen.’’ Which statement is an appointment short-term goal for the client?
A. The client will have blood glucose level between 90 and140 mg/dl
B. The client will demonstrate appropriate insulin injection technique
C. The nurse will monitor the client’s blood glucose levels four (4) times a day
D. The client will maintain normal kidney function with 30-ml/hr urine output
R: The short-term goal must address the response part of the nursing diagnosis, which is ‘’high risk for
hyperglycemia,’’ and this blood glucose level is within acceptable ranges for a client who is non
compliant.

13. The client diagnosed with type 2 diabetes is admitted to the intensive care unit (ICU) with
hyperosmolar hyperglycemic nonketotic syndrome (HHNS) coma. Which assessment data should the
nurse expect the client to exhibit?
 A. Kussmaul’s respirations
B. Diarrhea and epigastric pain
C. Dry mucous membranes
D. Ketone breath odor
R: Dry mucous membranes are a result of the hyperglycemia and occur with both HHNS and DKA

14. The elderly client is admitted to the intensive care department diagnosed with severe HHNS. Which
collaborative intervention should the nurse include in the plan of care?
A. Infuse 0.9% normal saline intravenously
B. Administer intermediate-acting insulin
C. Perform blood glucometer checks daily
D. Monitor arterial blood gas (ABG) results
R: The initial fluid replacement is 0.9% normal saline (an isotonic solution) intravenously, followed by
0.45% saline. The rate depends on the client’s fluid volume status and physical health, especially of the
heart

15. Which electrolyte replacement should the nurse anticipate being ordered by the health care
provider in the client diagnosed with diabetic ketoacidosis (DKA) who has just been admitted to the ICU?
A. Glucose
B. Potassium
C. Calcium
D. Sodium
R: The client in DKA loses potassium frominicased urinary output, acidosis, catabolic state, and vomiting.
Replacement is essential for preventing cardiac dysrhythmias secondary to hypokalemia

16. The client diagnosed with HHNS was admitted yesterday with a blood glucose level of 780 mg/dl.
The client’s blood glucose level is now 300 mg/dl, Which intervention should the nurse implement
A. Increase the regular insulin IV drip
B. Check the client’s urine for ketones
C. Provide the client with a therapeutic diabetic meal
D. Notify the HCP to obtain an orease insulin
R: When the glucose level is decreased to around 300 mg/dl, the regular insulin infusion therapy is
decreased. Subcutaneous insulin will be administered per siding scale

17. The client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom.
Which intervention should the nurse implement first?
A. Administer 50% dextrose (IVP)
B. Notify the health care provider
C. Move the client t the ICU
D. Check the serum glucose level
R: The nurse should assume the client is hypoglycemic and administer IVP dextrose, which will rouse the
client immediately. If the collapse is the result of hyperglycemia, this additional dextrose will not further
injure the client.

18. Which assessment data indicate the client diagnosed with diabetic ketoacidosis is responding to the
medical treatment?
A. The client has tented skin turgor and dry mucous membranes
B. The client is alert and oriented to date, time, and place
C. The client’s ABG results are pH 7.29, Paco24 44, HCO3 15
D. The client’s serum potassium level is 3.3 mEq/L
R: The client’s level of unconsciousness can be altered because of dehydration and acidosis. If the client’s
sensorium is intact, the client is getting better and responding to the medical treatment.

19. The UAP on the medical floor tells the nurse the client diagnosed with DKA wants something else to
eat for lunch. Which intervention should the nurse implement?
A. Instruct the UAP to get the client additional food
B. Notify the dietitian about the client’s request
C. Request the HCP increase the client’s caloric intake
D. Tell the UAP the client cannot have anything else
R: The client will not be compliant with the diet if he or she is still hungry. Therefore, the nurse should
request the dietitian talk to the client to try adjust the meals so the client will adhere to the diet

20. The emergency department nurse is caring for a client diagnosed with HHNS who has a blood
glucose of 680 mg/dl. Which question should the nurse ask the client to determine the cause of this
acute complication?
A. ‘’When was the time you took your insulin?’’
B. ‘’When did you have your last meal?’’
C. ‘’Have you had some type of infection lately?’’
D. ‘’How long have you had diabetes?’’
R: The most common precipitating factor is infection. The manifestations may be slow to appear, with
onset ranging from 24 hours to 2 weeks

21. The nurse is discussing ways lo prevent diabetic ketoacidosis with the client
diagnosed with type 1 diabetes. Which instruction is most important to discuss with
the client?
A. Refer the client to the American Diabetes Association.
B. Do not take any over-the-counter (OTC) medications.
C. Take the prescribed insulin even when unable to eat because of illness.
D. Explain the need to get the annual flu and pneumonia vaccines.

