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CHAPTER 19
The Endocrine System
19.1•The nurse is reviewing laboratory results for a healthy 68-year-old client who is a
new client to a medical practice. The glycosylated hemoglobin (HbA1c) result is 6.0%.
The nurse knows that
1. the client needs a workup to determine the cause of the anemia.
2. the client has undiagnosed type 2 diabetes mellitus.
3. the client has had an average blood glucose level of 120 over the past 3 months.
4. the client needs a referral to a dietician.
Answer: 3
Rationale: The glycosylated hemoglobin gives the practitioner an estimate of the client’s
blood glucose over the past 3 months by measuring how much glucose is attached to the
hemoglobin in red blood cells, which have an average life span of about 4 months. A
HbA1c of 6 relates to an average glucose level of 120. Ideally, the glycosylated
hemoglobin should be less than 7.0%. The glycosylated hemoglobin does not relate to
anemia and is not used to diagnose diabetes. There is no need for a dietician referral
based on this data.
Assessment
Physiological Integrity
Analysis
19.2•The priority goal for older clients diagnosed with diabetes mellitus is
1.
2.
3.
4.
maintenance of proper glycemic control.
yearly eye examinations.
keeping appointments with podiatrists for foot care.
recognizing the symptoms of myocardial infarction and knowing the correct action
to take.
Answer: 1
Rationale: Maintenance of proper control over glucose levels is imperative to stop the
damaging affects associated with abnormally high levels of blood glucose. Yearly eye
examinations, proper foot care, and being aware of the manifestations of coronary heart
disease are important, but proper blood glucose control will decrease the likelihood of
these complications of diabetes from occurring.
Planning
Physiological Integrity
Application
19.3•Smoking cessation is especially important for clients with diabetes mellitus because
smoking
1. promotes weight gain.
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2. is a major factor in the development of diabetic neuropathy.
3. accelerates arteriosclerotic changes in blood vessels.
4. increases insulin resistance.
Answer: 3
Rationale: Smoking is especially unhealthy for diabetic clients because smoking
accelerates the arteriosclerotic effects that occur in blood vessels from elevated levels of
blood glucose. Smoking is not associated with weight gain; in fact, people use weight
gain as an excuse not to quit smoking. Poor glycemic control in diabetics is associated
with the development of complications including diabetic neuropathy. Smoking does not
affect insulin resistance.
Diagnosis
Physiological Integrity
Analysis
19.4•A risk factor for the diabetic client associated with aggressive glycemic control is
1. the development of foot ulcers.
2. decreased vision acuity associated with diabetic retinopathy.
3. frequent skin yeast infections.
4. hypoglycemic episodes.
Answer: 4
Rationale: Aggressive glycemic control involves keeping the blood glucose level at levels
low enough to decrease complications of diabetes mellitus. This increases the risk of
hypoglycemia. Blood glucose levels that are too low put clients at risk for falls,
disorientation, and dehydration. Foot ulcers, diabetic retinopathy, and frequent skin yeast
infections are all associated with poor glucose control with elevated glucose blood levels.
Planning
Physiological Integrity
Analysis
19.5•A nurse interviews an older nondiabetic client during an appointment for a yearly
physical examination. Which of the statements made by the client are most suggestive of
a possible diagnosis of diabetes?
1. “I feel a bit tired by midafternoon and take a 30-minute nap most days.”
2. “I’ve been experiencing blurred vision frequently during the past month.”
3. “I sometimes have muscle aches in my upper legs at night.”
4. “I’m slightly winded when I walk up a flight of stairs but it passes quickly.”
Answer: 2
Rationale: Blurred vision can be associated with high glucose levels and may be a
symptom of undiagnosed diabetes mellitus. Fatigue that responds to a short nap, having
some muscle aches at night, and being slightly short of breath after walking up a flight of
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stairs with a quick recovery may be within the normal functioning of a healthy older
client.
Assessment
Physiological Integrity
Analysis
19.6•The most important diet guideline for older clients with diabetes mellitus to follow
is
1. consistently eat at regular times including meals and snacks.
2. eliminate as much fat from the diet as possible.
3. include foods rich in calcium at every meal.
4. include the majority of the caloric intake in the morning meal.
