med surge II exam 3

Explain: Parathyroid hormone and calcium balance

PTH is released when serum calcium falls. It increases blood calcium by stimulating bone resorption, increasing renal calcium reabsorption, and activating vitamin D to improve intestinal absorption. Excess PTH → hypercalcemia; insufficient PTH (often after neck surgery) → hypocalcemia.

Hyperparathyroidism

skeletal pain/tenderness because bones are broken down. S+S - PUD, pancreatitis, renal calculi. Dx - calcium >13, bone scan, x-ray

Hypoparathyroidism

S+S similar to hypocalcemia; calcium levels decreased, vit.D

deficiency

Hypocalcemia

increased neuromuscular excitability—tingling around mouth/fingers, muscle cramps, tetany, hyperreflexia, seizures, laryngospasm, prolonged QT.

Hypercalcemia

decreased neuromuscular excitability—weakness, lethargy, constipation, nausea, polyuria, renal stones, shortened QT and dysrhythmias. Monitor ECG and airway when symptomatic.

Trousseau's Sign

carpal spasm when BP cuff is inflated above systolic pressure (latent tetany).

Chvostek Sign

facial twitching when facial nerve is tapped. Both suggest hypocalcemia, particularly following thyroid/parathyroid surgery.

Type 1 diabetes

autoimmune pancreatic beta-cell destruction → absolute insulin deficiency; requires lifelong insulin; DKA more common.

Type 2 diabetes

insulin resistance plus progressive insulin-secretory defect; often gradual onset; treated with nutrition, activity, noninsulin drugs and/or insulin; HHS more common.

Explain: Classic signs of diabetes (polyuria, polydipsia, polyphagia)

Polyuria: glucose spills into urine and causes osmotic diuresis.

Polydipsia: thirst from fluid loss/dehydration.

Polyphagia: hunger because glucose cannot be used effectively by cells. Also fatigue, weight loss (especially type 1), blurred vision and poor wound healing.

Explain: Diagnostic tests for diabetes (glucose tolerance, HgbA1C, urine ketones)

Diabetes thresholds: fasting plasma glucose ≥126 mg/dL; random plasma glucose ≥200 mg/dL with classic symptoms; 2-hour 75-g OGTT ≥200 mg/dL; A1c ≥6.5%. Repeat/confirm if no unequivocal hyperglycemia. A1c reflects approximately 2-3 months. Urine/blood ketones evaluate ketosis/DKA, not diabetes diagnosis alone.

DKA

marked insulin deficit → fat breakdown and ketone production → metabolic acidosis; usually type 1; glucose often >250 mg/dL (can be lower), pH

HHS

profound hyperglycemia and hyperosmolar dehydration with minimal ketosis/acidosis; usually type 2; glucose often >600 mg/dL, altered mental status. Triggers: infection, missed insulin, acute illness. Priorities: ABCs, IV isotonic fluids, monitor potassium/ECG, IV regular insulin per protocol when K is safe, hourly glucose and frequent electrolytes, treat trigger. Total-body potassium is depleted even if initial serum K is high.

Rapid (lispro/aspart/glulisine)

onset ~10-30 min, peak ~0.5-3 h, duration ~3-5 h; give with meals

short (regular) insulin

onset ~30-60 min, peak ~2-4 h, duration ~5-8 h; give ~30 min before meals; regular insulin is standard for IV infusion in DKA/HHS

Intermediate (NPH)

onset ~1-2 h, peak ~4-12 h, duration ~12-18 h; cloudy.

Long (glargine/detemir)

onset ~1-2 h, little/no pronounced peak, duration ~20-24 h (detemir variable); do not mix glargine with other insulins. Timing varies by formulation and slides; verify prescribed product.

Explain: Mixing insulins (regular before NPH)

When ordered together in one syringe, inject air into NPH (cloudy), then regular (clear); draw up regular CLEAR before NPH CLOUDY. This avoids contaminating regular insulin with NPH. Never mix glargine or detemir with other insulin.

