Maternal-Child McKinney Ch 51: The Child with an Endocrine or Metabolic Alteration

1. New parents ask the nurse, "Why is it necessary for our baby to have the newborn blood test?" The nurse explains that the priority outcome of mandatory newborn screening for inborn errors of metabolism is

a. appropriate community referral for affected infants.

b. parental education about raising a special needs child.

c. early identification of serious genetically transmitted metabolic diseases.

d. early identification of electrolyte imbalances.

ANS: C

Mandatory genetic screening allows early identification of genetically transmitted metabolic disorders. These disorders can be managed best with early diagnosis and in some cases, early treatment prevents serious physical and cognitive delays. Community referral is appropriate after a diagnosis is made. Parental education will be important, but that is not the goal of screening. Although electrolyte imbalances could occur with some of the inborn errors of metabolism, this is not the priority outcome, nor would the newborn screen detect electrolyte imbalances.

4. Diabetes insipidus is a disorder of the

a. anterior pituitary.

b. posterior pituitary.

c. adrenal cortex.

d. adrenal medulla.

ANS: B

The principal disorder of posterior pituitary hypofunction is diabetes insipidus. ADH is produced in the hypothalamus and stored in the posterior pituitary gland. When ADH is not released appropriately by the posterior pituitary gland, DI occurs. The anterior pituitary produces hormones such as growth hormone, thyroid-stimulating hormone, adrenocorticotropic hormone, gonadotropin, prolactin, and melanocyte-stimulating hormone. The adrenal cortex produces aldosterone, sex hormones, and glucocorticoids. The adrenal medulla produces catecholamines.

5. A child is hospitalized after a serious motor vehicle crash and has developed increased urination. What action by the nurse takes priority?

a. Weigh the child daily.

b. Monitor the child's intake and output.

c. Assess the daily serum sodium level.

d. Restrict dietary sodium intake.

ANS: C

This child might have diabetes insipidus; being in a car crash has the potential for a head injury. That coupled with frequent urination leads the nurse to suspect DI. A high serum sodium and low urine specific gravity are hallmarks of this condition. The priority action for the nurse is to review the child's most recent serum sodium. Daily weights and I&O are also important for many children but is not as specific for this condition as assessing the sodium level. The child may or may not need a sodium restriction, but assessment comes first.

6. What should the nurse include in the teaching plan for parents of a child with diabetes insipidus who is receiving DDAVP?

a. Increase the dosage of DDAVP as the urine specific gravity (SG) increases.

b. Give DDAVP only if urine output decreases.

c. The child should have free access to water and toilet facilities at school.

d. Cleanse skin before administering the transdermal patch.

ANS: C

The child's teachers should be aware of the diagnosis and treatment plan, and the child should have free access to water and toilet facilities at school. DDAVP needs to be given as ordered by the physician. If the parents are monitoring urine SG at home, they would not increase the medication dose for increased SG; the physician may order an increased dosage for very dilute urine with decreased SG. DDAVP needs to be given continuously as ordered by the physician. DDAVP is typically given intranasally or by subcutaneous injection. For nocturnal enuresis, it may be given orally.

16. Type 1 diabetes mellitus is suspected in an adolescent. Which clinical manifestation may be present?

a. Moist skin

b. Weight gain

c. Fluid overload

d. Blurred vision

ANS: D

Blurred vision is one manifestation of diabetes mellitus type 1. Other manifestations include dehydration with dry skin and weight loss, polyuria, and polyphagia.

17. A parent asks the nurse why self-monitoring of blood glucose is being recommended for her child with diabetes. The nurse should base the explanation on the knowledge that

a. it is a less expensive method of testing.

b. it is not as accurate as laboratory testing.

c. children are better able to manage the diabetes.

d. the parents are better able to manage the disease.

ANS: C

Blood glucose self-management has improved diabetes management and can be used successfully by children from the time of diagnosis. Insulin dosages can be adjusted based on blood sugar results. The child learns to be in better control by utilizing blood glucose monitoring. Blood glucose monitoring may be more expensive but provides improved management. It is as accurate as equivalent testing done in laboratories. The ability to self-test allows the child to balance diet, exercise, and insuli n. The parents are partners in the process, but the child should be taught how to manage the disease.

18. What is the best time for the nurse to assess the peak effectiveness of subcutaneously administered regular insulin?

a. Two hours after administration

b. Four hours after administration

c. Immediately after administration

d. Thirty minutes after administration

ANS: A

The peak action for regular (short-acting) insulin is 2 to 3 hours after subcutaneous administration. The other times do not correspond to the peak action time.

