Endocrine Problems of the Adult Client

1. A client is brought to the emergency department in an unresponsive state, and a diagnosis of

hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which
anticipated primary health care provider’s prescription?

1. Endotracheal intubation

2. 100 units of NPH insulin

3. Intravenous infusion of normal saline

4. Intravenous infusion of sodium bicarbonate

Answer: 3 Rationale: The primary goal of treatment in hyperosmolar hyperglycemic syndrome (HHS) is
to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous (IV)
fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV
infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium
bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium
levels. Intubation and mechanical ventilation are not required to treat HHS. Test-

2. An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the
nurse about the functioning of the pump, the nurse bases the response on which information about the
pump?

1. It is timed to release programmed doses of either short-duration or NPH insulin into the bloodstream
at specific intervals.

2. It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring
blood glucose levels.

3. It is surgically attached to the pancreas and infuses regular insulin into the pancreas. This releases
insulin into the bloodstream.

4. It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-
administer an additional bolus dose from the pump before each meal.

Answer: 4 Rationale: An insulin pump provides a small continuous dose of short-duration (rapid- or
short-acting) insulin subcutaneously throughout the day and night. The client can self-administer an
additional bolus dose from the pump before each meal as needed. Short-duration insulin is used in an
insulin pump. An external pump is not attached surgically to the pancreas.

3. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department.
Which findings support this diagnosis? Select all that apply.

1. Increase in pH
2. Comatose state

3. Deep, rapid breathing

4. Decreased urine output

5. Elevated blood glucose level

Answer: 2, 3, 5 Rationale: Because of the profound deficiency of insulin associated with DKA, glucose
cannot be used for energy and the body breaks down fat as a secondary source of energy. Ketones,
which are acid by-products of fat metabolism, build up, and the client experiences a metabolic
ketoacidosis. High serum glucose contributes to an osmotic diuresis and the client becomes severely
dehydrated. If untreated, the client will become comatose due to severe dehydration, acidosis, and
electrolyte imbalance. Kussmaul’s respirations, the deep rapid breathing associated with DKA, is a
compensatory mechanism by the body. The body attempts to correct the acidotic state by blowing off
carbon dioxide (CO2), which is an acid. In the absence of insulin, the client will experience severe
hyperglycemia. Option 1 is incorrect, because in acidosis the pH would be low. Option 4 is incorrect
because a high serum glucose will result in an osmotic diuresis and the client will experience polyuria.

4. The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and
ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose
should be taken if which symptoms develop? Select all that apply.

1. Polyuria

2. Shakiness

3. Palpitations

4. Blurred vision

5. Lightheadedness

6. Fruity breath odor

Answer: 2, 3, 5 Rationale: Shakiness, palpitations, and lightheadedness are signs/symptoms of

hypoglycemia and would indicate the need for food or glucose. Polyuria, blurred vision, and a fruity
breath odor are manifestations of hyperglycemia.

5. A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the
treatment of hyperglycemia. What is the appropriate intervention to decrease the client’s anxiety?

1. Administer a sedative.

2. Convey empathy, trust, and respect toward the client.

3. Ignore the signs and symptoms of anxiety, anticipating that they will soon disappear.
4. Make sure that the client is familiar with the correct medical terms to promote understanding of what
is happening.

Answer: 2 Rationale: Anxiety is a subjective feeling of apprehension, uneasiness, or dread. The

appropriate intervention is to address the client’s feelings related to the anxiety. Administering a
sedative is not the most appropriate intervention and does not address the source of the client’s
anxiety. The nurse should not ignore the client’s anxious feelings. Anxiety needs to be managed before
meaningful client education can occur.

6. The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse
recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes
which statement?

1. “I will stop taking my insulin if I’m too sick to eat.”

2. “I will decrease my insulin dose during times of illness.”

3. “I will adjust my insulin dose according to the level of glucose in my urine.”

4. “I will notify my primary health care provider (PHCP) if my blood glucose level is higher than 250
mg/dL (13.9 mmol/L).”

Answer: 4 Rationale: During illness, the client with type 1 diabetes mellitus is at increased risk of diabetic
ketoacidosis, due to hyperglycemia associated with the stress response and due to a typically decreased
caloric intake. As part of sick day management, the client with diabetes should monitor blood glucose
levels and should notify the PHCP if the level is higher than 250 mg/dL (13.9 mmol/L). Insulin should
never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be
adjusted without the PHCP’s advice and are usually adjusted on the basis of blood glucose levels, not
urinary glucose readings.

