pharm endocrine/dm

1. A patient has a free T4 level of 0.6 ng/dL and a free T3 of 220 pg/dL. The patient asks the nurse what these laboratory values mean. How will the nurse respond?
a. "These laboratory values indicate that you may have Graves' disease."
b. "These results suggest you may have hyperthyroidism."
c. "We will need to obtain a total T4 and a total T3 to tell for sure."
d. "We will need to obtain a TSH level to better evaluate your diagnosis."

ANS: D
A free T4 level of less than 0.9 ng/dL and a free T3 of less than 230 pg/dL are consistent with hypothyroidism, but measurement of the thyroid-stimulating hormone (TSH) level is necessary to distinguish primary hypothyroidism from secondary hypothyroidism. Total T3 and T4 levels are not as helpful as free T3 and T4 levels. These laboratory values indicate hypothyroidism, not hyperthyroid conditions such as Graves' disease.

2. A nurse obtaining an admission history on an adult patient notes that the patient has a heart rate of 62 beats per minute, a blood pressure of 105/62 mm Hg, and a temperature of 96.2°F. The patient appears pale and complains of always feeling cold and tired. The nurse will contact the provider to discuss tests for which condition?
a. Cretinism
b. Graves' disease
c. Hypothyroidism
d. Plummer's disease

ANS: C
This patient is showing signs of hypothyroidism: a low heart rate, low temperature, pale skin, and feeling cold and tired. In adults, thyroid deficiency is called hypothyroidism. In children, thyroid deficiency is called cretinism. Graves' disease and Plummer's disease are conditions caused by thyroid excess.

3. The nurse is caring for a pregnant patient recently diagnosed with hypothyroidism. The patient tells the nurse she does not want to take medications while she is pregnant. What will the nurse explain to this patient?
a. Hypothyroidism is a normal effect of pregnancy and usually is of no consequence.
b. Neuropsychologic deficits in the fetus can occur if the condition is not treated.
c. No danger to the fetus exists until the third trimester.
d. Treatment is required only if the patient is experiencing symptoms.

ANS: B
Maternal hypothyroidism can result in permanent neuropsychologic deficits in the child. Hypothyroidism is not a normal effect of pregnancy and is a serious condition that can affect both mother and fetus. The greatest danger to the fetus occurs in the first trimester, because the thyroid does not fully develop until the second trimester. Early identification is essential. Symptoms often are vague. Treatment should begin as soon as possible, or mental retardation and other developmental problems may occur.

4. A nurse caring for a patient notes that the patient has a temperature of 104°F and a heart rate of 110 beats per minute. The patient's skin is warm and moist, and the patient complains that the room is too warm. The patient appears nervous and has protuberant eyes. The nurse will contact the provider to discuss:
a. cretinism.
b. Graves' disease.
c. myxedema.
d. Plummer's disease.

ANS: B
The signs and symptoms in this patient are consistent with hyperthyroidism, and because the patient's eyes are protuberant, they also are consistent with Graves' disease. Cretinism is hypothyroidism in children. Myxedema is severe hypothyroidism. Plummer's disease is a hyperthyroidism condition without exophthalmos.

5. A patient in her twenties with Graves' disease who takes methimazole [Tapazole] tells a nurse that she is trying to conceive and asks about disease management during pregnancy. What will the nurse tell her?
a. Methimazole is safe to take throughout pregnancy.
b. Propylthiouracil should be taken throughout her pregnancy.
c. The patient should discuss changing to propylthiouracil from now until her second trimester with her provider.
d. The patient should discuss therapy with iodine-131 instead of medications with her provider.

ANS: C
Methimazole is not safe during the first trimester of pregnancy, because it is associated with neonatal hypothyroidism, goiter, and cretinism; however, it is safe in the second and third trimesters. Propylthiouracil is recommended for pregnant patients only in the first trimester and during lactation only if a thionamide is absolutely necessary. Iodine-131 is used in women older than 30 years who have not responded to medication therapy and is contraindicated during pregnancy.

6. A nurse is teaching a patient who has been diagnosed with hypothyroidism about levothyroxine [Synthroid]. Which statement by the patient indicates a need for further teaching?
a. "I should not take heartburn medication without consulting my provider."
b. "I should report insomnia, tremors, and an increased heart rate to my provider."
c. "If I take a multivitamin with iron, I should take it 4 hours after the Synthroid."
d. "If I take calcium supplements, I may need to decrease my dose of Synthroid."

ANS: D
Patients taking calcium supplements should take these either 4 hours before or after taking levothyroxine, because they interfere with levothyroxine absorption. Many heartburn medications contain calcium, so patients should consult their provider before taking them. Insomnia, tremors, and tachycardia are signs of levothyroxine toxicity and should be reported. Iron also interferes with levothyroxine absorption, so dosing should be 4 hours apart.

7. A patient has been taking levothyroxine for several years and reports that "for the past 2 weeks, the drug doesn't seem to work as well as before." What will the nurse do?
a. Ask the patient when the prescription was last refilled.
b. Expect the patient to have an elevated temperature and tachycardia.
c. Suggest that the patient begin taking calcium supplements.
d. Tell the patient to try taking the medication with food.

