Answers and RationalesBy,

Kate, Anthony, Michelle, and Kelly

1) As a nurse, you are providing care to a client with myxedema coma. Priority nursing care would include which of the following?

(1) Measures to decrease body temperature (2) Measures to decrease heart rate (3) Measures to maintain airway, fluid and electrolyte

balance, and cardiovascular status (4) Measures to decrease blood pressure

Answer: 3Rationale: Myxedema coma is a life-threatening crisis

manifested by hypothermia, hyponatremia, hypoglycemia, lactic acidosis, cardiovascular collapse, and coma. Maintaining airway and circulation are the priority interventions. 

2) A client diagnosed with primary hyperparathyroidism demonstrates that she understands the teaching plan when the client makes which of the following statements?

(1) “I know I must have surgery to remove my parathyroid gland.”

(2) “I must take diuretics the rest of my life.” (3) “I must eat a diet low in potassium.” (4) “I must limit my daily fluid intake.”

Answer: 1Rationale: The treatment for primary hyperparathyroidism is

a parathyroidectomy (surgical removal of parathyroid glands). Options 2, 3, and 4 are incorrect treatments for primary hyperparathyroidism. 

3) The priority nursing diagnosis for a client with hypoparathyroidism would be which of the following?

(1) Risk for fluid volume excess (2) Risk for injury (3) Anxiety related to lack of knowledge (4) Knowledge deficit

Answer: 2Rationale: Risk for injury related to hypocalcemia is the

priority diagnosis as injury may occur as a result of low calcium levels and tetany. The client is at risk for fluid volume deficit, and anxiety and knowledge deficit would not be a priority over injury. 

4) A client with hypothyroidism is taking levothyroxine sodium (Synthroid), a thyroid replacement hormone. Which of the following statements made by the client would indicate additional teaching is required?

(1) “I know I will be on this medication for the rest of my life.” (2) “I don’t eat excessive amounts of cabbage or spinach.” (3) “I take my Synthroid with food.” (4) “I take my Synthroid in the mornings.”

Answer: 3Rationale: For best absorption, thyroid medications should be

taken 1 hour before meals, or 2 hours after meals. Lifelong treatment of hypothyroidism is necessary. Foods that inhibit thyroid hormone (TH) synthesis, such as cabbage, spinach, and carrots should not be consumed in excessive amounts. Thyroid medications should be taken in the morning to reduce the possibility of insomnia. 

5) In providing care for a client being admitted for hyperparathyroidism, the nurse anticipates implementing which of the following aactions?

(1) Administering intravenous calcium gluconate (2) Administering large amounts of intravenous saline (3) Maintaining strict fluid restriction (4) Monitoring for tetany

Answer: 2Rationale: Hypercalcemia is the primary complication of

hyperparathyroidism, and the manifestations of the disorder are directly related to the effects of hypercalcemia. Administering large amounts of intravenous saline promotes renal excretion of calcium. Calcium gluconate would increase serum calcium levels, and tetany is a symptom of hypocalcemia 

6) A client with exophthalmos as a result of Graves’ disease has expressed a desire for the medications to “hurry up and work so that my eyes will go down.” The nurse’s response to the client will be based on which of the following?

(1) Reversal of exophthalmos occurs after a therapeutic level of the antithyroid medication is achieved.

(2) Reversal of exophthalmos occurs after treatment with ophthalmic medications.

(3) Changes in the eyes as a result of Graves’ disease are not reversible, even after treatment of the disease.

(4) Exophthalmos as a result of Graves’ disease is only a temporary symptom, and should resolve spontaneously.

Answer: 3Rationale: Exophthalmos occurs as a result of accumulation of

fat deposits and by-products in the retro-orbital tissues. Even with treatment of Graves’ disease, these changes are not reversible. The client should receive instructions on proper eye care.

7) A thirty five year old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect?

  A. Atherosclerosis B. Diabetic nephropathy C. Autonomic neuropathy D. Somatic neuropathy

Answer: C

Rationale: Autonomic neuropathy is a group of symptoms that occur when there is damage to nerves that regulate blood pressure, heart rate, bowel and bladder emptying, digestion, and other body functions.  Autonomic neuropathy is associated with diabetic neuropathy.

8 . Which of the following clinical characteristics do not apply towards a patient diagnosed with Type 2 DM?

A. Plasma hypoosmolalityB. DehydrationC. ObesityD. Fasting blood sugar greater than 200 mg/dl

Answer: ARationale: Patients with Type 2 DM present with plasma

hyperosmolality.