R: The client is on a special diet and should not have any additional food. 2. The client will not be
compliant with the diet if he or she is still hungry. Therefore, the nurse should request the dietitian talk
to the client to try to adjust the meals so the client will adhere to the diet. 3. The nurse does not need to
notify the HP for an increase in caloric intake. The appropriate referral is to the dietitian. 4 The client is
on a special diet. The nurse needs to help the client maintain compliance with the medical treatment and
should refer the client to the dietitian

22. The charge nurse is making client assignments in the intensive care unit. Which
client should be assigned to the most experienced nurse?
A. The client with type 2 diabetes who has a blood glucose level of 348 mg/dL
B. The client diagnosed with type 1 diabetes who is experiencing hypoglycemia.
C. The client with DKA who has multifocal premature ventricular contractions.
D. The client with HHNS who has a plasma osmolarity of 290 mOsm/L

R: Multifocal PVCs, which are secondary to hypokalemia and can occur in clients with DKA, are a
potentially life-threatening emergency. This client needs an experienced nurse.

23. Which arterial blood gas results should the nurse expect in the client diagnosed
with diabetic ketoacidosis?
A. pH 7.34, Pao2 99, Paco2 48, HCO3 24.
B. pH 7.38, Pao2 95, Paco2 40, HCO3 22.
C. pH 7.46, Pao2 85. Paco2 30, HCO3 26.
D. pH 7.30, Pao2 90, Paco2 30, HCO3 18.

R: Ph low = acidosis, HCO3 low = acidosis. Therefore this is metabolic acidosis

24. The client is admitted to the ICU diagnosed with DKA. Which interventions should
the nurse implement? Select all that apply.
A. Maintain adequate ventilation.
B. Assess fluid volume status.
C. Administer intravenous potassium.
D. Check for urinary ketones.
E. Monitor intake and output.

A 123
B.1.2.34
C. 1 and 2 only
D. All of the above

R: The nurse should always address the airway when a client is seriously ill. The client must be assessed
for fluid volume deficit and then for fluid volume excess after fluid replacement is started. The electrolyte
imbalance of primary con- cern is depletion of potassium. Ketones are excreted in the urine; levels are
documented from negative to large amount. Ketones should be monitored frequently. The nurse must
ensure the client's fluid intake and output are equal.

25. Which laboratory value should be monitored by the nurse for the client
diagnosed with diabetes insipidus?
A. Serum sodium
B. Serum calcium
C. Urine glucose
D. Urine white blood cells
R: 1. The client will have an elevated sodium level as a result of low circulating blood volume. The fluid is
being lost through the urine. Diabetes means "to pass through" in Greek, indicating polyuria, a symptom
shared with diabetes mellitus. Diabetes insipidus is a totally separate disease process.

26. The nurse is discharging a client diagnosed with diabetes insipidus. Which statement made by the
client warrants further intervention?
A. "I will keep a list of my medications in my wallet and wear a Medic Alert bracelet."
B. "I should take my medication in the morning and leave it refrigerated at home.”
C. "I should weigh myself every morning and record any weight gain.
D. "If I develop a tightness in my chest, I will call my health-care provider.

R: Medication for DI is usually taken every 8 to 12 hours, depending on the client. The client should keep
the medication close at hand.

1. The client should keep a list of medication being taken and wear a Medic Alert bracelet.
3. The client is at risk for fluid shifts. Weighing every morning allows the client to follow the fluid shifts.
Weight gain indicates too much medication.
4. Tightness in the chest could be an indicator the medication is not being tolerated; if this occurs, the
client should notify the health-care provider.