ANS: A
Not all levothyroxine preparations have the same drug bioavailability; therefore, if a patient is experiencing differing effects, the pharmacist may have switched brands. Asking a patient about a recent refill may help to explain why the drug has different effects. An elevated temperature and tachycardia would be signs of toxicity, not of a decrease in effectiveness. Calcium supplements and food would only interfere with absorption and further reduce the drug's effectiveness.

8. A patient with hypothyroidism begins taking PO levothyroxine [Synthroid]. The nurse assesses the patient at the beginning of the shift and notes a heart rate of 62 beats per minute and a temperature of 97.2°F. The patient is lethargic and difficult to arouse. The nurse will contact the provider to request an order for which drug?
a. Beta blocker
b. Increased dose of PO levothyroxine
c. Intravenous levothyroxine
d. Methimazole [Tapazole]

ANS: C
Intravenous administration of levothyroxine is used for myxedema coma. This patient is showing signs of severe hypothyroidism, or myxedema. A beta blocker is useful in patients who show signs of hyperthyroidism to minimize cardiac effects. Because the half-life of oral levothyroxine is so long, increasing the PO dose will not provide immediate relief of this patient's symptoms. Methimazole is used to treat hyperthyroidism.

9. A patient is admitted to the hospital and will begin taking levothyroxine [Synthroid]. The nurse learns that the patient also takes warfarin [Coumadin]. The nurse will notify the provider to discuss \____ the \____ dose.
a. reducing; levothyroxine
b. reducing; warfarin
c. increasing; levothyroxine
d. increasing; warfarin

ANS: B
Levothyroxine accelerates the degradation of vitamin K-dependent clotting factors, which enhances the effects of warfarin. Patients taking warfarin who start taking levothyroxine may need to have their warfarin dose reduced. It is not correct to increase or decrease the levothyroxine dose or to increase the warfarin dose.

10. An older adult patient is diagnosed with hypothyroidism. The initial free T4 level is 0.5 mg/dL, and the TSH level is 8 microunits/mL. The prescriber orders levothyroxine [Levothroid] 100 mcg/day PO. What will the nurse do?
a. Administer the medication as ordered.
b. Contact the provider to discuss giving the levothyroxine IV.
c. Request an order to give desiccated thyroid (Armour Thyroid).
d. Suggest that the provider lower the dose.

ANS: D
In older adult patients, initial dosing of levothyroxine should start low and be increased gradually. A typical starting dose for an elderly patient is 25 to 50 mcg/day. It is not correct to administer the medication without questioning the provider. Unless the patient has signs of myxedema, there is no need to give the medication IV. Desiccated thyroid is no longer used except in patients who have been taking it long term.

11. A 1-year-old child with cretinism has been receiving 8 mcg/kg/day of levothyroxine [Synthroid]. The child comes to the clinic for a well-child checkup. The nurse will expect the provider to:
a. change the dose of levothyroxine to 6 mcg/kg/day.
b. discontinue the drug if the child's physical and mental development are normal.
c. increase the dose to accommodate the child's increased growth.
d. stop the drug for 4 weeks and check the child's TSH level.

ANS: A
In the treatment of cretinism, thyroid dosing decreases with age. For infants 6 to 12 months of age, the dose is 6 mcg/kg/day. At 1 year of age, the dose is reduced to 5 to 6 mcg/kg/day. For all children, treatment should continue for 3 years. It is incorrect to increase the dose with age. After 3 years of therapy, the patient undergoes a trial of 4 weeks without the drug, followed by assessment of the TSH and T4 levels, to determine whether the drug may be discontinued.

12. The nurse prepares a patient with Graves' disease for radioactive iodine (131I) therapy. Which statement made by the patient best demonstrates understanding of 131I therapy?
a. "I will have to isolate myself from my family for 1 week so that I don't expose them to radiation."
b. "This drug will be taken up by the thyroid gland and will destroy the cells to reduce my hyperthyroidism."
c. "This drug will help reduce my cold intolerance and weight gain."
d. "I will need to take this drug on a daily basis for at least 1 year."

ANS: B
Iodine-131 can be used to destroy thyroid tissue in patients with hyperthyroidism; no further teaching is necessary. The patient does not need to isolate himself from others. The treatment will not reduce intolerance to cold, nor will it affect weight gain. The patient will not need the treatment daily.

13. A nurse is teaching a patient who will begin taking methimazole [Tapazole] for Graves' disease about the medication. Which statement by the patient indicates understanding of the teaching?
a. "Because of the risk for liver toxicity, I will need frequent liver function tests."
b. "I should report a sore throat or fever to my provider if either occurs."
c. "I will need a complete blood count every few months."
d. "It is safe to get pregnant while taking this medication."

ANS: B
Agranulocytosis is rare but can occur with methimazole, so patients should report signs of infection, such as a sore throat or fever. Liver toxicity is not a side effect, so liver function tests are not indicated. Because agranulocytosis often develops rapidly, periodic blood counts do not guarantee early detection. Methimazole is contraindicated in the first trimester of pregnancy.