7. A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood
glucose level is 950 mg/dL (52.9 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is
initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240
mg/dL (13.3 mmol/L). The nurse would next prepare to administer which medication?

1. An ampule of 50% dextrose

2. NPH insulin subcutaneously

3. IV fluids containing dextrose

4. Phenytoin for the prevention of seizures

Answer: 3 Rationale: Emergency management of DKA focuses on correcting fluid and electrolyte
imbalances and normalizing the serum glucose level. If the corrections occur too quickly, serious
consequences, including hypoglycemia and cerebral edema, can occur. During management of DKA,
when the blood glucose level falls to 250 to 300 mg/dL (13.9 to 16.7 mmol/L), the IV infusion rate is
reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL (13.9
mmol/L), or until the client recovers from ketosis. Fifty percent dextrose is used to treat hypoglycemia.
NPH insulin is not used to treat DKA. Phenytoin is not a usual treatment measure for DKA.

8. The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications.
Which sign or symptom, if frequently exhibited in the client, indicates that the client is at risk for chronic
complications of diabetes if the blood glucose is not adequately managed?

1. Polyuria

2. Diaphoresis

3. Pedal edema

4. Decreased respiratory rate

Answer: 1 Rationale: Chronic hyperglycemia, resulting from poor glycemic control, contributes to the
microvascular and macrovascular complications of diabetes mellitus. Classic symptoms of hyperglycemia
include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in hypoglycemia. Hypoglycemia is an
acute complication of diabetes mellitus; however, it does not predispose a client to the chronic
complications of diabetes mellitus. Therefore, option 2 can be eliminated because this finding is
characteristic of hypoglycemia. Options 3 and 4 are not associated with diabetes mellitus.

9. The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The
nurse places priority on which client problem?

1. Lack of knowledge

2. Inadequate fluid volume

3. Compromised family coping

4. Inadequate consumption of nutrients

Answer: 2 Rationale: An increased blood glucose level will cause the kidneys to excrete the glucose in
the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to
dehydration. This fluid loss must be replaced when it becomes severe. Options 1, 3, and 4 are not
related specifically to the information in the question.

10. The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client reports a
history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24
hours. Which additional statement by the client indicates a need for further teaching?

1. “I need to stop my insulin.”

2. “I need to increase my fluid intake.”

3. “I need to monitor my blood glucose every 3 to 4 hours.”

4. “I need to call my primary health care provider (PHCP) because of these symptoms.”

Answer: 1 Rationale: When a client with diabetes mellitus is unable to eat normally because of illness,
the client still should take the prescribed insulin or oral medication. The client should consume
additional fluids and should notify the PHCP. The client should monitor the blood glucose level every 3
to 4 hours. The client should also monitor the urine for ketones during illness.

11. The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client’s
nostril. The nurse should take which initial action?

1. Lower the head of the bed.

2. Test the drainage for glucose.

3. Obtain a culture of the drainage.

4. Continue to observe the drainage.

Answer: 2 Rationale: After hypophysectomy, the client should be monitored for rhinorrhea, which could
indicate a cerebrospinal fluid leak. If this occurs, the drainage should be collected and tested for the
presence of cerebrospinal fluid. Cerebrospinal fluid contains glucose, and if positive, this would indicate
that the drainage is cerebrospinal fluid. The head of the bed should remain elevated to prevent
increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture.
Continuing to observe the drainage without taking action could result in a serious complication.

12. The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic
hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which primary health
care provider prescriptions should the nurse anticipate receiving? Select all that apply.

