Question 1

Acute adrenal crisis is caused by

Accepted Answer

An adrenal crisis occurs because of a lack of corticosteroids.This may be due to lack of endogenous cortisol production,lack of ACTH production,or inhibition of natural cortisol production by exogenous cortisol administration.Acute renal failure would not be associated with adrenal crisis.High doses of corticosteroids are associated with Cushing's syndrome.Testosterone overdose would not be associated with adrenal crisis.Steroid hormones may possess some corticoid properties.

Question 2

The nurse is assigned to care for a patient who presented to the emergency department with diabetic ketoacidosis.A continuous insulin intravenous infusion is started,and hourly bedside glucose monitoring is ordered.The targeted blood glucose value after the first hour of therapy is

Accepted Answer

Initial insulin infusions should be administered with a target blood glucose reduction of 35 to 90 mg/dL per hour.Decreases of less than this rate may be associated with inadequate insulin replacement and allow for the persistence of the ketotic state.Rapid reductions of blood glucose may precipitate life-threatening cerebral edema; thus,controlled reduction of glucose is required.

Question 3

Which of the following statements is true about the medical management of diabetic ketoacidosis?

Accepted Answer

Volume replacement promotes hemodilution in the face of a hyperosmolar state.Insulin administration promotes entry of glucose into cells and relieves ketosis.As volume is replaced and glucose normalizes,the acidosis often resolves.Insulin administration,not lactate levels,is guided by blood glucose values.Sodium bicarbonate is administered only to correct severe acidosis (pH <7.1).Degree of acidosis is assessed through arterial blood gas readings and serum ketone levels.

Question 4

Which of the following is a high-priority nursing diagnosis for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome?

Accepted Answer

Both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome result in dehydration and hypovolemia; therefore,fluid volume deficit is a priority nursing diagnosis.Even though activity intolerance is a potential nursing diagnosis related to the fatigue associated with metabolic changes in hyperglycemic conditions,it is not a first priority.Hyperthermia is associated with thyroid crisis.Although overweight and obesity are risk factors for type 2 diabetes,during metabolic crisis,the patient has inadequate energy available to tissues because of limited availability and poor utilization of insulin.

Question 5

A patient is admitted to the oncology unit with a small-cell lung carcinoma.During the admission,the patient is noted to have a significant decrease in urine output accompanied by shortness of breath,edema,and mental status changes.The nurse is aware that this clinical presentation is consistent with

Accepted Answer

SIADH may be induced by ectopic sources of antidiuretic hormone,including small-cell lung carcinoma.The clinical presentation of a dilutional hypervolemia is consistent with SIADH.Adrenal crisis is characterized by fluid loss if secondary to decreased cortisol and aldosterone levels resulting in sodium loss.Diabetes insipidus is characterized by increased urine output and is not typically caused by lung tumors.Myxedema coma,although characterized by facial and peripheral edema,does not result from small-cell lung carcinoma.

Question 6

A patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis.Following aggressive fluid resuscitation and intravenous (IV)insulin administration,the blood glucose begins to normalize.In addition to glucose monitoring,which of the following electrolytes requires close monitoring?

Accepted Answer

Potassium must be closely monitored.In the early stages of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome,the potassium value is often high,but it may lower to critical levels once fluid balance has been restored and glucose has returned to more normal levels.Insulin administration used in the treatment of diabetic ketoacidosis further promotes the lowering of potassium as the electrolyte is relocated to the cellular bed.Calcium levels do not drastically change in hyperosmolar states and are not a primary concern unless phosphate replacement is initiated.Chloride levels typically follow sodium levels and normalize with fluid replacement.Sodium levels may initially be elevated as a result of dehydration but will be corrected with fluid replacement.

Question 7

A patient is receiving hydrocortisone sodium succinate for adrenal crisis.What other medication does the nurse prepare to administer?

Accepted Answer

Patients receiving hydrocortisone sodium succinate need to be on a regime to prevent GI bleeding.A proton pump inhibitor would be a good choice.Insulin is used in the treatment of diabetes or for glycemic control in acutely ill nondiabetics.Canagliflozin is an oral anti-hyperglycemic medication.Propranolol is a beta blocker often used in thyroid storm to blunt the effects of sympathetic nervous system stimulation.

Question 8

An individual with type 2 diabetes who takes glipizide has begun a formal exercise program at a local gym.While exercising on the treadmill,the individual becomes pale,diaphoretic,shaky,and has a headache.The individual feels as though she is going to pass out.What is the individual's priority action?