14. A patient arrives in the emergency department with a heart rate of 128 beats per minute and a temperature of 105°F. The patient's skin feels hot and moist. The free T4 level is 4 ng/dL, the free T3 level is 685 pg/dL, and the TSH level is 0.1 microunits/mL. The nurse caring for this patient will expect to administer:
a. intravenous levothyroxine.
b. iodine-131 (131I).
c. methimazole [Tapazole].
d. propylthiouracil (PTU).

ANS: D
Propylthiouracil is used for patients experiencing thyroid storm, and this patient is showing signs of that condition. Levothyroxine is given IV for hypothyroidism. 131I is used in patients over age 30 who have not responded to other therapies. Methimazole is used long term to treat hyperthyroidism, but PTU is more useful for emergency treatment.

1. The nurse working on a high-acuity medical-surgical unit is prioritizing care for four patients who were just admitted. Which patient should the nurse assess first?
a.
The NPO patient with a blood glucose level of 80 mg/dL who just received 20 units of 70/30 Novolin insulin
b.
The patient with a pulse of 58 beats per minute who is about to receive digoxin [Lanoxin]
c.
The patient with a blood pressure of 136/92 mm Hg who complains of having a headache
d.
The patient with an allergy to penicillin who is receiving an infusion of vancomycin [Vancocin]

ANS: A
The NPO patient with hypoglycemia who just received 70/30 Novolin insulin takes priority, because this patient needs to consume a good source of glucose immediately or perhaps the NPO status will be discontinued for this shift. The digoxin may be withheld for the patient with a pulse of 58 beats per minute, but this is not a priority action. The patient with a headache needs to be followed up, but because the blood pressure is 136/92 mm Hg, the headache is probably not caused by hypertension. The patient with an allergy to penicillin will not have a reaction to the vancomycin.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 676 | pp. 678-679

2. A patient with type 1 diabetes is eating breakfast at 7:30 AM. Blood sugars are on a sliding scale and are ordered before a meal and at bedtime. The patient's blood sugar level is 317 mg/dL. Which formulation of insulin should the nurse prepare to administer?
a.
No insulin should be administered.
b.
NPH
c.
70/30 mix
d.
Lispro [Humalog]

ANS: D
Regular insulin is indicated for sliding scale coverage. Insulin is definitely indicated for this high blood sugar level. NPH is used for scheduled insulin doses and is a longer-acting insulin. A 70/30 mix is also used for scheduled insulin coverage.

PTS: 1 DIF: Cognitive Level: Application REF: p. 676 | pp. 678-679

3. A nurse is educating the staff nurses about ketoacidosis. To evaluate the group's understanding, the nurse asks, "Which sign or symptom would not be consistent with ketoacidosis?" The group gives which correct answer?
a.
Blood glucose level of 600 mg/dL
b.
Blood glucose level of 60 mg/dL
c.
Acidosis
d.
Ketones in the urine

ANS: B
A patient with diabetic ketoacidosis (DKA) has a high glucose level (at least 500 mg/dL or higher); therefore, a glucose level of 60 mg/dL would not be consistent with DKA. A blood glucose level of 600 mg/dL, acidosis, and ketones in the urine are consistent with DKA.

PTS: 1 DIF: Cognitive Level: Analysis REF: pp. 694-695

4. The nurse assesses a newly diagnosed patient for short-term complications of diabetes. What does this assessment include?
a.
Evaluation for hyperglycemia, hypoglycemia, and ketoacidosis
b.
Cranial nerve testing for peripheral neuropathy
c.
Pedal pulse palpation for arterial insufficiency
d.
Auscultation of the carotids for bruits associated with atherosclerosis

ANS: A
High blood sugar, low blood sugar, and ketoacidosis are short-term complications of diabetes. Microvascular and macrovascular complications, such as peripheral neuropathy, are long-term complications of diabetes. Arterial insufficiency and atherosclerosis also are long-term complications of diabetes.

PTS: 1 DIF: Cognitive Level: Application REF: p. 669

5. Which statement is accurate about the long-term complications of diabetes?
a.
Long-term complications are almost always the result of hypoglycemia and ketoacidosis.
b.
The complication rates for patients with optimally controlled type 2 diabetes are the same as for those whose disease is not optimally controlled.
c.
Optimal control of type 1 diabetes produces excessive episodes of life-threatening hypoglycemia.
d.
Optimal control of both types of diabetes reduces the risk of eye, kidney, and nerve damage.

ANS: D
In both types of diabetes, optimal control of the disease slows the development of microvascular complications. Short-term complications are more apt to result from hypoglycemia and ketoacidosis. Patients with type 2 diabetes have fewer complications if their blood sugar level is optimally controlled. Hypoglycemia does not occur more frequently in patients with optimally controlled type 1 diabetes.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 669

6. A patient with type 1 diabetes recently became pregnant. The nurse plans a blood glucose testing schedule for her. What is the recommended monitoring schedule?
a.
Before each meal and before bed
b.
In the morning for a fasting level and at 4:00 PM for the peak level
c.
Six or seven times a day
d.
Three times a day, along with urine glucose testing

ANS: C
A pregnant patient with type 1 diabetes must have frequent blood sugar monitoring (eg, six or seven times a day) to manage both the patient and the fetus so that no teratogenic effects occur. Monitoring the blood sugar level before meals and at bedtime is not significant enough to provide the necessary glycemic control. Morning and 4:00 PM monitoring is not enough to provide glycemic control. Urine glucose testing is not sensitive enough to aid glycemic control, and monitoring three times a day is not enough.