27. The client is admitted to the medical unit with a diagnosis of rule-out diabetes insipidus (DI). Which
instructions should the nurse teach regarding a fluid deprivation test?
A. The client will be asked to drink 100 mL of fluid as rapidly as possible and then will not be allowed
fluid for 24 hours.
B. The client will be administered an injection of antidiuretic hormone (ADH), and urine output will be
measured for four (4) to six (6) hours.
C. The client will have nothing by mouth (NPO), and vital signs and weights will be done hourly until
the end of the test.
D. An IV will be started with normal saline, and the client will be asked to to hold the urine in the
bladder until a sonogram can be done try]

R: 3. The client is deprived of all fluids, and if the client has DI the urine production will not diminish. Vital
signs and weights are taken every hour to determine circulatory status. If a marked decrease in weight
or vital signs occurs, the test is immediately terminated.
1. The client is not allowed to drink during the test.
2. This test does not require any medications to be administered, and vasopressin will treat the DI, not
help diagnose it.
4. No fluid is allowed and a sonogram is not involved.

28. The nurse is caring for clients on a medical floor. Which client should be assessed first?
A. The dient diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who has a weight
gain of 1.5 pounds since yesterday.
B. The client diagnosed with a pituitary tumor who has developed diabetes insipidus (DI) and has an
intake of 1,500 mL and an output of 1,600 mL in the last 8 hrs.
C. The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) who is having
muscle twilching.
D. The client diagnosed with diabetes insipidus (DI) who is complaining of feeling tired after having to
get up at night.

R: 3. Muscle twitching is a sign of early sodium imbalance. If an immediate intervention is not made, the
client could begin to seize.
1. Clients with SIADH have a problem with retaining fluid. This is expected.
2. This client's intake and output are relatively the same
4. The client has to get up all night to urinate, so the client feeling tired is expected.

29. The health-care provider has ordered 40 units/24 hr of intranasal

vasopressin for a client diagnosed with diabetes insipidus. Each metered
spray delivers 10 units. The client takes the medication every 12 hours.
How many sprays are delivered at each dosing time?
A.1
B.2
C.3
D.4

R: Two (2) sprays per dose. 40 g of medication every 24 hours is to be given in doses administered every
12 hours. First, determine number of doses needed: 24 ÷ 12 = 2 doses Then, determine the amount of
medication to be given in each of those two (2) doses: 40 ÷ 2 = 20 g of medication per dose Finally,
determine how many sprays are needed to deliver the 20 mg when each spray delivers 10 g: 20 ÷ 10 = 2
sprays

30. After stabilization of Addison's disease, the nurse teaches the client about stress management. The
nurse should instruct the client to:
A. Remove all sources of stress from daily life.
B. Use relaxation techniques such as music.
C. Take antianxiety drugs daily.
D. Avoid discussing stressful experiences.

R: 2. Finding alternative methods of dealing with stress, such as relaxation techniques, is a cornerstone
of stress management. Removing all sources of stress from one's life is not possible. Antianxiety drugs
are prescribed for temporary management during periods of major stress, and they are not an
intervention in stress management classes. Avoiding discussion of stressful situations will not necessarily
reduce stress.

31. When teaching a client newly diagnosed with primary Addison's disease, the nurse should explain
that the disease results from:
A. Insufficient secretion of growth hormone (GH).
B. Dysfunction of the hypothalamic pituitary.
C. Idiopathic atrophy of the adrenal gland.
D. Oversecretion of the adrenal medulla.

R: Primary Addison's disease refers to a problem in the gland itself that results from idiopathic atrophy of
the glands. The process is believed to be autoimmune in nature. The most common causes of primary
adrenocortical insufficiency are autoimmune destruction (70%) and tuberculosis (20%). Insufficient
secretion of GH causes dwarfism or growth delay. Hyposecretion of glucocorticoids, aldosterone, and
androgens occur with Addison's disease. Pituitary dysfunction can cause Addison's disease, but this is not
a primary disease process. Oversecretion of the adrenal medulla causes pheochromocytoma.

32. The client is diagnosed with hypothyroidism. Which signs/symptoms would the nurse expect the
client to exhibit?
A. Complaints of extreme fatigue and hair loss.
B. Exophthalmos and complaints of nervousness.
C. Complaints of profuse sweating and flushed skin.
D. Tetany and complaints of stiffness of the hands.
R: A decrease in the thyroid hormone causes decreased metabolism, which leads to fatigue and hair loss.

33. The nurse identifies the client problem "risk for imbalanced body temperature" for the client
diagnosed with hypothyroidism. Which intervention would be included in the client problem?
A. Encourage the use of an electric blanket.
B. Protect from exposure to cold and drafts.
C. Keep the room temperature cool.
D. Space activities to promote rest.
R:Decreased metabolism causes the client to be cold frequently; therefore, protecting the client from
exposure to cold will help increase comfort and decrease further heat loss.