Accepted Answer

The patient is displaying classic symptoms of hypoglycemia.The patient is on sulfonylurea therapy,which carries the risk of hypoglycemia.The walking may be more exercise than she is used to and may thereby cause hypoglycemia.Fifteen grams of carbohydrate is appropriate for initial management of hypoglycemia.Hypoglycemia does not place the patient at risk for dehydration.The patient requires immediate treatment and could pass out while going to the first-aid station.It cannot be assumed that the gym has access to diabetes treatment supplies.Additional doses of oral diabetes medications should not be taken without consulting the health care team.An additional dose of glipizide could promote further hypoglycemia.

Question 9

Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome?

Accepted Answer

Hyperosmolar hyperglycemic syndrome is more common in type 2 diabetes; influenza is a stressor that would result in further increases in blood sugar.Some individuals with advanced Alzheimer's disease cannot communicate thirst needs and may be incontinent,making hypertonic fluid loss more difficult to estimate.Uncontrolled type 1 diabetes is associated with diabetic ketoacidosis.Interruption of insulin delivery related to a missed insulin dose in type 1 diabetes creates a situation of absolute insulin deficiency and is associated with diabetic ketoacidosis.A patient with type 2 diabetes who is new to insulin is at risk for hypoglycemia.

Question 10

A patient presents to the emergency department with the following clinical signs:
Pulse: 132 beats/min
Blood pressure: 88/50 mm Hg
Respiratory rate: 32 breaths/min
Temperature: 104.8°F
Chest x-ray: Findings consistent with congestive heart failure
Cardiac rhythm: Atrial fibrillation with rapid ventricular response
These signs are consistent with which disorder?

Accepted Answer

Tachycardia,vascular collapse,rapid cardiac rhythms,congestive heart failure,and severe hyperthermia are consistent with the clinical manifestations of the hypermetabolic state of thyroid storm.Adrenal insufficiency presents with weakness,fatigue,weight loss,anorexia,abdominal pain,and hyperpigmentation.Myxedema coma is an extreme form of hypothyroidism and is characterized by signs of hypometabolism,including bradycardia,hypotension,hypothermia,cold intolerance,and neurological sluggishness.SIADH is characterized by fluid retention,hyponatremia,and hemodilution.Heat intolerance and atrial fibrillation are not typical characteristics of the condition.

Question 11

A patient has been on daily,high-dose glucocorticoid therapy for the treatment of rheumatoid arthritis.His prescription runs out before his next appointment with his physician.Because he is asymptomatic,he thinks it is all right to withhold the medication for 3 days.What is likely to happen to this patient?

Accepted Answer

Patients on long-term corticosteroid therapy are at high risk for adrenal crisis,because therapy suppresses the endogenous production of steroids.Adrenal crisis may be precipitated by sudden withdrawal of glucocorticoid therapy.Thyroid storm may occur when antithyroid medications are suddenly withdrawn.Rheumatoid arthritis is likely to exacerbate with the withdrawal of glucocorticoids.Adrenal crisis may occur shortly after withdrawal of glucocorticoids.

Question 12

Which of the following laboratory values would be more common in patients with diabetic ketoacidosis?

Accepted Answer

A pH of 7.24 is indicative of an acidotic state that may accompany diabetic ketoacidosis.
Glucose values of more than 1000 mg/dL are more commonly associated with hyperosmolar hyperglycemic syndrome.Diabetic ketoacidosis is associated with positive urine ketones and an increased anion gap.

Question 13

A patient with type 1 diabetes who is receiving a continuous subcutaneous insulin infusion via an insulin pump contacts the clinic to report mechanical failure of the infusion pump.The nurse instructs the patient to begin monitoring for signs of:

Accepted Answer

If the insulin pump fails,the patient with type 1 diabetes will have a complete interruption of insulin delivery; diabetic ketoacidosis will occur.Adrenal insufficiency would not result from insulin pump failure.Hyperosmolar,hyperglycemic state is a hyperglycemic complication associated with type 2 diabetes; this patient has type 1 diabetes.Interruption of insulin delivery in type 1 diabetes would result in hyperglycemia,not hypoglycemia.

Question 14

A patient presents to the emergency department with suspected thyroid storm.The nurse should be alert to which of the following cardiac rhythms while providing care to this patient?