PTS: 1 DIF: Cognitive Level: Application REF: p. 670

7. An adolescent patient recently attended a health fair and had a serum glucose test. The patient telephones the nurse and says, "My level was 125 mg/dL. Does that mean I have diabetes?" What is the nurse's most accurate response?
a.
"Unless you were fasting for longer than 8 hours, this does not necessarily mean you have diabetes."
b.
"At this level, you probably have diabetes. You will need an oral glucose tolerance test this week."
c.
"This level is conclusive evidence that you have diabetes."
d.
"This level is conclusive evidence that you do not have diabetes."

ANS: A
If a person has not fasted for 8 hours, a blood sugar level of 125 mg/dL would be considered normal, because it is less than 200 mg/dL for a random sampling. Also, a person must have positive outcomes on two separate days to be diagnosed with diabetes. This patient does not need to have an oral glucose tolerance test, because the 125 mg/dL reading is so far below 200 mg/dL, which would require further work-up. No conclusive evidence indicates that this patient has diabetes, because the random sample value is so low, and the patient has not had two separate tests on different days. However, this also is not conclusive evidence that the patient does not have diabetes.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 671

8. A nurse provides dietary counseling for a patient newly diagnosed with type 1 diabetes. Which instruction should be included?
a.
"You may eat any foods you want and cover the glucose increase with sliding scale, regular insulin."
b.
"Most of the calories you eat should be in the form of protein to promote fat breakdown and preserve muscle mass."
c.
"Your total caloric intake should not exceed 1800 calories in a 24-hour period."
d.
"You should use a carbohydrate counting approach to maintain glycemic control."

ANS: D
Patients with diabetes should be given intensive insulin therapy education using either a carbohydrate counting or experience-based estimation approach in achieving glycemic control. A patient with diabetes cannot eat any foods desired and then cover the glucose increase with a sliding scale of regular insulin. Evidence suggests that there is not an ideal percentage of calories that should be ingested from carbohydrate, fat, or protein. Every patient with diabetes must be assessed individually to determine the number of total calories the person should have daily. The total caloric intake should be spread evenly throughout the day, with meals spaced 4 to 5 hours apart.

PTS: 1 DIF: Cognitive Level: Application REF: p. 671

9. What is the most reliable measure for assessing diabetes control over the preceding 3-month period?
a.
Self-monitoring blood glucose (SMBG) graph report
b.
Patient's report
c.
Fasting blood glucose level
d.
Glycosylated hemoglobin level

ANS: D
The glycosylated hemoglobin level tells much about what the plasma glucose concentration has been, on average, over the previous 2 to 3 months. The SMBG graph report is done by the patient and indicates each blood sugar level the patient has on a daily basis. It is not as reliable as the glycosylated hemoglobin level, because the equipment used might not be accurate and the testing may not reflect actual measurements 100% of the time. The patient's report of blood sugar levels is not considered as accurate as the glycosylated hemoglobin level for the same reason that the SMBG is not. One fasting blood glucose level indicates the patient's blood sugar level for that one time when it was obtained.

PTS: 1 DIF: Cognitive Level: Application REF: p. 671

10. A patient with type 1 diabetes reports mixing NPH and regular insulin to allow for one injection. What should the nurse tell the patient?
a.
This is an acceptable practice.
b.
These two forms of insulin are not compatible and cannot be mixed.
c.
Mixing these two forms of insulin may increase the overall potency of the products.
d.
NPH insulin should only be mixed with insulin glargine.

ANS: A
NPH insulin is the only insulin suitable for mixing with short-acting insulins, such as insulin aspart [NovoLog]. These insulins are compatible and are mixed frequently for management of diabetics. The overall potency of each insulin is not increased by mixing them. Insulin glargine cannot be mixed with any other insulin for administration.

PTS: 1 DIF: Cognitive Level: Analysis REF: pp. 679-680

11. Insulin glargine is prescribed for a hospitalized patient who has diabetes. When will the nurse expect to administer this drug?
a.
Approximately 15 to 30 minutes before each meal
b.
In the morning and at 4:00 PM
c.
Once daily at bedtime
d.
After meals and at bedtime

ANS: C
Glargine insulin is indicated for once daily subcutaneous administration to treat adults and children with type 1 diabetes and adults with type 2 diabetes. According to the package labeling, the once-daily injection should be given at bedtime. Glargine insulin should not be given more than once a day, although some patients require bid dosing to achieve a full 24 hours of basal coverage.

PTS: 1 DIF: Cognitive Level: Application REF: p. 679

12. A patient with type 1 diabetes who takes insulin reports taking propranolol for hypertension. Why is the nurse concerned?
a.
The beta blocker can cause insulin resistance.
b.
Using the two agents together increases the risk of ketoacidosis.
c.
Propranolol increases insulin requirements because of receptor blocking.
d.
The beta blocker can mask the symptoms of hypoglycemia.