34. Which nursing intervention should be included in the plan of care for the client diag- nosed with
hyperthyroidism?
A. Increase the amount of fiber in the diet.
B. Encourage a low-calorie, low-protein diet.
C. Decrease the client's fluid intake to 1000 mL day.
D. Provide six (6) small, well-balanced meals a day.
R: The client with hyperthyroidism has an increased appetite; therefore, well-balanced meals served
several times throughout the day will help with the client's constant hunger.

35. The client is admitted to the intensive care department diagnosed with myxedema coma. Which
assessment data would warrant immediate inter- vention by the nurse?
A. Serum blood glucose level of 74 mg/dL.
B. Pulse oximeter reading of 90%.
C. Telemetry reading showing sinus bradycardia.
D. The client is lethargic and sleeps all the time.
R:A pulse oximeter reading of less than 93% is significant. A 90% pulse oximeter read- ing indicates a
PaO2 of approximately 60 on an arterial blood gas; this is severe hypox- emia and requires immediate
intervention.

36. A client reports that she has gained weight and that her face and body are "rounder," while her legs
and arms have become thinner. A tentative diagnosis of Cushing's disease is made. The nurse should
further assess the client for:
A. Orthostatic hypotension.
B. Muscle hypertrophy in the extremities.
C. Bruised areas on the skin.
D. Decreased body hair.

37. Galactorrhea is caused by overproduction of which hormone?

 A. Prolactin
B. Adrenocorticotropic hormone (ACTH)
C. Growth hormone (GH)
D. Thyroid-stimulating hor,ome (TSH)

38. Which of the following signs and symptoms are common in male clients with prolactin-secreting
tumors?
A. Severe lethargy and fatigue.
B. Decreased libido and impotence.
C. Bony proliferation of the hands, jaw, and feet.
D. Deepening or coarsening of the voice.
R: Excessive prolactin secretion in men results in decreased libido and impotence; these are often the
only significant signs and symptoms until the tumor becomes large.

39. A client is to have a transsphenoidal hypo- physectomy to remove a large, invasive pituitary tumor.
The nurse should instruct the client that the surgery will be performed through an incision in the:
A. Back of the mouth.
B. Nose.
C. Sinus channel below the right eye.
D. Upper gingival mucosa in the space between the upper gums and lip.
R: With transsphenoidal hypophysectomy, the sella turcica is entered from below, through the sphenoid
sinus. There is no external incision; the incision is made between the upper lip and gums.

40. To help minimize the risk of postoperative respiratory complications after a hypophysectomy, during
preoperative teaching, the nurse should instruct the client how to:
A. Use blow bottles.
B. Turn in bed.
C. Take deep breaths.
D. Cough.
R: Deep breathing is the best choice for help- ing prevent atelectasis.

41. Following a transsphenoidal hypophysectomy, the nurse should assess the client for.
A. Cerebrospinal fluid (CSF) leak
B. Fluctuating blood glucose levels.
C. Cushing's syndrome.
D. Cardiac arrythmias.

Rationale: Cerebrospinal fluid (CSF) leakage is the leading cause of morbidity following
transsphenoidal surgery (TSS) for pituitary adenomas . CSF leakage can lead to headache and
meningitis.

42. A client expresses concern about how a hypophysectomy will affect his sexual function. Which of the
following statements provides the most accurate information about the physiologic effects of
hypophysectomy?
A. .Removing the source of excess hormone should restore the client's libido, erectile function,
and fertility
B. Potency will be restored, but the client will remain infertile.
 C. Fertility will be restored, but impotence and decreased libido will persist.
D. Exogenous hormones will be needed to restore erectile function after the adenoma is removed.

Rationale: The client's sexual problems are directly related to the excessive prolactin level.
Removing the source of excessive hormone secretion should allow the client to return gradually
to a normal physiologic pattern. Fertility will return, and erectile function and sexual desire will
return to baseline as hormone levels return to normal

43. Before undergoing a transsphenoidal hypophysectomy for pituitary adenoma, the client asks the
nurse how the surgeon will close the incision made in the dura. The nurse should respond based on the
knowledge that:
A. Dissolvable sutures are used to close the dura.
B. Nasal packing provides pressure until normal wound healing occurs.
C. A patch is made with a piece of fascia.
D. A synthetic mesh is placed to facilitate healing.