Explain: Hypoglycemia signs, timing, and prevention

Blood glucose

Explain: Sick-day rules for diabetes management

Continue basal insulin (never abruptly stop for type 1), check glucose more frequently (often every 3-4 h), check ketones when indicated, drink fluids, consume carbohydrates if unable to eat normal meals, follow individual sick-day correction plan. Seek care for persistent vomiting, moderate/large ketones, dehydration, rapid breathing, confusion or persistent high glucose.

Explain: Diabetic nephropathy — early signs

Earliest common clinical marker is moderately increased urine albumin (microalbuminuria; urine albumin-to-creatinine ratio 30-300 mg/g). Often no symptoms initially. Monitor urine albumin, eGFR, BP; manage glucose and BP to slow progression.

Explain: Dietary planning for newly diagnosed diabetics

Consistent carbohydrate intake, portion control and balanced meals; emphasize vegetables, fiber-rich carbohydrates, lean protein and unsaturated fats; limit sugary drinks/refined carbohydrates. Coordinate carbohydrate intake with insulin; use individualized dietitian teaching rather than eliminating all carbs.

Explain: Sliding scale insulin and infusion calculations

Correction/sliding scale: use the ordered glucose range to identify units; avoid assuming an unprovided scale. Infusion: mL/hr = ordered units/hr ÷ concentration (units/mL). Example: 100 units in 100 mL = 1 unit/mL; 6 units/hr = 6 mL/hr. For a weight-based order, units/hr = units/kg/hr × kg. Double-check pump, glucose and potassium monitoring.

Explain: Complications of rapid glucose correction (cerebral edema)

Rapid changes in serum osmolality during DKA/HHS treatment may contribute to cerebral edema, particularly in children. Watch for headache, deteriorating level of consciousness, bradycardia, vomiting or seizures; notify provider immediately. Follow ordered fluid/insulin protocols and avoid overly rapid osmolar shifts.

Addison's disease

Addison (primary adrenal insufficiency): low cortisol and often low aldosterone → fatigue, weight loss, hypotension, dehydration, hyperpigmentation, hyponatremia, hyperkalemia, hypoglycemia.

Cushing's disease

excess cortisol (Cushing disease specifically pituitary ACTH excess) → central obesity, moon face, buffalo hump, thin extremities, purple striae, easy bruising, muscle wasting, hyperglycemia, hypertension, infection risk.

Explain: Addisonian crisis — treatment and patient teaching

Acute adrenal crisis: severe hypotension/shock, dehydration, weakness, possible hypoglycemia, hyponatremia/hyperkalemia.

Emergency treatment: IV hydrocortisone, rapid IV isotonic saline (dextrose if needed), monitor glucose/electrolytes/BP, treat precipitating illness. Teach lifelong replacement, never abruptly stop steroids, increase dose for stress/illness per written plan, carry emergency steroid injection and medical alert identification.

Explain: Cushing's syndrome physical findings and dietary modifications

Moon face, truncal obesity, dorsocervical fat pad, thin skin, purple striae, bruising, proximal weakness, poor healing, hypertension and hyperglycemia. Nutrition: adequate/high protein for tissue repair; lower sodium for fluid retention/BP; manage carbohydrates for hyperglycemia; adequate calcium/vitamin D for bone health; potassium as clinically indicated.

Explain: Medication teaching (steroids, methylprednisolone)

Take as prescribed, usually with food to reduce GI upset; monitor infection, glucose, BP, weight/edema and mood changes. Long-term use can suppress adrenal function, so do NOT stop suddenly; taper only as ordered. Report fever, black stools or severe weakness. Patients needing chronic replacement require stress-dose instructions.

Hypothyroidism

↑TSH, ↓free T4; fatigue, weight gain, cold intolerance, constipation, dry skin, bradycardia, slowed reflexes.

Hyperthyroidism

↓TSH, ↑free T4/T3; weight loss, heat intolerance, sweating, diarrhea, tremor, anxiety, tachycardia and sometimes exophthalmos with Graves. Secondary/pituitary disorders can show different TSH patterns.