ANS: D
Beta blockers can delay awareness of and response to hypoglycemia by masking signs associated with stimulation of the sympathetic nervous system (eg, tachycardia, palpitations) that hypoglycemia normally causes. Furthermore, beta blockade impairs glycogenolysis, which is one means by which the body can counteract a fall in blood glucose; beta blockers, therefore, can worsen insulin-induced hypoglycemia. Propranolol does not cause insulin resistance. The incidence of DKA is not increased by concurrent use of propranolol and insulin. Insulin requirements are not increased because of receptor blocking by propranolol.

PTS: 1 DIF: Cognitive Level: Analysis REF: pp. 683-684

13. Which statement is correct about the contrast between acarbose and miglitol?
a.
Miglitol has not been associated with hepatic dysfunction.
b.
With miglitol, sucrose can be used to treat hypoglycemia.
c.
Miglitol is less effective in African Americans.
d.
Miglitol has no gastrointestinal side effects.

ANS: A
Unlike acarbose, miglitol has not been associated with hepatic dysfunction. Sucrose should not be used to treat hypoglycemia with miglitol. Miglitol is more effective in African American patients. Miglitol has gastrointestinal side effects.

PTS: 1 DIF: Cognitive Level: Application REF: pp. 689-690

14. An elderly patient who has type 2 diabetes has a history of severe hypoglycemia. The patient's spouse asks the nurse what the optimum A1c level is for the patient. Which is correct?
a.
Between 6.5 and 7.0
b.
Below 7.0
c.
Below 8.0
d.
Between 7.0 and 8.5

ANS: C
For patients with a history of severe hypoglycemia and those with a limited life expectancy or advanced micro- and macrovascular complications, the target A1c level should be below 8.0. For most other patients with diabetes, the target is 7.0 and below.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 674

15. A patient who has type 2 diabetes will begin taking glipizide [Glucotrol]. Which statement by the patient is concerning to the nurse?
a.
"I will begin by taking this once daily with breakfast."
b.
"It is safe to drink grapefruit juice while taking this drug."
c.
"I may continue to have a glass of wine with dinner."
d.
"I will need to check my blood sugar once daily or more."

ANS: C
Glipizide is a sulfonylurea antidiabetic agent and can cause a disulfiram-like reaction when combined with alcohol. Patients should be taught to avoid alcohol while taking this medication. The initial dosing is once daily with breakfast. There is no drug interaction with grapefruit juice. Patients will need to monitor their blood glucose.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 688

1. A patient newly diagnosed with diabetes expresses concern about losing her vision. Which interventions should be included in the plan of care to reduce this risk? (Select all that apply.)
a.
Initiation of reliable contraception to prevent pregnancy
b.
Ways to reduce hyperglycemic episodes
c.
Use of a prokinetic drug (eg, metoclopramide)
d.
Smoking cessation
e.
Emphasis on the importance of taking antihypertensive drugs consistently

ANS: B, D, E
Tighter glycemic control and fewer hyperglycemic episodes have been correlated with fewer complications. Smoking cessation and strict compliance with any drugs prescribed for hypertension also help reduce the risk of complications. The use of contraception or a prokinetic drug is not related to a reduced risk of vision loss in patients with diabetes.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 669

2. A nurse counsels a patient with diabetes who is starting therapy with an alpha-glucosidase inhibitor. The patient should be educated about the potential for which adverse reactions? (Select all that apply.)
a.
Hypoglycemia
b.
Flatulence
c.
Elevated iron levels in the blood
d.
Fluid retention
e.
Diarrhea

ANS: B, E
Acarbose and miglitol frequently cause flatulence, cramps, abdominal distention, borborygmus (rumbling bowel sounds), and diarrhea. Acarbose also can cause liver damage. Neither acarbose nor miglitol causes hypoglycemia, elevated iron levels, or fluid retention.

PTS: 1 DIF: Cognitive Level: Application REF: pp. 689-690

1. A child with Prader-Willi syndrome (PWS) has short stature, and the provider is considering treatment with growth hormone. Which aspect of this child's history should the nurse report to the provider?
a. Behavior problems
b. Low muscle tone
c. Mental impairment
d. Sleep apnea

D
Growth hormone must be avoided in patients with PWS who are severely obese, who have a history of upper airway obstruction or sleep apnea, or who have severe respiratory impairment because of a risk of sudden death associated with these disorders. Behavior problems, low muscle tone, and mental impairment are commonly associated with PWS and are not contraindications to treatment with growth hormone.

2. A nurse is providing teaching for a nondiabetic adult who develops growth hormone deficiency and who will begin treatment with somatropin [Humatrope]. Which statement by the patient indicates understanding of the teaching?
a. "Intramuscular dosing is more effective than subcutaneous dosing."
b. "I will have increased muscle mass and strength as well as increased height."
c. "I will need to monitor my blood pressure frequently while taking this drug."
d. "I will need to take insulin while using this, because it causes hyperglycemia."

C
Growth hormone in adults causes an increase in systolic blood pressure, so patients should be taught to monitor blood pressure while taking the drug. Subcutaneous dosing is as effective as IM dosing and is preferred, because it is less painful. Although muscle mass will increase, strength and height will not. Growth hormone is diabetogenic but causes significant problems in patients with preexisting diabetes.