9) You are treating a 45 year old male with diabetes who is being discharged after having been treated for diabetic ketoacidosis. You determine that additional discharge teaching is needed regarding the patient's care after you hear the patient's spouse state the following:

A. He washes his feet daily, wears well fitted shoes, and inspects them with a mirror for any blisters or sores.

B. He checks his fasting blood sugar daily and regularly takes his glucophage (Metformin) when his blood sugar exceeds 125 mg/dl.

C. Rapid, labored breathing, with fruity smelly breath is an indication that the patient is hyperglycemic and experiencing ketoacidosis.

D. Headaches, nausea, sweating, lethargy, confusion, and slurred speech and tingling around the mouth may be an indication that too much insulin has been administered.

Answer: BRationale: Glucophage is an oral hypoglycemic that lowers serum

glucose levels by inhibiting hepatic glucose production and increases the insulin sensitivity of peripheral tissue.  Glucophage is ineffective for insulin dependent diabetes mellitus.  You know that the patient is Type 1 IDDM because he was admitted for diabetic ketoacidocis, which is rarely seen in Type 2 NIDDM.

10) You are caring for a 65 year old women who has end stage renal disease as a result of untreated Type 2 Diabetes Mellitus. The patient's 38 year old daughter is visiting and she asks if her grandmother's condition is genetic and if she is at risk for kidney failure. You respond appropriately by stating:

A. There is no genetic correlation with her mother's kidney failure, her kidneys have failed due to complications with many years of high concentration of blood glucose, which disrupts the kidney's ability to filter the blood.

B. Although Type 2 Diabetes has a genetic risk factor, the daughter is older than the maximum age of onset (30).

C. Since her mother had the disease, the daughter is at risk for being predisposed to diabetes and she should monitor for symptoms of frequent urination as well as frequent hunger and thirst.

D. As long as the daughter restricts are diet with well managed meals, exercises to maintain a recommended BMI under 30 she will eliminate her risk of inheriting her mother's conditions.

Answer: CRationale: Type 2 diabetes has a strong genetic predisposition and

children of patients with type 2 NIDDM should be instructed to self-monitor for the symptoms of NIDDM to ensure early treatment.

11) As a Clinical Nurse Leader, you meet regularly with the unit's nutritionist to discuss the nutrition plans for patient's with Diabetes Mellitus. While reviewing the nutritionist's discharge paperwork, you identify the following error in the the patient nutrition information.

A. Patients with diabetes should consume a protein intake of 25-30% of total daily calories.

B. Diabetic patients should have a daily carbohydrate intake of 130 g of carbohydrates per day, with preferred carbohydrates sources being fruit, vegetables, and whole grains.

C. Dietary fat, especially saturated and trans fatty acids should be restricted to reduce the risk for cardiovascular disease.

D. Dietary sweeteners, such as sucrose, do not increase blood glucose levels.

Answer: ARationale: Patients with diabetes should consume a protein

intake that is 15-20% of total daily calories, with some patients with kidney disease requiring a further restriction of 10% total daily calories.

12) Which lab results indicate that fluid restrictions have been effective in treating syndrome of inappropriate antidiuretic hormone (SIADH)?

 a. Increased urine specific gravityb. Increased serum sodiumc. Decreased serum osmolarity d. Decreased hematocrit

Answer: bRationale: Increased serum sodium indicates effective therapy

from fluid restriction. Urine specific gravity increases and serum osmolarity decreases when SIADH is not treated. Hemoconcentration is a result of hypovolemic hyponatremia caused by diabetes insipidus.

13) When assessing a client with diabetes insipidus (DI), which of the following signs and symptoms would you expect? (Circle all that apply.)

a. Polyuria b. Increased thirst c. Hypertension d. Poor turgor e. Bradycardia f. Weak pulses

Answer: a, b, d, fRationale: Due to a deficiency in ADH, patients with DI excrete

large volumes of dilute urine. This massive water loss can cause dehydration resulting in an increased sensation of thirst and poor skin turgor. This state of hypovolemia also manifests as hypotension, weak pulse pressure, and compensatory tachycardia.