Accepted Answer

Increased heart rate and tachydysrhythmia,including atrial fibrillation,may accompany thyroid storm.Bradycardiac rhythms may be suggestive of hypothyroidism.

Question 15

The most significant clinical finding of acute adrenal crisis associated with fluid and electrolyte imbalance is

Accepted Answer

Adrenal insufficiency may be characterized by inadequate amounts of cortisol and aldosterone.Aldosterone acts to retain sodium,resulting in water retention and potassium loss.Inadequate levels of aldosterone therefore result in hyponatremia,fluid loss,and hyperkalemia.Inadequate cortisol levels may cause weight loss,weakness,and hypoglycemia.Fluid volume deficit may accompany adrenal crisis as a result of sodium loss from decreases in cortisol and aldosterone.Hypoglycemia may accompany adrenal crisis as a consequence of inadequate amounts of cortisol,which limits gluconeogenesis.Hyponatremia may accompany adrenal crisis because of sodium losses secondary to aldosterone insufficiency that often accompanies the condition.

Question 16

A patient with a history of type 1 diabetes and an eating disorder is found unconscious.In the emergency department,the following lab values are obtained: Glucose: 648 mg/dL PH: 6.88 P_aCO₂: 20 mm Hg P_aO₂: 95 mm Hg HCO₃-: undetectable Anion gap: >31 Na⁺: 127 mEq/L K⁺: 3.5 mEq/L Creatinine: 1.8 mg/dL After the patient's airway and ventilation have been established,the next priority for this patient is:

Accepted Answer

After airway is established,the next priority in management of DKA is fluid resuscitation with 1 liter of normal saline over 1 hour.The fluid resuscitation should begin before administration of insulin.Potassium may be added to fluid replacement bags after the first liter of normal saline has infused,provided that the serum potassium is greater than 3.3 mEq/L.Although bicarbonate replacement is indicated in this clinical situation,the bicarbonate is administered by infusion,not by IV push,until the pH exceeds 7.0.

Question 17

In the management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome,when is an intravenous (IV)solution that contains dextrose started?

Accepted Answer

Normal saline is the best initial fluid choice for management of hyperglycemic states.However,when the glucose reaches about 250 mg/dL,solutions containing dextrose are added to prevent hypoglycemia.Hypotonic solutions are required to replace intracellular fluid deficits,and dextrose is required to prevent hypoglycemia later when glucose levels reach initial targets.A glucose level of 70 mg/dL is suggestive of hypoglycemia and would require oral glucose replacement,a 50% dextrose bolus,or glucagon administration.

Question 18

An elderly female patient has presented to the emergency department with altered mental status,hypothermia,and clinical signs of heart failure.Myxedema is suspected.Which of the following laboratory findings support this diagnosis?

Accepted Answer

Thyroid hormones are low in myxedema.Thyroid-stimulating hormone is usually high in relation to the feedback mechanisms for hormone regulation if myxedema is caused by primary hypothyroidism.Elevated adrenocorticotropic hormone may be seen in pituitary conditions or adrenal insufficiency.Elevated cortisol levels accompany Cushing's syndrome.Elevated T₃ and T₄ levels are consistent with hyperthyroidism.

Question 19

The nurse is caring for a patient with a diagnosis of head trauma.The nurse notes that the patient's urine output has increased tremendously over the past 18 hours.The nurse suspects that the patient may be developing

Accepted Answer

Diabetes insipidus results in large volumes of urine; dehydration and hypovolemia can result.Head trauma and resulting increased intracranial pressure are potential causes of diabetes insipidus.High urine output following head trauma is associated with diabetes insipidus.Even though hyperosmolar hyperglycemic syndrome results in osmotic diuresis,the cause is a deficiency in insulin in type 2 diabetes,not head trauma.SIADH may occur with head trauma but results in reduced urine output and,potentially,hypervolemia.

Question 20

In hyperosmolar hyperglycemic syndrome,the laboratory results are similar to those of diabetic ketoacidosis,with three major exceptions.What differences would you expect to see in patients with hyperosmolar hyperglycemic syndrome?

Accepted Answer

In patients with hyperosmolar hyperglycemic syndrome (HHS),glucose is higher; osmotic diuresis is greater,resulting in higher osmolality; and ketosis is usually absent.Glucose values in HHS are typically higher than those of diabetic ketoacidosis and are not typically accompanied by ketosis.

Quiz 19: Endocrine Alterations