3. A 7-year-old child who is otherwise healthy is receiving mecasermin [Increlex] replacement therapy to treat severe primary deficiency of insulin-like growth factor-1 (IGF-1). The child develops tonsillar hypertrophy. The nurse anticipates that the provider will recommend:
a. antibiotics.
b. reducing the dose of mecasermin.
c. discontinuing the mecasermin.
d. tonsillectomy.

D
Mecasermin can cause hypertrophy of the tonsils, which can be managed by tonsillectomy if needed. Antibiotics are not indicated, because the tonsil enlargement is not caused by infection. Neither reducing the dose of mecasermin nor discontinuing the drug is indicated.

4. A nurse is preparing to administer a dose of growth hormone and reconstitutes the medication. After adding the diluent, the nurse notices that the preparation is cloudy. What will the nurse do?
a. Administer the drug as ordered.
b. Discard the drug and prepare another dose.
c. Notify the prescriber.
d. Shake the drug to dissipate the particles.

B
The medication should not be injected if the preparation is cloudy or contains particulate matter. The drug should be discarded and another dose drawn up and administered. There is no need to notify the prescriber. The preparation should never be shaken.

5. A patient is hospitalized with head trauma after a motor vehicle accident. The nurse caring for the patient notes a marked increase in the output of pale, dilute urine. The nurse suspects which condition?
a. Diabetes insipidus
b. Diabetes mellitus
c. Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
d. Water intoxication

A
Deficiency of antidiuretic hormone (ADH) produces hypothalamic diabetes insipidus, in which large volumes of dilute urine are produced. Head trauma can cause the hypothalamus to stop producing ADH. Diabetes mellitus is an endocrine disorder of the pancreas that causes the production of large volumes of nondilute urine. SIADH is a condition in which too much ADH is produced, causing oliguria. Water intoxication occurs with SIADH.

6. The nurse is caring for a patient receiving desmopressin [Stimate]. The nurse is performing a physical assessment and notes that the patient is drowsy and listless and complains of a recent onset of headache. Which finding would be most consistent with these symptoms?
a. Hyperglycemia
b. Hypernatremia
c. Hypertension
d. Water intoxication

D
Water intoxication is manifested by drowsiness, listlessness, and headache. The patient's signs and symptoms are not consistent with hypernatremia or hyperglycemia, and there is no indication of hypertension.

7. A patient with antidiuretic hormone deficiency is receiving desmopressin (DDAVP). The nurse will teach this patient to:
a. avoid grapefruit juice.
b. increase sodium intake.
c. monitor blood pressure.
d. reduce fluid intake.

D
Patients taking desmopressin should be taught to reduce fluid intake to avoid fluid overload, because this drug prevents continued fluid loss. Desmopressin metabolism is not affected by grapefruit juice. Increasing the sodium intake would only cause increased fluid retention. Desmopressin is a weak pressor agent and does not adversely affect hemodynamics, so monitoring blood pressure is not necessary.

8. A nurse teaches a nursing student about the differences between desmopressin (DDAVP) and vasopressin [Pitressin]. Which statement by the student indicates a need for further teaching?
a. "Desmopressin has a shorter duration of action than vasopressin."
b. "Desmopressin is easier to administer than vasopressin."
c. "Vasopressin can be used in cardiac resuscitation."
d. "Vasopressin can cause serious adverse cardiovascular effects."

A
Desmopressin has a long duration of action, which is the reason it is preferred for the treatment of diabetes insipidus. It can be administered intranasally, so it is easier to administer than vasopressin. Vasopressin has hemodynamic effects that can be beneficial during cardiac resuscitation but that also can cause serious adverse cardiovascular effects.

9. A patient with acromegaly asks the nurse about treatments for this condition. What will the nurse tell the patient?
a. Drugs are generally used after surgical and radiation therapies have been tried.
b. Drug therapy is easy to administer.
c. Drug therapy is inexpensive.
d. Drug therapy is generally short term.

A
Drugs for acromegaly are generally reserved for patients who do not respond to other therapies or for whom these therapies are not viable options. Drug therapy requires daily subQ injections and is expensive. Drug therapy is indefinite, not short term.

10. A clinic patient who has cirrhosis of the liver develops hypervolemic hypernatremia. Which medication will the nurse expect the provider to order?
a. Conivaptan [Vaprisol]
b. Desmopressin [DDAVP]
c. Tolvaptan [Samsca]
d. Vasopressin [Pitressin]

C
Tolvaptan is an oral vasopressin antagonist indicated for reducing hypernatremia in patients with euvolemic or hypervolemic hypernatremia. Conivaptan has the same indications, but it is administered IV for hospitalized patients. Desmopressin and vasopressin are antidiuretic hormone replacement medications that will make the condition worse.

11. A male patient reports decreased libido and the nurse notes galactorrhea during a physical assessment. The nurse will report these findings to the provider and will anticipate an order for which medication?
a. Cabergoline
b. Conivaptan
c. Dopamine
d. Prolactin

A
The patient is showing signs of prolactin hypersecretion. Cabergoline is a dopamine agonist and is used to inhibit prolactin release. Conivaptan is used to treat hypernatremia. Dopamine is not given. Prolactin would make the condition worse.