Answer: 1
Rationale: The diabetic client should be encouraged to eat meals and snacks at regular
times throughout the day. This consistent food intake is a strategy to maintain the blood
glucose levels near normal most of the time. Fats should not be eliminated but limited to
less than 30% of the total caloric intake. Eating foods rich in calcium are generally
healthy but are not related to blood glucose control. Generally, the caloric intake should
be spread throughout the day. Clients who are planning to be physically active for a set
period of time may want to increase their caloric intake prior to the activity to maintain
proper glucose levels.
Intervention
Physiological Integrity
Application
19.7•Which is an appropriate guideline for the older diabetic client who wants to include
alcoholic beverages in the diet?
1. Diabetics should never drink alcoholic beverages at all because alcohol is “empty
calories.”
2. An alcoholic beverage, such as 12 ounces of beer or 5 ounces of wine, can be
substituted for a snack.
3. The alcohol must be included in the total caloric intake and used as a substitute for
protein calories.
4. Alcohol should always be consumed with food to prevent the onset of
hypoglycemia.
Answer: 4
Rationale: Clients who enjoy drinking alcohol can include it within limits in their diabetic
diets. Alcohol should not be consumed without food because it has the potential to cause
hypoglycemia. Although the calories from alcohol are considered empty, they can be
calculated into the total caloric intake and substituted as fat calories. Alcohol should not
be used as a snack replacement because of the potential of hypoglycemia.
Intervention
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Physiological Integrity
Application
19.8•An older client with diabetes mellitus has received a thorough medical examination
and is cleared to begin a walking program. The nurse working with the client
recommends that the client
1. wear shoes with thick inflexible soles.
2. include a warm-up period at the beginning and a cool-down period at the end with a
slower pace.
3. continue walking if she becomes short of breath because this will strengthen the
heart and build resilience.
4. carry extra insulin in case she begins to feel weak while walking.
Answer: 2
Rationale: The diabetic client who is starting a walking program should follow
recommendations for any walking program, which includes a slower-paced period at the
beginning of the walk (the warm-up) and at the end of the walk (the cool-down). Shoes
are important to the diabetic walker and should be thick with flexible soles to cushion the
steps, absorb shock, and reduce the chance of developing blisters. If a client becomes
short of breath, she or he should stop until the symptoms pass. The client should have 10
to 15 grams of carbohydrates available, such as three to five pieces of hard regular candy,
in case hypoglycemia occurs. Taking extra insulin would only further lower the blood
glucose level.
Intervention
Physiological Integrity
Application
19.9•Metformin (Glucophage) is an antidiabetic medication that
1. stimulates the beta cells of the pancreas to secrete insulin.
2. has the potential to induce hypoglycemia in older clients.
3. is contraindicated in clients with renal insufficiency.
4. has adverse effects, including weight gain and elevated blood lipid levels.
Answer: 3
Rationale: Metformin (Glucophage) is contraindicated for clients with renal insufficiency
and clients over age 80. It is a biguanide that improves insulin sensitivity by enhancing
glucose uptake and use of the muscles. It rarely causes hypoglycemia. Additional
beneficial effects include mild weight loss and improved lipid profiles in clients with
high lipid levels.
Intervention
Physiological Integrity
Application
19.10•Which of the following statements about the use of insulin in the treatment of
diabetic clients is correct?
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1. Insulin is used along with oral hypoglycemic agents to control blood glucose levels
in clients with type 1 diabetes mellitus.
2. Insulin should be injected intramuscularly in the thigh or buttock regions.
3. Insulin is the primary treatment for non-ketotic hyperosmolar hyperglycemic coma
(NKHHC), a potential complication for clients with type 2 diabetes mellitus.
4. Insulin is available in products that combine intermediate-acting and short-acting
insulin to simplify dosing and provide better glucose control.
Answer: 4
Rationale: Insulin is available in combination products, such as 70/30 insulin, which is
70% NPH and 30% regular insulin, and 75/25 humalog mix, which is 75% NPH and 25%
lispro insulin. These insulins are an easy way for clients to administer combined doses of
insulin and achieve better glucose control. Clients with type 1 diabetes mellitus are
insulin dependent because the pancreas produces little or no insulin. Insulin is
administered by subcutaneous route in the arms, legs, buttocks, thighs, or stomach. Type
2 diabetes clients can develop NKHHC, which has a high mortality rate. These clients are
extremely dehydrated from osmotic diuresis. Treatment for NKHHC centers around fluid
resuscitation and control of dehydration. Glucose levels may decrease without insulin
therapy if hydration is adequately restored.