Rationale: The dural opening is typically repaired with a patch of muscle or fascia taken from the
abdomen or thigh. The client should be prepared preoperatively for the presence of this
additional incision in the abdomen or thigh. The client will need the patch of muscle or fascia to
replace the dura. Disposable sutures alone will not provide an intact suture line. Nasal packing
will not provide closure for the dural opening. A synthetic mesh is not the tissue of choice for
surgical repair of the dura.

44. Initial treatment for a cerebrospinal fluid (CSF) leak after transsphenoidal hypophysectomy would
most likely involve:
A. Repacking the nose.
B. Returning the client to surgery.
C. Enforcing bed rest with the head of the bed elevated.
D. Administering high-dose corticosteroid therapy.

Rationale: Sleeping with the head elevated helps decrease pain and swelling.

45. To provide oral hygiene for a client recovering from transsphenoidal hypophysectomy, the nurse
should instruct the client to:
A. Rinse the mouth with saline solution.
B. Perform frequent toothbrushing.
C. Clean the teeth with an electric toothbrush.
D. Floss the teeth thoroughly

46. The nurse teaches the client to report signs and symptoms of which potential complication after
hypophysectomy?
A. Acromegaly.
B. Cushing's disease.
C. Diabetes mellitus.
D. Hypopituitarism.
 Rationale: Complications encountered after tumor removal include CSF leak, diabetes insipidus,
hypopituitarism, meningitis, postoperative hematoma, injury to the carotid artery or optic nerve,
vasospasm, ophthalmoplegia, subarachnoid hemorrhage, and tension pneumocephalus.

47. After pituitary surgery, the nurse should assess the client for which of the following?
A. A Urine specific gravity less than 1.010.
B. Urine output between 1 and 2 L/day.
C. Blood glucose level higher than 300 mg/dL.
D. D Urine negative for glucose and ketones.

Rationale: Low specific gravity indicates renal failure, which results in a fixed specific gravity
between 1.007 and 1.010. Central diabetes insipidus (CDI) is a common complication after
pituitary surgery.

48. Vasopressin (Pitressin) s administered to the client with diabetes insipidus because it:
A. Decreases blood pressure.
B. Increases tubular reabsorption of water.
C. Increases release of insulin from the pancreas.
D. Decreases glucose production within the liver.

Rationale: The antidiuretic action of vasopressin is ascribed to increasing reabsorption of water

by the renal tubules. Diabetes insipidus is caused by a lack of antidiuretic hormone (ADH), also
called vasopressin, which prevents dehydration, or the kidney's inability to respond to ADH. ADH
enables the kidneys to retain water in the body.

49. The client diagnosed with a pituitary tumor developed syndrome of inappropriate antidiuretic
hormone (SIADH). Which interventions should the nurse implement?
A. Assess for dehydration and monitor blood glucose levels.
B. Assess for nausea and vomiting and weigh daily.
C. Monitor potassium levels and encourage fluid intake.
D. Administer vasopressin IV and conduct a fluid deprivation test.

Rationale: Early signs and symptoms are nausea and vomiting. The client has the syndrome of
inappropriate secretion of antidiuretic (against allowing the body to urinate) hormone. In other
words, the client is producing a hormone that will not allow the client to urinate.

1. The client has excess fluid and is not dehydrated, and blood glucose levels are not affected.
3. The client experiences dilutional hyponatremia, and the body has too much fluid already.
4. Vasopressin is the name of the antidiuretic hormone. Giving more increases the client's
problem. Also, a water challenge test is performed, not a fluid deprivation test.

50. The nurse is admitting a client to the neurological intensive care unit who is postoperative
transsphenoidal hypophysectomy. Which data warrant immediate intervention?
A. The client is alert to name but is unable to tell the nurse the location.
B. The client has an output of 2,500 mL since surgery and an intake of 1,000 ml.
C. The client's vital signs are T 97.6°F, P 88, R 20, and BP 130/80.
D. The client has a 3-cm amount of dark-red drainage on the turban dressing.

Rationale:The output is more than double the intake in a short time. This client could be
developing diabetes insipidus, a complication of trauma to the head.

1. Neurological status is monitored every one (1) to two (2) hours. This client's neurological
status appears intact. Clients waking up in an intensive care area may not be aware of their
surroundings.
3. These vital signs are within normal limits.
4. A transsphenoidal hypophysectomy is performed by surgical access above the gum line and
through the nasal passage. There is no dressing. A drip pad is taped below the nares.