1. Which are indications for discontinuing growth hormone (GH) therapy in children with documented growth hormone deficiency? (Select all that apply.)
a. Epiphyseal closure has begun.
b. A satisfactory adult height has been achieved.
c. Serum GH levels have been normal for 12 consecutive months.
d. Normal serum growth hormone levels occur.
e. The child no longer responds to the hormone.

A, B, E
Treatment with GH for a child with a documented GH deficiency may continue until a satisfactory adult height has been achieved, if a child does not show a response to the hormone, or until epiphyseal closure begins. Treatment does not continue for life, and GH should not be administered during or after closure of the epiphyses. Treatment does not depend on growth hormone levels; these are measured to ensure therapeutic dosing.

2. What are the effects of prolactin secretion in males? (Select all that apply.)
a. Breast development
b. Decreased libido
c. Delayed puberty
d. Galactorrhea
e. Infertility

B, C, D
Prolactin can cause decreased libido, delayed puberty, and galactorrhea in males, but it does not cause breast development or infertility.

A patient who has chronic adrenal insufficiency is admitted to the hospital for an open cholecystectomy. The nurse obtaining the admission history learns that the patient takes hydrocortisone 25 mg PO daily in the morning. The patient's surgery is scheduled for the next morning. The nurse will expect an order to:
a.
administer the usual morning dose of hydrocortisone 25 mg PO.
b.
administer hydrocortisone 50 mg PO in the morning.
c.
administer hydrocortisone 50 mg IV before surgery.
d.
withhold the morning dose of hydrocortisone and give it after surgery.

ANS: C
Patients who take steroids need extra steroid before situations that cause stress, such as surgery. Failure to administer the increased dose can prove fatal. For surgeries that cause moderate stress, such as a cholecystectomy, patients should be given 50 mg of hydrocortisone intravenously the day of the procedure, followed by a taper over 1 to 2 days to the usual replacement dose. Giving the usual dose or giving an increased oral dose is not indicated.

PTS: 1 DIF: Cognitive Level: Application REF: p. 728

A patient who has been newly diagnosed with adrenal hormone deficiency will begin taking hydrocortisone. The nurse provides teaching for this patient. Which statement by the patient indicates understanding of the teaching?
a.
"I may take all of my daily dose in the morning or divide it in half and take it twice daily."
b.
"I will need to take this medication until my symptoms completely clear, and then I may stop."
c.
"Side effects are common with hydrocortisone, even with therapeutic doses."
d.
"When I am sick, I should take three times the normal dose for 3 days in a row."

ANS: D
Patients who take hydrocortisone as replacement need to be taught to increase their daily dose during times of stress, because the drug causes adrenal suppression, and the adrenals will not be able to release cortisone as usual during stress. A general rule of thumb is the "3 by 3 rule": take 3 times the usual dose for 3 days when sick. The daily dose is usually given once in the morning; if late-day fatigue occurs, patients may split the dose and take two-thirds in the morning and one-third in the late afternoon or evening. Treatment is lifetime. Side effects are uncommon when hydrocortisone is given in therapeutic doses.

PTS: 1 DIF: Cognitive Level: Application REF: p. 728

A patient with Cushing's syndrome has undergone surgery and radiation treatment. The nurse will expect to teach the patient about which medication?
a.
Cosyntropin
b.
Dexamethasone
c.
Fludrocortisone acetate [Florinef]
d.
Ketoconazole [Nizoral]

ANS: D
The role of drugs in the treatment of Cushing's syndrome is limited; drugs are used only as adjuncts to surgery and radiation therapy. The most effective agent is ketoconazole, which suppresses steroid synthesis. Cosyntropin is used to diagnose adrenal insufficiency. Dexamethasone is a glucocorticoid used for replacement therapy and to diagnose Cushing's syndrome. Fludrocortisone is used for chronic mineralocorticoid replacement.

PTS: 1 DIF: Cognitive Level: Application REF: pp. 727-728

A patient who has been taking 25 mg of hydrocortisone each morning for several months reports feeling fatigued late in the day each day. What will the nurse tell the patient to discuss with the provider?
a.
Adding a mineralocorticoid to the drug regimen
b.
Assessing serum electrolytes to check for toxicity
c.
Increasing the dose to 50 mg daily
d.
Splitting the daily dose into a morning and an afternoon dose

ANS: D
Patients generally take hydrocortisone once daily in the morning to mimic the body's natural cortisol release cycle. However, some patients develop fatigue late in the day. These patients may split the daily dose, taking two-thirds in the morning and one-third in the afternoon or early evening. Mineralocorticoids are given to maintain intravascular volume and regulate sodium, potassium, and hydrogen, so adding this drug would not help with fatigue. Fatigue is not a sign of steroid toxicity. Increasing the dose is not indicated.

PTS: 1 DIF: Cognitive Level: Application REF: p. 728

A patient with arthritis is admitted to the hospital. The patient's serum glucose level is 350 gm/dL, and the blood pressure is 182/98 mm Hg. The nurse notes that the patient's face appears rounded and puffy. The patient complains of feeling weak. What will the nurse do?
a.
Ask which drugs the patient takes for arthritis.
b.
Contact the provider to discuss whether the patient has a pituitary carcinoma.
c.
Request an order for ketoconazole [Nizoral].
d.
Suspect that this patient has Addison's disease.