1. Initiate an infusion of 3% NaCl.

2. Administer intravenous furosemide.

3. Restrict fluids to 800 mL over 24 hours.

4. Elevate the head of the bed to high-Fowler’s. 5. Administer a vasopressin antagonist as prescribed.

Answer: 1, 3, 5 Rationale: Clients with SIADH experience excess secretion of antidiuretic hormone (ADH),
which leads to excess intravascular volume, a declining serum osmolarity, and dilutional hyponatremia.
Management is directed at correcting the hyponatremia and preventing cerebral edema. Hypertonic
saline is prescribed when the hyponatremia is severe, less than 120 mEq/L (120 mmol/L). An
intravenous (IV) infusion of 3% saline is hypertonic. Hypertonic saline must be infused slowly as
prescribed, and an infusion pump must be used. Fluid restriction is a useful strategy aimed at correcting
dilutional hyponatremia. Vasopressin is an ADH; vasopressin antagonists are used to treat SIADH.
Furosemide may be used to treat extravascular volume and dilutional hyponatremia in SIADH, but it is
only safe to use if the serum sodium is at least 125 mEq/L (125 mmol/L). When furosemide is used,
potassium supplementation should also occur and serum potassium levels should be monitored. To
promote venous return, the head of the bed should not be raised more than 10 degrees for the client
with SIADH. Maximizing venous return helps avoid stimulating stretch receptors in the heart that signal
to the pituitary that more ADH is needed.

13. A client is admitted to an emergency department, and a diagnosis of myxedema coma is made.
Which action should the nurse prepare to carry out initially?

1. Warm the client.

2. Maintain a patent airway.

3. Administer thyroid hormone.

4. Administer fluid replacement.

Answer: 2 Rationale: Myxedema coma is a rare but serious disorder that results from persistently low
thyroid production. Coma can be precipitated by acute illness, rapid withdrawal of thyroid medication,
anesthesia and surgery, hypothermia, and the use of sedatives and opioid analgesics. In myxedema
coma, the initial nursing action is to maintain a patent airway. Oxygen should be administered, followed
by fluid replacement, keeping the client warm, monitoring vital signs, and administering thyroid
hormones by the intravenous route.

14. The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis
(DKA). In the acute phase, the nurse plans for which priority intervention?

1. Correct the acidosis.

2. Administer 5% dextrose intravenously.

3. Apply a monitor for an electrocardiogram.

4. Administer short-duration insulin intravenously.

Answer: 4 Rationale: Lack of insulin (absolute or relative) is the primary cause of DKA. Treatment
consists of insulin administration (short- or rapid-acting), intravenous fluid administration (normal saline
initially, not 5% dextrose), and potassium replacement, followed by correcting acidosis. Cardiac
monitoring is important due to alterations in potassium levels associated with DKA and its treatment,
but applying an electrocardiogram monitor is not the priority action.

15. A client with type 1 diabetes mellitus who takes NPH daily in the morning calls the nurse to report
recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an
adequate understanding of the peak action of NPH insulin and exercise?

1. “I should not exercise since I am taking insulin.”

2. “The best time for me to exercise is after breakfast.”

3. “The best time for me to exercise is mid- to late afternoon.”

4. “NPH is a basal insulin, so I should exercise in the evening.”

Answer: 2 Rationale: Exercise is an important part of diabetes management. It promotes weight loss,
decreases insulin resistance, and helps control blood glucose levels. A hypoglycemic reaction may occur
in response to increased exercise, so clients should exercise either an hour after mealtime or after
consuming a 10- to 15-g carbohydrate snack, and they should check their blood glucose level before
exercising. Option 1 is incorrect because clients with diabetes should exercise, though they should check
with their primary health care provider before starting a new exercise program. Option 3 in incorrect;
clients should avoid exercise during the peak time of insulin. NPH insulin peaks at 4 to 12 hours;
therefore, afternoon exercise takes place during the peak of the medication. Option 4 is incorrect; NPH
insulin is an intermediate acting insulin, not a basal insulin.

16. The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for
primary hyperparathyroidism. Which client complaints would be characteristic of this disorder? Select all
that apply.

1. Polyuria

2. Headache

3. Bone pain

4. Nervousness

5. Weight gain

Answer: 1, 3 Rationale: The role of parathyroid hormone (PTH) in the body is to maintain serum calcium
homeostasis. In hyperparathyroidism, PTH levels are high, which causes bone resorption (calcium is
pulled from the bones). Hypercalcemia occurs with hyperparathyroidism. Elevated serum calcium levels
produce osmotic diuresis and thus polyuria. This diuresis leads to dehydration (weight loss rather than
weight gain). Loss of calcium from the bones causes bone pain. Options 2, 4, and 5 are not associated
with hyperparathyroidism. Some gastrointestinal symptoms include anorexia, nausea, vomiting, and
constipation.

17. The nurse is teaching a client with hyperparathyroidism how to manage the condition at home.
Which response by the client indicates the need for additional teaching?

1. “I should consume less than 1 liter of fluid per day.”

2. “I should use my treadmill or go for walks daily.”

3. “I should follow a moderate-calcium, high-fiber diet.”