19. What is the primary concern for a 7-year-old child with type 1 diabetes mellitus who asks his mother not to tell anyone at school that he has diabetes?

a. The child's safety

b. The privacy of the child

c. Development of a sense of industry

d. Peer group acceptance

ANS: A

Safety is the primary issue. School personnel need to be aware of the signs and symptoms of hypoglycemia and hyperglycemia and the appropriate interventions. While privacy is a concern, for the child's safety, key personnel need to know about the diagnosis and what to do in an emergency. The treatment of type 1 diabetes should not interfere with the school-age child's development of a sense of industry. Peer group acceptance, along with body image, are issues for the early adolescent with type 1 diabetes. This is not of greater priority than the child's safety.

20. What is the best nursing action when a child with type 1 diabetes mellitus is sweating, trembling, and pale?

a. Offer the child a glass of water.

b. Give the child 5 units of regular insulin subcutaneously.

c. Give the child a glass of orange juice.

d. Give the child glucagon subcutaneously.

ANS: C

Four ounces of orange juice is an appropriate treatment for the conscious child who is exhibiting signs of hypoglycemia. This contains 15 grams of carbohydrate. A glass of water is not indicated in this situation. An easily digested carbohydrate is indicated when a child exhibits symptoms of hypoglycemia. Insulin would lower blood glucose and is contraindicated for a child with hypoglycemia. Subcutaneous injection of glucagon is used to treat hypoglycemia when the child is unconscious.

21. Which sign is the nurse most likely to assess in a child with hypoglycemia?

a. Urine positive for ketones and serum glucose greater than 300 mg/dL

b. Normal sensorium and serum glucose greater than 160 mg/dL

c. Irritability and serum glucose less than 60 mg/dL

d. Increased urination and serum glucose less than 120 mg/dL

ANS: C

Irritability and serum glucose less than 60 mg/dL are manifestations of hypoglycemia. Serum glucose greater than 300 mg/dL and urine positive for ketones are indicative of diabetic ketoacidosis. Normal sensorium and serum glucose greater than 160 mg/dL are associated with hyperglycemia. Increased urination is an indicator of hyperglycemia. A serum glucose level less than 120 mg/dL is within normal limits.

22. When would a child diagnosed with type 1 diabetes mellitus most likely demonstrate a decreased need for insulin?

a. During the "honeymoon" phase

b. During adolescence

c. During growth spurts

d. During minor illnesses

ANS: A

During the "honeymoon" phase, which may last from a few weeks to a year or longer, the child is likely to need less insulin. Insulin requirements are generally higher during adolescence, growth spurts, and illnesses.

23. What should a nurse advise the parents of a child with type 1 diabetes mellitus who is not eating as a result of a minor illness?

a. Give the child half his regular morning dose of insulin.

b. Substitute simple carbohydrates or calorie-containing liquids for solid foods.

c. Give the child plenty of unsweetened, clear liquids to prevent dehydration.

d. Take the child directly to the emergency department.

ANS: B

A sick-day diet of simple carbohydrates or calorie-containing liquids will maintain normal serum glucose levels and decrease the risk of hypoglycemia. The child should receive his regular dose of insulin even if he does not have an appetite. If the child is not eating as usual, he needs calories to prevent hypoglycemia. During periods of minor illness, the child with type 1 diabetes mellitus can be managed safely at home.

24. Which is the nurse's best response to the parents of a 10-year-old child newly diagnosed with type 1 diabetes mellitus who are concerned about the child's continued participation in soccer?

a. "Consider the swim team as an alternative to soccer."

b. "Encourage intellectual activity rather than participation in sports."

c. "It is okay to play sports such as soccer unless the weather is too hot."

d. "Give the child an extra 15 to 30 g of carbohydrate snack before soccer practice."

ANS: D

Exercise lowers blood glucose levels. A snack with 15 to 30 g of carbohydrates before exercise will decrease the risk of hypoglycemia. Soccer is an appropriate sport for a child with type 1 diabetes as long as the child prevents hypoglycemia by eating a snack. Participation in sports is not contraindicated for a child with type 1 diabetes. The child with type 1 diabetes may participate in sports activities regardless of climate.

25. Which comment by a 12-year-old child with type 1 diabetes indicates deficient knowledge?

a. "I rotate my insulin injection sites every time I give myself an injection."

b. "I keep records of my glucose levels and insulin sites and amounts."

c. "I'll be glad when I can take a pill for my diabetes like my uncle does."

d. "I keep Lifesavers in my school bag in case I have a low-sugar reaction."

ANS: C

Children with type 1 diabetes will require life-long insulin therapy. Rotating sites may help with variable insulin absorption. Rotating spots within the same major site is important. Keeping records of serum glucose and insulin sites and amounts is appropriate. Prompt treatment of hypoglycemia reduces the possibility of a severe reaction. Keeping hard candy on hand is an appropriate action.