Intervention
Physiological Integrity
Application
19.11•An older client with diabetes mellitus is more likely to experience hypoglycemic
episodes if the client
1. develops a urinary tract infection.
2. skips a meal.
3. takes snacks between meals and at bedtime.
4. administers fast-acting insulin such as lispro (Humalog) before eating a meal.
Answer: 2
Rationale: Skipping a meal would put the diabetic client at risk of developing
hypoglycemia. If a diabetic client develops an infection, the blood glucose level is likely
to rise. Taking snacks between meals and at bedtime are methods to maintain the glucose
level at a steady normal level. Fast-acting insulin, such as lispro, should be administered
just before the client eats to promote consistent blood glucose levels.
Intervention
Physiological Integrity
Analysis
19.12•Hypothyroidism in older clients
1. develops with sudden manifestations of confusion and ataxia.
2. is treated with daily subcutaneous injections of levothyroxine (Synthroid).
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3. correlates with decreased blood levels of thyroid stimulating hormone (TSH) and
low levels of T3.
4. may cause manifestations of congestive heart failure, including cardiac enlargement.
Answer: 4
Rationale: Hypothyroidism mimics congestive heart failure with cardiac enlargement and
decreased cardiac contractility. The onset of thyroid deficiency is very gradual with a
wide range of symptoms. Neurological symptoms are sometimes mistaken for depression
or psychiatric disorders. Symptoms of hypothyroidism could include the gradual onset of
ataxia and confusion. Treatment for hypothyroidism is daily T4 replacement with
levothyroxine sodium (Synthroid), which is usually taken orally (parenteral forms are
available for intravenous route for clients unable to take medications orally). In the
majority of clients, diagnostic tests for hypothyroidism include an elevation of the TSH,
the hormone produced by the anterior pituitary gland, in response to low levels of the
hormones produced by the thyroid gland. T3 levels are not usually helpful in diagnosing
thyroid conditions.
Assessment
Physiological Integrity
Analysis
19.13•The preferred method of treatment for hyperthyroidism in older adults is
1.
2.
3.
4.
partial thyroidectomy.
ingestion of radioactive sodium iodine, I131.
combination treatment with Synthroid and amiodarone.
usually left untreated because there is little affect on the quality of life in older
adults.
Answer: 2
Rationale: Hyperthyroidism in older clients is most often caused by Graves’ disease or
toxic nodular goiter, which is diagnosed by subnormal or undetectable levels of TSH
(thyroid stimulating hormone). The treatment of choice is ingestion of the radioactive
iodine, which is picked up by the thyroid tissue and then destroys the tissue. This
treatment avoids surgery, anesthesia, and hospitalization. Surgical removal is reserved for
clients with symptoms too severe for treatment with radioactive iodine or nodules
suspicious for malignancy. Treatment with Synthroid would worsen symptoms, and
amiodarone is an antiarrhythmic drug that has induced hyperthyroidism in some clients.
Older clients with hyperthyroidism seldom present with the classic symptoms seen in
younger clients, but older clients may develop cardiac dysrhythmias, weight loss, fatigue,
and apathy and do require treatment.
Intervention
Physiological Integrity
Application
19.14•A monofilament test is used to determine a client’s risk for which of the following
complications of diabetes mellitus?
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1. diabetic ulcer of the foot
2. diabetic retinopathy
3. diabetic ketoacidosis
4. arterial insufficiency of the lower extremities
Answer: 1
Rationale: The monofilament test is used to assess a client for the presence of protective
sensation in the foot, which would alert the client to the development of a blister or foot
ulcer. Clients who can feel the filament at the designated sites are at reduced risk for
developing foot ulcers. A tuning fork can be substituted for the monofilament test.
Diabetic retinopathy would be discerned during an ophthalmic examination. Diabetic
ketoacidosis is diagnosed by clinical picture, elevated blood glucose levels, and presence
of ketones in the blood with acidosis. Arterial insufficiency in the lower extremities is
diagnosed by client symptoms and weak or absent peripheral pulses on physical
assessment.
Assessment
Physiological Integrity
Application
19.15•An older diabetic client feels shaky and checks his blood glucose level with his
blood glucose monitor. The blood sugar is 44. The client knows that he should eat 10 to
15 grams of carbohydrates immediately. Which is the best food choice for this client?