4. “My alendronate helps keep calcium from coming out of my bones.”

Answer: 1 Rationale: In hyperparathyroidism, clients experience excess parathyroid hormone (PTH)
secretion. A role of PTH in the body is to maintain serum calcium homeostasis. When PTH levels are
high, there is excess bone resorption (calcium is pulled from the bones). In clients with elevated serum
calcium levels, there is a risk of nephrolithiasis. One to two liters of fluids daily should be encouraged to
protect the kidneys and decrease the risk of nephrolithiasis. Moderate physical activity, particularly
weight-bearing activity, minimizes bone resorption and helps protect against pathological fracture.
Walking, as an exercise, should be encouraged in the client with hyperparathyroidism. Even though
serum calcium is already high, clients should follow a moderate-calcium diet, because a low-calcium diet
will surge PTH. Calcium causes constipation, so a diet high in fiber is recommended. Alendronate is a
bisphosphate that inhibits bone resorption. In bone resorption, bone is broken down and calcium is
deposited into the serum.

18. A client with a diagnosis of Addisonian crisis is being admitted to the intensive care unit. Which
findings will the interprofessional health care team focus on? Select all that apply.

1. Hypotension

2. Leukocytosis

3. Hyperkalemia

4. Hypercalcemia

5. Hypernatremia

Answer: 1, 3 Rationale: In Addison’s disease, also known as adrenal insufficiency, destruction of the
adrenal gland leads to decreased production of adrenocortical hormones, including the glucocorticoid
cortisol and the mineralocorticoid aldosterone. Addisonian crisis, also known as acute adrenal
insufficiency, occurs when there is extreme physical or emotional stress and lack of sufficient
adrenocortical hormones to manage the stressor. Addisonian crisis is a life-threatening emergency. One
of the roles of endogenous cortisol is to enhance vascular tone and vascular response to the
catecholamines epinephrine and norepinephrine. Hypotension occurs when vascular tone is decreased
and blood vessels cannot respond to epinephrine and norepinephrine. The role of aldosterone in the
body is to support the blood pressure by holding salt and water and excreting potassium. When there is
insufficient aldosterone, salt and water are lost and potassium builds up; this leads to hypotension from
decreased vascular volume, hyponatremia, and hyperkalemia. The remaining options are not associated
with Addisonian crisis.

19. The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being
treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a
possible hypoglycemic reaction? Select all that apply.

1. Tremors

2. Anorexia
3. Irritability

4. Nervousness

5. Hot, dry skin

6. Muscle cramps

Answer: 1, 3, 4 Rationale: Decreased blood glucose levels produce autonomic nervous system
symptoms, which are manifested classically as nervousness, irritability, and tremors. Option 5 is more
likely to occur with hyperglycemia. Options 2 and 6 are unrelated to the manifestations of
hypoglycemia. In hypoglycemia, usually the client feels hunger.

20. The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data
would indicate a potential complication associated with this disorder?

1. A urinary output of 50 mL/hr

2. A coagulation time of 5 minutes

3. A heart rate that is 90 beats per minute and irregular

4. A blood urea nitrogen level of 20 mg/dL (7.1 mmol/L)

Answer: 3 Rationale: Pheochromocytoma is a catecholamine-producing tumor usually found in the

adrenal medulla, but extra-adrenal locations include the chest, bladder, abdomen, and brain; it is
typically a benign tumor but can be malignant. Excessive amounts of epinephrine and norepinephrine
are secreted. The complications associated with pheochromocytoma include hypertensive retinopathy
and nephropathy, myocarditis, increased platelet aggregation, and stroke. Death can occur from shock,
stroke, kidney failure, dysrhythmias, or dissecting aortic aneurysm. An irregular heart rate indicates the
presence of a dysrhythmia. A coagulation time of 5 minutes is normal. A urinary output of 50 mL/hr is an
adequate output. A blood urea nitrogen level of 20 mg/dL (7.1 mmol/L) is a normal finding.

21. The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal
hypophysectomy and is recovering in the intensive care unit. Which findings should alert the nurse to
the presence of a possible postoperative complication? Select all that apply.