ANS: A
Many patients with arthritis are treated with glucocorticoids. Because the doses necessary to suppress inflammation are larger than the physiologic doses used to treat adrenal insufficiency, patients can develop signs of cortisol excess with cushingoid symptoms. This patient has an elevated glucose level, hypertension, and the characteristic moon facies and muscle weakness of Cushing's syndrome; therefore, the nurse would be correct to ask about the medications the patient takes for arthritis. A pituitary carcinoma could be the cause but is less likely. Ketoconazole is used after chemotherapy and radiation therapy in the treatment of a pituitary adenoma. This patient does not show signs of Addison's disease.

PTS: 1 DIF: Cognitive Level: Application REF: pp. 727-728

A patient is given 1 mg of dexamethasone at 11:00 PM; a plasma cortisol level recorded at 8:00 PM the next day is normal. The nurse knows that this is an indication that the patient has what condition?
a.
Addison's disease
b.
Congenital adrenal hyperplasia
c.
Cushing's syndrome
d.
Secondary adrenal insufficiency

ANS: C
The overnight dexamethasone suppression test, which is performed by administering dexamethasone as described, is used to diagnose Cushing's syndrome. In normal individuals, dexamethasone suppresses the release of adrenocorticotropic hormone (ACTH), thereby suppressing the synthesis and release of cortisol, which results in a low cortisol level. In patients with Cushing's syndrome, the cortisol level is normal or only mildly low. This is not an indication of Addison's disease, which is diagnosed by administering cosyntropin. Neither test is useful for diagnosing congenital adrenal hyperplasia or secondary adrenal insufficiency.

A patient is admitted with nausea, vomiting, diarrhea, and abdominal pain. The patient appears emaciated and complains of feeling weak. The nurse notes a heart rate of 98 beats per minute and a blood pressure of 88/54 mm Hg. The nurse reviews the chart and notes an increased serum potassium level and a decreased serum sodium level. The nurse expects the provider to order which medication initially?
a.
Cosyntropin [Cortrosyn]
b.
Dexamethasone
c.
Fludrocortisone [Florinef]
d.
Hydrocortisone

ANS: A
Cosyntropin is used to diagnose adrenal insufficiency, which this patient shows signs of having. Dexamethasone is used to diagnose Cushing's syndrome. Fludrocortisone, a mineralocorticoid, is used with hydrocortisone to treat primary adrenal insufficiency; both of these drugs will be administered after the diagnosis has been confirmed.

PTS: 1 DIF: Cognitive Level: Application REF: p. 730

8. A nurse is explaining congenital adrenal hyperplasia (CAH) to a group of nursing students. Which statement by a student indicates understanding of the teaching?
a.
"CAH is caused by a deficiency of ACTH production."
b.
"CAH is the result of an inability to synthesize glucocorticoids."
c.
"Newborn screening provides a definitive diagnosis for CAH"
d.
"The enzyme 21-alpha-hydroxylase increases the production of androgens."

ANS: B
CAH results from an inborn deficiency of the enzymes needed for glucocorticoid synthesis. The condition is marked by increased production of ACTH, because the pituitary attempts to enhance glucocorticoid synthesis. Newborn screening indicates a deficiency of 21-alpha-hydroxylase; if this is noted, follow-up testing must be done to confirm a diagnosis of CAH. The enzyme 21-alpha-hydroxylase increases the production of glucocorticoids. When this enzyme is deficient, androgens are produced in excess because of stimulation by ACTH.

PTS: 1 DIF: Cognitive Level: Application REF: p. 729

The nurse is providing patient education to a patient who will begin taking fludrocortisone [Florinef] as adjunctive therapy to hydrocortisone. Which statement by the patient indicates understanding of the teaching?
a.
"I should move from sitting to standing slowly."
b.
"I should report any swelling of my hands and feet."
c.
"I should report weight loss to my provider."
d.
"I should report excessive urine output."

ANS: B
Fludrocortisone is a mineralocorticoid that regulates sodium, potassium, and water balance. Water and sodium retention is a particular concern, so the patient should be taught to report any signs of fluid retention, such as swelling of the hands and feet. Fludrocortisone elevates the blood pressure, so hypotension is not a concern. Because fluid retention causes weight gain, patients should be taught to report any increase in weight. Patients should report decreased urine output.

PTS: 1 DIF: Cognitive Level: Application REF: p. 730

The nurse is providing patient education about glucocorticoid therapy to a patient preparing to be discharged home. Which statement made by the patient best demonstrates understanding of glucocorticoid therapy?
a.
"I will take the entire dose early with breakfast."
b.
"I may take two-thirds of the dose in the morning and one-third in the afternoon."
c.
"I will divide the dose in half and take half in the morning and half in the evening."
d.
"I will take a dose with each meal."

ANS: B
Patients should be instructed to follow the prescribed dosing schedule. Some prescribers recommend dividing the daily dose by taking two-thirds in the morning and one-third in the evening. Other prescribers recommend taking the entire daily dose at bedtime. Taking the dose at breakfast, dividing the dose in half, and taking a dose with each meal are not recommended dosing schedules.

PTS: 1 DIF: Cognitive Level: Application REF: p. 728