Explain: Levothyroxine administration teaching and effectiveness evaluation

Take once daily on an empty stomach with water, 30-60 min before breakfast; separate from iron/calcium supplements by at least 4 h. Often lifelong. Do not change brands/dose without provider. Improvement: energy, bowel function, cold tolerance, heart rate and TSH/free T4 normalize; report palpitations/chest pain (possible excess dose).

Explain: Grave's disease management and monitoring

Autoimmune hyperthyroidism (TSH receptor stimulation). Antithyroid drugs (methimazole; PTU in selected circumstances), beta blockers for tachycardia/tremor, radioactive iodine or thyroidectomy as indicated. Monitor TSH/free T4, pulse, weight, temperature and eye symptoms. Report fever/sore throat on antithyroid drugs (possible agranulocytosis); monitor liver toxicity signs.

Explain: Thyroid storm — signs and emergency management

Life-threatening severe thyrotoxicosis: very high fever, marked tachycardia/arrhythmias, agitation/delirium, vomiting/diarrhea, heart failure. Emergency care: airway/oxygen, cooling, IV fluids, beta blocker as appropriate, antithyroid medication, iodine AFTER thionamide, glucocorticoids and treatment of trigger; continuous cardiac monitoring.

Explain: Post-thyroidectomy discharge teaching

Protect airway and monitor for neck swelling/bleeding, stridor or breathing difficulty (emergency). Report tingling, cramps or spasms (hypocalcemia from parathyroid injury). Support head/neck, avoid heavy lifting/neck strain as directed, care for incision, attend thyroid/calcium lab follow-up and take replacement hormone/calcium if prescribed.

Explain: Diagnostic tests: mammogram, biopsy confirmation

Mammography screens/assesses breast abnormalities; ultrasound helps characterize a mass (solid vs cystic), MRI in selected high-risk/diagnostic situations. A suspicious finding requires tissue sampling—core needle biopsy provides definitive pathologic diagnosis; mammogram alone does not confirm cancer.

Explain: Post-mastectomy care and discharge instructions

Monitor incision, drains, drainage volume/color, pain and arm circulation. Teach drain care and recording output, incision hygiene, prescribed exercises/gradual range of motion, no heavy lifting until cleared, and follow-up. If lymph nodes removed, monitor for lymphedema; protect affected arm from injury and follow individualized precautions.

Explain: Recognizing signs of infection or complications after breast surgery

Report fever, increasing redness/warmth, swelling, purulent/foul drainage, wound separation, sudden increased bloody drain output, hematoma or uncontrolled pain. Arm swelling/heaviness may indicate lymphedema; acute chest pain/dyspnea may signal embolism.

Explain: Benign prostatic hyperplasia (BPH) — symptoms and interventions

Nonmalignant enlargement compresses urethra → hesitancy, weak stream, dribbling, incomplete emptying, nocturia, urgency/frequency and possible retention. Assess bladder distention/postvoid residual, urine output, UTI. Treatment may include alpha blockers (tamsulosin; watch orthostatic hypotension), 5-alpha-reductase inhibitors (finasteride; slow onset), or TURP for obstruction.

Explain: Continuous bladder irrigation (CBI) — expected findings and priority actions

After TURP, 3-way catheter with irrigation prevents clot obstruction. Expected output starts pink/red and becomes light pink/clear; small clots may occur initially. Maintain ordered flow and catheter patency, assess bladder distention/spasms and drainage. True urine output = total drainage − irrigation instilled. If drainage stops, check tubing/kinks, assess patient and follow prescribed irrigation/notification protocol; never let inflow continue against an obstructed outflow.

Explain: Post-prostatectomy monitoring and urine output assessment

Monitor bleeding, vitals, clots, urinary drainage and catheter patency, infection, pain and signs of TUR syndrome after TURP (confusion, nausea, hypertension/bradycardia from fluid absorption). With CBI, subtract infused irrigation from total drainage to calculate actual urine. Teach no straining, heavy lifting or prolonged sitting until cleared; hydrate as directed.