1. Anxiety 2. Leukocytosis

3. Chvostek’s sign

4. Urinary output of 800 mL/hr

5. Clear drainage on nasal dripper pad

Answer: 2, 4, 5 Rationale: Acromegaly results from excess secretion of growth hormone, usually caused
by a benign tumor on the anterior pituitary gland. Treatment is surgical removal of the tumor, usually
with a sublingual transsphenoidal complete or partial hypophysectomy. The sublingual transsphenoidal
approach is often through an incision in the inner upper lip at the gum line. Transsphenoidal surgery is a
type of brain surgery, and infection is a primary concern. Leukocytosis, or an elevated white count, may
indicate infection. Diabetes insipidus is a possible complication of transsphenoidal hypophysectomy. In
diabetes insipidus there is decreased secretion of antidiuretic hormone, and clients excrete large
amounts of dilute urine. Following transsphenoidal surgery, the nasal passages are packed and a dripper
pad is secured under the nares. Clear drainage on the dripper pad is suggestive of a cerebrospinal fluid
leak. The surgeon should be notified and the drainage should be tested for glucose. A cerebrospinal fluid
leak increases the postoperative risk of meningitis. Anxiety is a nonspecific finding that is common to
many disorders. Chvostek’s sign is a test of nerve hyperexcitability associated with hypocalcemia and is
seen as grimacing in response to tapping on the facial nerve. Chvostek’s sign has no association with
complications of sublingual transsphenoidal hypophysectomy.

22. The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include
a fasting blood glucose level of 70 mg/dL (3.9 mmol/L), temperature of 101° F (38.3° C), pulse of 82
beats per minute, respirations of 20 breaths per minute, and blood pressure of 118/68 mm Hg. Which
finding would be the priority concern to the nurse?

1. Pulse

2. Respiration

3. Temperature

4. Blood pressure

Answer: 3 Rationale: In the client with type 2 diabetes mellitus, an elevated temperature may indicate
infection. Infection is a leading cause of hyperosmolar hyperglycemic syndrome in the client with type 2
diabetes mellitus. The other findings are within normal limits.

23. The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse
determines that the client understands discharge instructions if the client states that which signs and
symptoms are associated with this diagnosis? Select all that apply.

1. Tremors

2. Weight loss

3. Feeling cold

4. Loss of body hair

5. Persistent lethargy

6. Puffiness of the face

Answer: 3, 4, 5, 6 Rationale: Feeling cold, hair loss, lethargy, and facial puffiness are signs of
hypothyroidism. Tremors and weight loss are signs of hyperthyroidism.
24. A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the
priority for this client?

1. Hoarseness

2. Hypocalcemia

3. Audible stridor

4. Edema at the surgical site

Answer: 3 Rationale: Thyroidectomy is the removal of the thyroid gland, which is located in the anterior
neck. It is very important to monitor airway status, as any swelling to the surgical site could cause
respiratory distress. Although all of the options are important for the nurse to monitor, the priority
nursing

25. A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and
symptoms indicating a complication of this disorder? Select all that apply.

1. Fever

2. Nausea

3. Lethargy

4. Tremors

5. Confusion

6. Bradycardia

action is to monitor the airway.

Answer: 1, 2, 4, 5 Rationale: Thyroid storm is an acute and life-threatening complication that occurs in a
client with uncontrollable hyperthyroidism. Signs and symptoms of thyroid storm include elevated
temperature (fever), nausea, and tremors. In addition, as the condition progresses, the client becomes
confused. The client is restless and anxious and experiences tachycardia.

26. The nurse is teaching a client with diabetes mellitus how to mix regular insulin and NPH insulin in the
same syringe. Which action, if performed by the client, indicates the need for further teaching?

1. Withdraws the NPH insulin first

2. Withdraws the regular insulin first

3. Injects air into NPH insulin vial first

4. Injects an amount of air equal to the desired dose of insulin into each vial
Answer: 1 Rationale: When preparing a mixture of short-acting insulin, such as regular insulin, with
another insulin preparation, the short-acting insulin is drawn into the syringe first. This sequence will
avoid contaminating the vial of short-acting insulin with insulin of another type. Options 2, 3, and 4
identify correct actions for preparing NPH and short-acting insulin.

27. The home care nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin
NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should
tell the client to take which action?

1. Freeze the insulin.

2. Refrigerate the insulin.

3. Store the insulin in a dark, dry place.

4. Keep the insulin at room temperature.

Answer: 2 Rationale: Insulin in unopened vials should be stored under refrigeration until needed. Vials
should not be frozen. When stored unopened under refrigeration, insulin can be used up to the
expiration date on the vial. Options 1, 3, and 4 are incorrect.