26. Which laboratory finding confirms that a child with type 1 diabetes is experiencing diabetic ketoacidosis?

a. No urinary ketones

b. Low arterial pH

c. Elevated serum carbon dioxide

d. Elevated serum phosphorus

ANS: B

Severe insulin deficiency produces metabolic acidosis, which is indicated by a low arterial pH. Urinary ketones, often in large amounts, are present when a child is in diabetic ketoacidosis. Serum carbon dioxide is decreased in diabetic ketoacidosis. Serum phosphorus is decreased in diabetic ketoacidosis.

1. Which nursing interventions are appropriate for a child with type 1 diabetes who is experiencing deficient fluid volume related to abnormal fluid losses through diuresis and emesis? (Select all that apply.)

a. Initiate IV access.

b. Begin IV fluid replacement with normal saline.

c. Begin IV fluid replacement with D5 1/2NS.

d. Weigh on arrival to the unit and then every other day.

e. Maintain strict intake and output monitoring.

ANS: A, B, E

IV access should always be obtained on a hospitalized child with dehydration and a history of type 1 diabetes. Maintaining circulation is a priority nursing intervention. If the child is vomiting and unable to maintain adequate hydration, fluid volume replacement/rehydration is needed. Normal saline is the initial IV rehydration fluid. Maintaining strict intake and output is essential in calculating rehydration status. D5 1/2NS is not the recommended fluid for rehydration of this patient. Weighing the patient on arrival is important, but following the initial weight, the child needs to be weighed more frequently than every other day. Comparison of admission weight and a weight every 8 hours provides an indication of hydration status.

2. What is the priority nursing goal for a 14-year-old with Graves' disease?

a. Relieving constipation

b. Allowing the adolescent to make decisions about whether or not to take medication

c Verbalizing the importance of adherence to the medication regimen

d. Developing alternative educational goals

ANS: C

A priority goal is for the adolescent to verbalize the need to remain adherent ot the medication regime. The adolescent with Graves' disease is not constipated. Adherence to the medication schedule si important ot ensure optimal health and wellness. Medications should not be skipped, and dose regimens should not be tapered by the child without consultation with the child's medical provider. The management of Graves' disease does not interfere with school attendance and does not require alternative educational plans.

3. What information provided by the nurse would be helpful to a 15-year-old adolescent taking methimazole three times a day?

a. Pill dispensers and alarms on a watch can be effective reminders to take

the medication.

b. She can take the medication when she is feels symptomatic.

.c She can take two pills before school and one pill at dinner, which is easier to

remember.

d. The mother can be responsible for reminding her to take her medication.

ANS: A

Methimazole is an antithyroid medication that should be taken three times a day. Reminders will facilitate taking medication as ordered. This medication needs to be taken regularly, not on an as-needed basis. The dosage cannot be combined to reduce the frequency of

administration. An adolescent is old enough and mature enough to be responsible for taking medications.

7. A child with growth hormone deficiency is receiving GH therapy. What is the best time for the GH to be administered?

a.

At bedtime

b.

After meals

.c

Before meals

d.

On arising ni the morning

ANS: A

Injections are best given at bedtime to more closely approximate the physiologic release of GH.

8. Anurse is explaining growth hormone deficiency to parents of achild admitted ot rule out this problem. Which metabolic alteration that si related ot growth hormone deficiency should the nurse explain to the parent?

a. Hypocalcemia

b . .Hypoglycemia

c. Diabetes insipidus

d. Hyperglycemia

ANS: B

Growth hormone helps maintain blood sugar at normal levels. Calcium is not affected. Diabetes insipidus is a disorder of the posterior pituitary. Growth hormone is produced by the anterior pituitary. Hyperglycemia results from an insufficiency of insulin, which is produced by the beta cells ni the islets of Langerhans ni the pancreas.

9.

At what age is sexual development ni boys and girls considered to be precocious?

10.

.a Boys, 1 years; girls, 9 years

b. Boys, 12 years; girls, 10 years

c. Boys, 9 years; girls, 8 years

d. Boys, 10 years; girls, 9 1/2 years

ANS: C

Manifestations of sexual development before age 9 ni boys and age 8 ni girls is considered precocious and should be investigated. The other ages fall within the expected range of pubertal onset.

10 What is the most appropriate intervention for the parents of a 6-year-old child with precocious puberty?

a. Advise the parents to consider birth control for their daughter.

b. Explain the importance the child having relationships with same-age peers.

c. Reassure parents that there are no long-term consequences.

d. Counsel parents that there is no treatment currently available for this disorder.