Explain: Post-hysterectomy discharge instructions and complication prevention (DVT risk)

Avoid heavy lifting, straining, intercourse/tampons and driving until cleared; perform wound/perineal care and keep follow-up. Early ambulation, leg exercises, hydration and prescribed compression/anticoagulants reduce DVT risk. Report unilateral calf swelling/pain, chest pain or dyspnea, heavy vaginal bleeding, fever, foul drainage or worsening abdominal pain.

Explain: Radiation therapy side effects and client preparation

Explain treatment and positioning; external beam does NOT make the patient radioactive. Possible fatigue, local skin irritation and GI/GU symptoms (diarrhea, dysuria) with pelvic radiation; internal brachytherapy may require radiation precautions, limited visitors and positioning per institutional protocol while source is in place. Avoid irritating treated skin; report severe symptoms.

Explain: Testicular cancer — health promotion and self-exam education

Often presents as painless unilateral testicular lump, heaviness or swelling; report promptly. Teach awareness/self-exam after warm shower: gently roll each testis between fingers and thumb, know normal epididymis, report new mass/change; exam is not a substitute for medical evaluation. Discuss fertility preservation before treatment when appropriate.

Explain: Populations needing regular breast exams

Encourage breast awareness and reporting new lumps, nipple discharge, dimpling or skin changes in all patients. Age/risk-based screening mammography is especially important for eligible adults and those with strong family history, genetic predisposition (e.g., BRCA), or prior chest radiation; screening intervals depend on risk and clinician guidance. Men with concerning breast findings also need evaluation.

Explain: Erectile dysfunction causes and medication contraindications (sildenafil and nitrates)

ED may result from diabetes/vascular disease, neurologic disease, medication effects, smoking, hormonal or psychological factors. Sildenafil (PDE5 inhibitor) increases penile blood flow; NEVER combine with nitrates (nitroglycerin/isosorbide) because profound hypotension can occur. Use caution with hypotension and alpha blockers; seek emergency care for prolonged painful erection.

Explain: Principles of culturally competent, person-centered nursing

Ask rather than assume; recognize each patient's beliefs, goals, health literacy and preferences. Use shared decision-making, dignity, privacy and equitable care.

Explain: Communication techniques for diverse populations

Use professional interpreter for language barriers (not children/family as default), plain language, open-ended questions, active listening and teach-back to verify understanding.

Explain: Incorporating cultural beliefs into care planning

Ask about dietary practices, modesty, family decision-making, religious practices and acceptable treatments; adapt plan safely and document preferences.

Explain: Respecting values and preferences during discharge teaching and treatment

Invite patient choices, explain risks/benefits in understandable terms, assess readiness and resources, negotiate a feasible plan and respect informed refusal.

Explain: Recognizing personal bias and ensuring equitable care delivery

Reflect on implicit bias, avoid stereotypes, use consistent clinical criteria, advocate for interpreter/access resources and reassess whether teaching and follow-up are feasible.

What electrolyte should the nurse anticipate monitoring in a patient with DKA?

Potassium.

Someone with elevated parathyroid hormone (PTH) will have what condition?

Hypercalcemia.

Which disease causes goiter, tachycardia, and diarrhea?

Graves' disease.

Which surgery has lymphedema as a possible postoperative complication?

Mastectomy.

What medications are used to treat hyperthyroidism?

Propylthiouracil (PTU) or methimazole.

You are teaching differences between Type 1 and Type 2 diabetes. Which is correct?

Type 1 has an abrupt onset of symptoms

What are signs and symptoms of thyroid storm?

Hyperpyrexia and tachycardia

What is the most common treatment for Addisonian crisis?

5% dextrose and glucocorticoids

Which hormone responds to low serum calcium by promoting calcium release from bones into the bloodstream?

PTH

Which home medication is contraindicated with sildenafil?

Isosorbide mononitrate

What exercise education should be provided to a diabetic patient beginning training for a half marathon?

Carry a sugar source.

List the steps of mixing NPH and regular insulin.

Cloudy, clear, clear, cloudy. (Air into NPH, air into regular, withdraw regular, withdraw NPH.)

If levothyroxine is effective, what happens to TSH levels?