27. Glimepiride is prescribed for a client with diabetes mellitus. The nurse instructs the client that which
food items are most acceptable to consume while taking this medication? Select all that apply.

1. Alcohol

2. Red meats

3. Whole-grain cereals

4. Low-calorie desserts

5. Carbonated beverages

Answer: 2, 3, 5 Rationale: When alcohol is combined with glimepiride, a disulfiram-like reaction may
occur. This syndrome includes flushing, palpitations, and nausea. Alcohol can also potentiate the
hypoglycemic effects of the medication. Clients need to be instructed to avoid alcohol consumption
while taking this medication. Low-calorie desserts should also be avoided. Even though the calorie
content may be low, carbohydrate content is most likely high and can affect the blood glucose. The
items in options 2, 3, and 5 are acceptable to consume.

28. The nurse is providing discharge teaching for a client newly diagnosed with type 2 diabetes mellitus
who has been prescribed metformin. Which client statement indicates the need for further teaching?

1. “It is okay if I skip meals once in a while.”

2. “I need to let my doctor know if I get unusually tired.”

3. “I need to constantly watch for signs of low blood sugar.”

4. “I will be sure to not drink alcohol excessively while on this medication.”

Answer: 3 Rationale: Metformin is classified as a biguanide and is the most commonly used medication
for type 2 diabetes mellitus initially. It is also often used as a preventive medication for those at high risk
for developing diabetes mellitus. When used alone, metformin lowers the blood glucose after meal
intake as well as fasting blood glucose levels. Metformin does not stimulate insulin release and therefore
poses little risk for hypoglycemia. For this reason, metformin is well suited for clients who skip meals.
Unusual somnolence as well as hyperventilation, myalgia, and malaise are early signs of lactic acidosis, a
toxic effect associated with metformin. If any of these signs or symptoms occur, the client should inform
the primary health care provider immediately. While it is best to avoid consumption of alcohol, it is not
always realistic or feasible for clients to quit drinking altogether; for this reason, clients should be
informed that excessive alcohol intake can cause an adverse reaction with metformin.

30. The primary health care provider (PHCP) prescribes exenatide for a client with type 1 diabetes
mellitus who takes insulin. The nurse should plan to take which most appropriate intervention?

1. Withhold the medication and call the PHCP, questioning the prescription for the client.

2. Teach the client about the signs and symptoms of hypoglycemia and hyperglycemia.

3. Monitor the client for gastrointestinal side effects after administering the medication.

4. Withdraw the insulin from the prefilled pen into an insulin syringe to prepare for administration.

Answer: 1 Rationale: Exenatide is an incretin mimetic used for type 2 diabetes mellitus only. It is not
recommended for clients taking insulin. Hence the nurse should withhold the medication and question
the PHCP regarding this prescription. Although options 2 and 3 are correct statements about the
medication, in this situation the medication should not be administered. The medication is packaged in
prefilled pens ready for injection without the need for drawing it up into another syringe.

31. A client with diabetes mellitus is taking Humulin NPH insulin and regular insulin every morning. The
nurse should provide which instructions to the client? Select all that apply.

1. Hypoglycemia may be experienced before dinnertime.

2. The insulin dose should be decreased if illness occurs.

3. The insulin should be administered at room temperature.

4. The insulin vial needs to be shaken vigorously to break up the precipitates.

5. The NPH insulin should be drawn into the syringe first, then the regular insulin.

Answer: 1, 3 Rationale: Humulin NPH is an intermediate-acting insulin. The onset of action is 60 to 120
minutes, it peaks in 6 to 14 hours, and its duration of action is 16 to 24 hours. Regular insulin is a short-
acting insulin. Depending on the type, the onset of action is 30 to 60 minutes, it peaks in 1 to 5 hours,
and its duration is 6 to 10 hours. Hypoglycemic reactions most likely occur during peak time. Insulin
should be at room temperature when administered. Clients may need their insulin dosages increased
during times of illness. Insulin vials should never be shaken vigorously. Regular insulin is always drawn
up before NPH.

32. The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes
mellitus. The client is prescribed repaglinide and metformin. The nurse should provide which
instructions to the client? Select all that apply.