ANS: B

Despite the child's appearance, the child needs to be treated according to her chronologic age

and to interact with children in the same age- group. An expected outcome is that the child will adjust socially by exhibiting age-appropriate behaviors and social interactions. Advising the parents of a 6-year-old to put their daughter on birth control is not appropriate and will not reverse the effects of precocious puberty. There may be both long-term physical and emotional consequences of this disorder. Treatment for precocious puberty si the administration of gonadotropin-releasing hormone blocker, which slows or reverses the development of secondary sexual characteristics and slows rapid growth and bone aging.

A neonate is displaying mottled skin, has a large fontanel and tongue, is lethargic, and is having difficulty feeding. The nurse recognizes that this is most suggestive of which disorder?

a. Hypocalcemia

.b Hypothyroidism

c. Hypoglycemia

d. Phenylketonuria (PKU)

ANS: B

11.

An infant with hypothyroidism may exhibit skin mottling, a large fontanel, a large tongue, hypotonia, slow reflexes, a distended abdomen, prolonged jaundice, lethargy, constipation,

seizures. Hypoglycemia causes the neonate to exhibit jitteriness, poor feeding, lethargy, seizures, respiratory alterations including apnea, hypotonia, high-pitched cry, bradycardia, cyanosis, and temperature instability. Infants with PKU may initially have digestive problems with vomiting, and they may have a musty or mousy odor ot the urine, infantile eczema, hypertonia, and hyperactive behavior.

12. A common clinical manifestation of congenital hypothyroidism is

a. insomnia.

b. diarrhea.

c. hoarse cry.

d. jitteriness.

ANS: C

Infants with congenital hypothyroidism often have a hoarse cry. They also sleep excessively, are constipated and lethargic.

A goiter is an enlargement or hypertrophy of which gland? a. Thyroid

b. Adrenal

.c Anterior pituitary

d. Posterior pituitary

ANS: A

A goiter is an enlargement or hypertrophy of the thyroid gland.

Exophthalmos (protruding eyeballs) may occur ni children with which condition? a. Hypothyroidism

b. Hyperthyroidism

c. Hypoparathyroidism

d. Hyperparathyroidism

ANS: B

Exophthalmos is a clinical manifestation of hyperthyroidism. It is not associated with the other conditions.

A neonate born with ambiguous genitalia is diagnosed with congenital adrenal hyperplasia. Therapeutic management includes administration of

a. vitamin D.

b. cortisone acetate.

c. stool softeners.

d. calcium carbonate.

ANS: B

Cortisone acetate si the treatment for congenital adrenal hyperplasia, and treatment is lifelong. Vitamin D, stool softeners, and calcium carbonate are not used ni therapy for this condition.

27.

An infant has just been diagnosed with Tay-Sachs disease. What action by the nurse is most appropriate?

a. Refer the family to a support group.

b. Educate the family on bone marrow transplant.

c. Teach the family how to promote growth and development.

d. Obtain informed consent for laser eye surgery.

ANS: A

Tay-Sachs is inevitably fatal, usually by early childhood. The family wil need much emotional support, which is found ni support groups where they wil interact with families who are or who have been ni a similar situation. Tay-Sachs is not treated with bone marow transplant or eye surgery. Development regresses with neurologic deterioration, and the infant usually exhibits macrocephaly, seizures, blindness, and deafness.

28. A nurse is caring for a child undergoing an ACT stimulation test. After administering the Cortrosyn according to policy, what action by the nurse takes priority?

a. Obtain a set of vital signs.

b. Monitor the urine output.

с. Facilitate a lab draw in 30 minutes.

d. Keep the child NPO.

ANS: C

For the ACTH stimulation test, cortisol levels are drawn before and 30 and 60 minutes after

cortisone administration. The nurses' priority is ot facilitate the lab being drawn on time. Obtaining vital signs and urine output and keeping the child NPO are not related to this test.

Which children admitted to the pediatric unit would the nurse monitor closely for development of SIADH? (Select all that apply.)

a. Anewly diagnosed preschooler with type 1diabetes

b. Aschool-age child returning from surgery for removal of a brain tumor

c. An infant with suspected meningitis

d. An adolescent with blunt abdominal trauma following a car accident

e. Aschool-age child with head trauma

ANS: B, C, E

Childhood SIADH usually is caused by disorders affecting the central nervous system, such

as infections (meningitis), head trauma, and brain tumors. Diabetes and abdominal trauma do not cause SIADH.

Achild is diagnosed with hypothyroidism. The nurse should expect to assess which symptoms associated with hypothyroidism? (Select all that apply.)

a. Weight loss b. Fatigue

c. Diarrhea

d. Dry, thick skin

e. Cold intolerance

ANS: B, D, E

A child with hypothyroidism will display fatigue, dry, thick skin, and cold intolerance. Weight loss and diarrhea are signs of hyperthyroidism.