TSH decreases.

What laboratory findings are associated with DKA?

Hyperglycemia, dehydration, and ketosis.

Order: Methylprednisolone 40 mg. Available: 80 mg/mL. How many mL should be administered?

0.5 mL

What can happen if blood glucose is lowered too rapidly in patients with DKA or HHS?

Cerebral edema.

What are the physical signs of Cushing's disease?

Moon face, buffalo hump, truncal obesity, thin extremities, purple striae, and thin skin.

What postoperative treatment device is commonly used after TURP?

Three-way Foley catheter with continuous bladder irrigation (CBI).

What does insulin do?

Promotes glucose uptake into cells, lowers blood glucose, and promotes glucose storage.

What patient education should be provided regarding levothyroxine administration?

Take it in the morning on an empty stomach.

What breathing pattern is associated with DKA?

Kussmaul respirations.

What is the first priority intervention for a patient with HHS?

Fluid replacement.

What urinary complaint is most likely in a patient with BPH?

Difficulty initiating urination and straining to void.

What does insulin do to potassium?

Moves potassium into cells, decreasing serum potassium levels.

A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client?

Chvostek's sign

A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client?

Regular insulin

A nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. When the nurse finds the client's blood glucose to be 48 mg/dL on the glucometer, which should be given?

Graham crackers

A nurse is preparing a client for radiation treatment following a mastectomy. Which adverse effect should the nurse inform the client to expect?

Fatigue

A nurse misreads a client's blood glucose as 210 mg/dL instead of 120 mg/dL and administers an excessive insulin dose before breakfast. What is the nurse's priority?

Monitor the client for hypoglycemia.

A nurse is monitoring a client who is postoperative following a thyroidectomy. Which finding is the priority to monitor?

Airway patency

A nurse is reviewing laboratory results of a client at risk for developing diabetes mellitus. Which result meets the diagnostic criteria?

Fasting blood glucose 155 mg/dL

A nurse is assessing a client who has Graves' disease. Which laboratory result should the nurse expect?

Decreased thyroid-stimulating hormone (TSH) level

A nurse is admitting an older adult client who has diabetic neuropathy with painful, burning feet. Which intervention should the nurse anticipate?

Place a bed cradle on the client's bed.

A nurse is caring for a client who is in a myxedema coma. Which action should the nurse take?

Place the client on aspiration precautions.

A nurse is assessing four clients on a medical unit. Which finding indicates hypercortisolism?

Moon face

A nurse is reviewing laboratory results for four clients. Which finding indicates hypoparathyroidism?

Phosphate 5.7 mg/dL

A nurse teaching a class reviews the differences between type 1 and type 2 diabetes. Which information is correct?

Type 1 has an abrupt onset of symptoms

Signs and symptoms include hyperpyrexia, tachycardia, and diarrhea.

thyroid storm

Someone with elevated parathyroid hormone (PTH) will likely have:

Hypercalcemia

Symptoms include hypoglycemia, hyponatremia, and GI disturbances.

Addison's disease

Which is a significant risk factor for cervical cancer?

Family history

Which procedure has lymphedema as a possible postoperative complication?

Mastectomy

Which postoperative patient will require maintenance of three-way catheter irrigation?

TURP

Chronic Complications of Type 2 Diabetes

Nephropathy

Hyperglycemic hyperosmolar syndrome signs and symptoms include blood glucose of 656 mg/dL, polyuria, and Kussmaul respirations. True or False

False

Which of the following can cause diabetic ketoacidosis (DKA)?

Skipping insulin

Insulin glargine and regular insulin may be mixed in the same syringe. True or False

False

A patient with hyperthyroidism exhibits symptoms such as heat intolerance, tachycardia, and weight loss. Which nursing intervention should be prioritized to help manage these symptoms?

Administer antithyroid medications as prescribed.

A 45-year-old patient with a history of obesity and a sedentary lifestyle is newly diagnosed with diabetes mellitus and started on oral hypoglycemic agents. Which type of diabetes does this presentation most likely indicate?

Type II Diabetes