Med-Surg Practice Test #3: Endocrine & Diabetes

Answer: B. Start the IV infusion of 0.9% sodium chloride at the prescribed rate.

Rationale: Clients in DKA lose large amounts of water and electrolytes through osmotic diuresis and are usually severely dehydrated, as the fast heart rate, low blood pressure and dry mucous membranes show. Restoring circulating volume with an isotonic IV fluid such as 0.9% sodium chloride comes first; it improves perfusion and also lowers the glucose. A continuous IV insulin infusion is then started per the facility's DKA protocol, once fluids are running and the potassium is known to be high enough (the ADA consensus uses about 3.5 mEq/L as the floor), because insulin moves potassium into the cells and can cause dangerous hypokalemia. Option A is wrong because bicarbonate is generally reserved for very severe acidosis (for example, a pH below about 7.0) and is not routine at a pH of 7.20. Option C is wrong because subcutaneous insulin is absorbed unpredictably in a dehydrated client, and insulin is not the first step. Option D is wrong because oral fluids cannot correct this degree of fluid loss, and a client with DKA is often nauseated and vomiting.

Answer: D. The client is restless and has high-pitched, noisy breathing on inspiration.

Rationale: High-pitched noisy breathing on inspiration (stridor) and restlessness signal a narrowing upper airway. After thyroid surgery this can come from a hematoma pressing on the trachea, swelling, injury to both recurrent laryngeal nerves, or laryngospasm from low calcium if the parathyroid glands were damaged. The nurse calls the rapid response team or surgeon right away, stays with the client and keeps the head of the bed up; many facilities keep suction, oxygen and a tracheostomy tray at the bedside after this surgery. The nurse should also check behind the neck for blood that has pooled under the client. Option A is wrong because a sore throat and pain on swallowing are expected after surgery and intubation. Option B is wrong because mild hoarseness is common for a few days; it should be reported and followed, but it is not the emergency. Option C is wrong because a small amount of serosanguineous drainage is expected; increasing bright red drainage or a growing neck swelling would need prompt reporting.

Answer: A. Aspirin by mouth for the fever

Rationale: Thyroid storm is a life-threatening surge of thyroid hormone effects, often triggered by infection, surgery or stopping antithyroid medication. Aspirin (salicylates) should be avoided because it displaces thyroid hormone from its binding proteins in the blood and raises the amount of free, active hormone, which can make the storm worse. The nurse should question the aspirin order and ask for a different antipyretic. Option B is appropriate because a beta blocker such as propranolol controls the fast heart rate, tremor and agitation. Option C is appropriate because PTU blocks new thyroid hormone production and also reduces conversion of T4 to the more active T3. Option D is appropriate because acetaminophen and external cooling are the preferred ways to bring down the fever. Treatment also commonly includes corticosteroids, iodine given after the antithyroid drug, fluids and treating the trigger, as the provider orders.

Answer: C. Assess the airway and breathing, and prepare to support ventilation while calling for help.

Rationale: This client shows signs of myxedema coma, a life-threatening form of severe hypothyroidism: decreased level of consciousness, low body temperature, slow heart rate, low blood pressure and slow, shallow breathing. Slowed breathing leads to carbon dioxide retention and respiratory failure, so the airway and ventilation are the first priority; many clients need mechanical ventilation. The provider will order IV thyroid hormone, often with IV hydrocortisone, plus fluids and close cardiac monitoring. Option A is wrong because rapid active warming dilates blood vessels and can cause cardiovascular collapse; passive rewarming with regular blankets and a warm room is used. Option B is wrong because a client who is hard to arouse cannot swallow safely, and oral absorption is unreliable in this state. Option D is wrong because sedatives further depress breathing and are given with great caution, if at all, in hypothyroidism.

Answer: A. A rounded face, a fat pad between the shoulders, thin skin with purple stretch marks, and high blood glucose

Rationale: Cushing syndrome results from too much cortisol, either from the body or, most often, from corticosteroid medicine. Classic findings include a rounded (moon) face, a fat pad on the upper back, central obesity with thin arms and legs, thin fragile skin that bruises easily, wide purple striae, high blood glucose, high blood pressure, low potassium, muscle weakness and a higher risk of infection and osteoporosis. Nursing care focuses on preventing infection and falls, protecting the skin and monitoring glucose. Option B describes adrenal insufficiency (Addison disease). Option C describes hyperthyroidism (Graves disease). Option D describes hypothyroidism. Corticosteroids taken long term should never be stopped suddenly; they are tapered as the provider directs to prevent adrenal crisis.