1. Diarrhea may occur secondary to the metformin.

2. The repaglinide is not taken if a meal is skipped.

3. The repaglinide is taken 30 minutes before eating.

4. A simple sugar food item is carried and used to treat mild hypoglycemia episodes.

5. Muscle pain is an expected effect of metformin and may be treated with acetaminophen.

6. Metformin increases hepatic glucose production to prevent hypoglycemia associated with repaglinide.

Answer: 1, 2, 3, 4 Rationale: Repaglinide, a rapid-acting oral hypoglycemic agent that stimulates

pancreatic insulin secretion, should be taken before meals (approximately 30 minutes before meals) and
should be withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide and the client
should always be prepared by carrying a simple sugar at all times. Metformin is an oral hypoglycemic
given in combination with repaglinide and works by decreasing hepatic glucose production. A common
side effect of metformin is diarrhea. Muscle pain may occur as an adverse effect from metformin, but it
might signify a more serious condition that warrants primary health care provider notification, not the
use of acetaminophen.

33. The nurse is teaching the client about his prescribed prednisone. Which statement, if made by the
client, indicates that further teaching is necessary?

1. “I can take aspirin or my antihistamine if I need it.”

2. “I need to take the medication every day at the same time.”

3. “I need to avoid coffee, tea, cola, and chocolate in my diet.”

4. “If I gain 5 pounds or more a week, I will call my doctor.”

Answer: 1 Rationale: Aspirin and other over-the-counter medications should not be taken unless the
client consults with the PHCP. The client needs to take the medication at the same time every day and
should be instructed not to stop the medication. A slight weight gain as a result of an improved appetite
is expected; however, after the dosage is stabilized, a weight gain of 5 pounds (2.25 kg) or more weekly
should be reported to the PHCP. Caffeine-containing foods and fluids need to be avoided because they
may contribute to steroid-ulcer development.
34. A client with hyperthyroidism has been given methimazole. Which nursing considerations are
associated with this medication? Select all that apply.

1. Administer methimazole with food.

2. Place the client on a low-calorie, low-protein diet.

3. Assess the client for unexplained bruising or bleeding.

4. Instruct the client to report side and adverse effects such as sore throat, fever, or headaches. 5. Use
special radioactive precautions when handling the client’s urine for the first 24 hours following initial
administration.

Answer: 1, 3, 4 Rationale: Common side effects of methimazole include nausea, vomiting, and diarrhea.
To address these side effects, this medication should be taken with food. Because of the increase in
metabolism that occurs in hyperthyroidism, the client should consume a high-calorie diet. Antithyroid
medications can cause agranulocytosis with leukopenia and thrombocytopenia. Sore throat, fever,
headache, or bleeding may indicate agranulocytosis and the primary health care provider should be
notified immediately. Methimazole is not radioactive and should not be stopped abruptly, due to the
risk of thyroid storm.

35. The nurse is monitoring a client receiving levothyroxine sodium for hypothyroidism. Which findings
indicate the presence of a side effect associated with this medication? Select all that apply.

1. Insomnia

2. Weight loss

3. Bradycardia

4. Constipation

5. Mild heat intolerance

Answer: 1, 2, 5 Rationale: Insomnia, weight loss, and mild heat intolerance are side effects of
levothyroxine sodium. Bradycardia and constipation are not side effects associated with this medication,
and rather are associated with hypothyroidism, which is the disorder that this medication is prescribed
to treat.

36. The nurse provides instructions to a client who is taking levothyroxine. The nurse should tell the
client to take the medication in which way?

1. With food

2. At lunchtime

3. On an empty stomach
4. At bedtime with a snack

Answer: 3 Rationale: Oral doses of levothyroxine should be taken on an empty stomach to enhance
absorption. Dosing should be done in the morning before breakfast.

37. The nurse should tell the client who is taking levothyroxine to notify the primary health care
provider (PHCP) if which problem occurs?

1. Fatigue

2. Tremors

3. Cold intolerance

4. Excessively dry skin

Answer: 2 Rationale: Excessive doses of levothyroxine can produce signs and symptoms of
hyperthyroidism. These include tachycardia, chest pain, tremors, nervousness, insomnia, hyperthermia,
extreme heat intolerance, and sweating. The client should be instructed to notify the PHCP if these
occur. Options 1, 3, and 4 are signs of hypothyroidism.

38. The nurse is providing instructions to the client newly diagnosed with diabetes mellitus who has
been prescribed pramlintide. Which instruction should the nurse include in the discharge teaching?

1. “Inject the pramlintide at the same time you take your other medications.”