14) The nurse is teaching a client about how to monitor for therapy effectiveness for SIADH. For which sign indicating effective management does the nurse instruct the client to look?

a. Dry mucous membranes b. Muscle twitching c. Increasing heart rate d. Daily weight gain less than 2 pounds

Answer: dRationale: Monitoring daily weights assesses the degree of

fluid restriction needed. A weight gain of 2 pounds for more daily or a gradual increase over several days is cause for concern. Dry mucous membranes are a sign of dehydration. Muscle twitching indicates a change in the client's neurological status, which could lead to seizures and coma if left unchecked. An increased heart rate indicates increased fluid retention.

15) Which order would you question when taking care of a patient with DI?

a. Strict I's and O's b. Record daily weight c. NPO d. Desmopressin acetate (DDAVP) 0.2mg PO BID

Answer: cRationale: The patient should be strongly encouraged to drink

fluids so as to maintain adequate hydration and prevent dehydration. Accurate measurement of intake and output and daily weight measurement help assess hydration and effectiveness of treatment. Desmopressin acetate is a synthetic form of vasopressin which is deficient in patients with diabetes insipidus.

16) The nurse is providing discharge instructions to the SIADH client on spironolactone therapy. Which comment by the client indicates a need for further teaching?

a. "This drug will help control my blood pressure." b. "I should eat a banana every day." c. "I must call the doctor if I have increased thirst and am more

tired than usual." d. "I need to increase my salt intake.“

Answer: bRationale: Spironolactone increases potassium levels, so

potassium supplements and foods rich in potassium should be avoided to prevent hyperkalemia. As a potassium-sparing diuretic and aldosterone antagonist, spironolactone does not control blood pressure. While taking this drug, any symptoms of hyponatremia, such as dryness of the mouth, thirst, lethargy, or drowsiness, must be reported. Increased dietary sodium intake may be necessary.

17) A patient who has been diagnosed with Addison’s disease is admitted to the hospital. You are informed that the patient is in an Addisonian crisis. The most severe complication of an Addisionian crisis that you should closely monitor for is

a. Paralytic ileus b. Respiratory distress c. Shock d. Pulmonary Embolism

Answer: cRationale: Addisonian crisis or acute adrenal crisis occurs

when there is acute insufficiency of adrenocorticoids. It results in a decrease in the production of cortisone and aldosterone. Both cortisol and aldosterone play an important role in maintaining blood pressure. A decrease in both hormones can cause hypotension and potentially shock if it’s not treated early.

18) The spouse of the patient with Addison’s disease gives you a brief medical history of the patient. Which statements provided by the patient’s spouse provide information to the nurse as to possible precipating factors of the crisis? Choose All that apply

a. Client stopped taking their prescribed hydrocortisone b. Client has type 1 diabetes mellitus c. Client is taking fludrocortisones (Florinef) d. Client was recently in a severe car accident

Answer: a and dRationale: An abrupt withdrawal of hydrocortisone can cause

the crisis. Also major stressors such as surgery, infections and trauma (ie. accident) can induce a Addisonian crisis. Since the patient is still taking Florinef there shouldn’t be any problems and DM1 has not been shown to influence an Addisonian crisis.

19) Which laboratory results support a patient’s new diagnosis of Cushings disease

a. Increased serum calcium levels b. Decreased serum sodium levels c. Increased serum cortisol levels d. Decreased serum glucose levels

Answer: cRationale: Cushings disease is characterized by an increase

in cortisol. It can be caused by an adrenal tumor, disorders of the pituitary or hypothalamus, which causes an increase in the release of ACTH. It can also be caused from long-term use of glucorticoid therapy, which results in excess cortisol levels. In addition to an increase in cortisol, other signs are an increase in sodium and an increase in glucose (opposite of the other answer options). Cushings does not have a direct effect on Calcium.

20) A patient is admitted to the hospital with Conn’s disease (hyperaldosterone). The nurse knows that they need to closely monitor for which fluid/electrolyte problem?

a. Hyperkalemia b. Hyponatremia c. Excess fluid volume d. Deficient fluid volume

Answer: cRationale: Hyperaldosterone leads to sodium retention

(hypernatremia), which increases fluid volume and blood pressure. Hypokalemia is also a common sign of Conn’s disease (not hyperkalemia).

21) Moon face, “buffalo” hump, purple striae, and truncal obesity are classic symptoms of which endorcrine disorder

a. Addison’s Disease b. Cushing’s Disease c. Grave’s Disease d. Hashimoto’s Disease

Answer: bRationale: Moon face, “buffalo” hump, purple striae, and

truncal obesity are all classic signs of Cushings due to an increase in cortisol levels.