Answer: C. Palpating the abdomen firmly during the physical assessment

Rationale: A pheochromocytoma is a tumor, usually of the adrenal medulla, that releases large amounts of catecholamines (epinephrine and norepinephrine). Pressing on the abdomen can squeeze the tumor and trigger a sudden release of catecholamines, causing a hypertensive crisis, stroke or dangerous dysrhythmias. The nurse avoids deep abdominal palpation and reports any blood pressure surge right away. Option A is appropriate because blood pressure can spike suddenly and needs close monitoring. Option B is appropriate because stress, noise and activity can provoke episodes. Option D is appropriate because plasma free metanephrines or a 24-hour urine collection for metanephrines are used to confirm the diagnosis; the nurse follows the lab's instructions for the collection and any diet or medication restrictions the provider orders.

Answer: B. Urine output of 900 mL over the last 2 hours with a urine specific gravity of 1.003

Rationale: Surgery near the pituitary gland and hypothalamus can disrupt antidiuretic hormone (ADH) and cause diabetes insipidus. Without ADH, the kidneys cannot concentrate urine, so the client passes large amounts of very dilute urine; a specific gravity this low (normal is roughly 1.005 to 1.030) with a very high hourly output points to diabetes insipidus. Untreated, it quickly leads to dehydration and high serum sodium. The nurse reports it right away, follows the provider's reporting thresholds for urine output, monitors intake and output, daily weight and serum sodium, and expects desmopressin and fluid replacement if it is confirmed. The nurse also watches for clear, watery nasal drainage, which can be cerebrospinal fluid, and teaches the client not to blow the nose, cough hard or bend at the waist. Option A is wrong because a mild headache controlled with prescribed medicine is expected. Option C is wrong because mouth breathing with nasal packing causes a dry mouth, which is managed with mouth care. Option D is wrong because a small amount of blood-tinged drainage is expected early after this surgery.

Answer: D. "I'll skip my insulin until I'm able to eat normally again."

Rationale: Illness raises stress hormones such as cortisol and epinephrine, which raise blood glucose even when the client eats little. A client with type 1 diabetes makes almost no insulin, so stopping insulin can lead to diabetic ketoacidosis within hours. The client should keep taking basal insulin and adjust doses using the sick-day plan from the provider. Option A shows correct understanding because glucose and ketones are checked more often during illness, commonly every few hours, as the plan directs. Option B shows correct understanding because carbohydrate-containing fluids prevent low blood glucose and sugar-free fluids help prevent dehydration. Option C shows correct understanding because ongoing vomiting, moderate or large ketones, or signs of dehydration need prompt medical advice, as the client's plan specifies.

Answer: C. "I'll check my blood sugar before I run and carry a fast-acting carbohydrate, like glucose tablets."

Rationale: Exercise increases glucose uptake by muscles and makes the body more sensitive to insulin, so clients who use insulin are at risk for hypoglycemia during and after activity. Checking glucose before exercise, carrying a fast-acting carbohydrate and wearing medical identification are key safety steps; the client follows the glucose targets for exercise that the provider sets. Option A is wrong because injecting into a limb that is about to be exercised can speed insulin absorption and cause hypoglycemia. Option B is wrong because exercising with high glucose and ketones can push glucose and ketones higher and worsen ketoacidosis; vigorous exercise is avoided when ketones are present. Option D is wrong because hypoglycemia can occur many hours after exercise, even overnight, as muscles refill their glucose stores.

Answer: A. Glucose 960 mg/dL, serum osmolality 352 mOsm/kg, pH 7.36, bicarbonate 24 mEq/L, urine ketones negative

Rationale: HHS usually develops over days in older adults with type 2 diabetes, often triggered by infection or poor fluid intake. The client still makes enough insulin to prevent major ketone production, so the picture is extreme hyperglycemia (often above 600 mg/dL), very high serum osmolality and severe dehydration, with a near-normal pH and bicarbonate and no or only small ketones. Confusion and other neurologic changes are common because of the high osmolality. Treatment centers on IV fluid replacement, then insulin and electrolyte replacement per protocol, with glucose and sodium corrected gradually and neurologic status checked closely. Option B shows diabetic ketoacidosis: high glucose with a low pH, low bicarbonate and large ketones. Option C shows hypoglycemia. Option D shows mild hyperglycemia, which does not explain this degree of confusion and dehydration.