2. “Take your prescribed pills 1 hour before or 2 hours after the injection.”

3. “Be sure to take the pramlintide with food so you don’t upset your stomach.”

4. “Make sure you take your pramlintide immediately after you eat so you don’t experience a low blood
sugar.”

Answer: 2 Rationale: Pramlintide is used for clients with types 1 and 2 diabetes mellitus who use insulin.
It is administered subcutaneously before meals to lower blood glucose level after meals, leading to less
fluctuation during the day and better long-term glucose control. Because pramlintide delays gastric
emptying, any prescribed oral medications should be taken 1 hour before or 2 hours after an injection of
pramlintide; therefore, instructing the client to take his or her pills 1 hour before or 2 hours after the
injection is correct. Pramlintide should not be taken at the same time as other medications. Pramlintide
is given immediately before the meal in order to control postprandial rise in blood glucose, not
necessarily to prevent stomach upset. It is incorrect to instruct the client to take the medication after
eating, as it will not achieve its full therapeutic effect

39. The nurse teaches the client who is newly diagnosed with diabetes insipidus about the prescribed
intranasal desmopressin. Which statements by the client indicate understanding? Select all that apply.
1. “This medication will turn my urine orange.”

2. “I should decrease my oral fluids when I start this medication.”

3. “The amount of urine I make should increase if this medicine is working.”

4. “I need to follow a low-fat diet to avoid pancreatitis when taking this medicine.”

5. “I should report headache and drowsiness to my doctor since these symptoms could be related to my
desmopressin.”

Answer: 2, 5 Rationale: In diabetes insipidus, there is a deficiency in antidiuretic hormone (ADH),

resulting in large urinary losses. Desmopressin is an antidiuretic hormone that enhances reabsorption of
water in the kidney. Clients with diabetes insipidus drink high volumes of fluid (polydipsia) as a
compensatory mechanism to counteract urinary losses and maintain fluid balance. Once desmopressin
is started, oral fluids should be decreased to prevent water intoxication. Therefore, clients with diabetes
insipidus should decrease their oral fluid intake when they start desmopressin. Headache and
drowsiness are signs of water intoxication in the client taking desmopressin and should be reported to
the primary health care provider. Desmopressin does not turn urine orange. The amount of urine should
decrease, not increase, when desmopressin is started. Desmopressin does not cause pancreatitis.

40. A daily dose of prednisone is prescribed for a client. The nurse provides instructions to the client
regarding administration of the medication and should instruct the client that which time is best to take
this medication?

1. At noon

2. At bedtime

3. Early morning

4. Any time, at the same time, each day

Answer: 3 Rationale: Corticosteroids (glucocorticoids) should be administered before 9 a.m.

Administration at this time helps minimize adrenal insufficiency and mimics the burst of glucocorticoids
released naturally by the adrenal glands each morning. Options 1, 2, and 4 are incorrect.

41. The client with hyperparathyroidism is taking alendronate. Which statements by the client indicate
understanding of the proper way to take this medication? Select all that apply.

1. “I should take this medication with food.”

2. “I should take this medication at bedtime.”

3. “I should sit up for at least 30 minutes after taking this medication.”

4. “I should take this medication first thing in the morning on an empty stomach.”
5. “I can pick a time to take this medication that best fits my lifestyle as long as I take it at the same time
each day.”

Answer: 3, 4 Rationale: Alendronate is a bisphosphonate used in hyperparathyroidism to inhibit bone

loss and normalize serum calcium levels. Esophagitis is an adverse effect of primary concern in clients
taking alendronate. For this reason, the client is instructed to take alendronate first thing in the morning
with a full glass of water on an empty stomach, not to eat or drink anything else for at least 30 minutes
after taking the medication, and to remain sitting upright for at least 30 minutes after taking it.

42. A client with diabetes mellitus visits a health care clinic. The client’s diabetes mellitus previously had
been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180 to
200 mg/dL (10 to 11.1 mmol/L). Which medication, if added to the client’s regimen, may have
contributed to the hyperglycemia?

1. Atenolol

2. Prednisone

3. Phenelzine

4. Allopurinol

Answer: 2 Rationale: Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and
potassium supplements. Option 1, a beta blocker, and option 3, a monoamine oxidase inhibitor, have
their own intrinsic hypoglycemic activity. Option 4 decreases urinary excretion of sulfonylurea agents,
causing increased levels of the oral agents, which can lead to hypoglycemia.