1. a half cup of diet soda pop
2. half of an apple with the peel
3. a half cup of orange juice
4. three to five pieces of sugar-free candy
Answer: 3
Rationale: The best choice to treat the hypoglycemia is a concentrated carbohydrate
source that can be taken quickly to raise the glucose to a safe level. Orange juice is the
best option because it can be taken and absorbed quickly and is a good source of
concentrated carbohydrate. There is no glucose available in diet soda pop or sugar-free
candy. The apple would have to be chewed before the client could get the appropriate
carbohydrate.
Intervention
Physiological Integrity
Application
19.16•A nurse is preparing a teaching plan for a client with diabetes mellitus regarding
proper foot care. Which instruction is included in this plan?
1.
2.
3.
4.
Soak feet in hot water.
Avoid using mild soap on the feet.
Apply a moisturizing lotion to dry feet but not between the toes.
Always have a podiatrist cut your toenails; never cut them yourself.
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Answer: 3
Rationale: The client is instructed to use a moisturizing lotion on the feet and to avoid
applying lotion between the toes. The client should be instructed not to soak the feet. The
client should be instructed to use mild soap on the feet. The client may cut his or her own
toenails, but if the nails are thick or if the client has low vision, a podiatrist should cut the
toenails.
Application; Health Promotion and Maintenance; Planning
19.17•A client newly diagnosed with diabetes mellitus has been stabilized with daily
insulin injections. A nurse prepares a discharge teaching plan regarding the insulin and
plans to reinforce which of the following concepts?
1. Always keep insulin refrigerated.
2. Ketones in the urine signify a need for less insulin.
3. Increase the amount of insulin before exercise.
4. Systematically rotate insulin injection sites.
Answer: 4
Rationale: Injection sites should be rotated. To minimize injection site discomfort, insulin
should be at room temperature when administered. Ketones in the urine may indicate a
need for more insulin. Insulin should not be adjusted prior to exercise.
Application; Physiological Integrity; Planning
19.18•A nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of
complications. Which of the following, if exhibited in the client, would indicate
hyperglycemia and warrant physician notification?
1. Polyuria
2. Diaphoresis
3. Hypertension
4. Increased pulse rate
Answer: 1
Rationale: Classic symptoms of hyperglycemia include polydipsia, polyuria, and
polyphagia. Options 2, 3, and 4 are not signs of hyperglycemia.
Analysis; Physiological Integrity; Assessment
19.19•The family of a bedridden client with type 2 diabetes mellitus and chronic renal
failure calls a nurse to report the following symptoms: headache, polydipsia, and
increased lethargy. To determine a possible diagnosis, the nurse asks the family which
most important question?
1.
2.
3.
4.
“What is the client’s urinary output?”
“What is the client’s capillary blood glucose level?”
“Has there been any change in the dietary intake?”
“Have you increased the amount of fluids provided?”
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Answer: 2
Rationale: Hyperglycemic hyperosmolar nonketotic syndrome occurs in clients with type
2 diabetes mellitus. The onset of symptoms may be gradual. The symptoms include
polyuria, polydipsia, dehydration, mental status alterations, weight loss, and weakness.
Options 1, 3, and 4 are incorrect interpretations of the client’s symptoms.
19.20•A home health nurse visits a client with a diagnosis of type 1 diabetes mellitus.
The client states he has been vomiting and had diarrhea for the past 36 hours. He also has
had no food intake in the same time frame. Which 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 the physician because of these symptoms.”
Answer: 1
Rationale: The client needs to continue taking his prescribed insulin or oral medications.
The rest of the statements are correct in this situation.
Analysis; Physiological Integrity; Assessment
19.21•A student nurse is caring for a client recently diagnosed with hypothyroidism.
When reviewing the nursing admission assessment, which of the following findings
symptoms would the student nurse expect to see documented?
1. Hot flashes
2. Tachycardia
3. Fatigue
4. Nausea
Answer: 3
Rationale: Symptoms of hypothyroidism include fatigue, increased need for sleep,
bradycardia, cold intolerance, ataxia and balance difficulties, and hypothermia. Options
1, 2, and 4 are not symptoms of hypothyroidism.
Application; Physiological Integrity; Assessment
19.22•A nursing instructor asks a student to describe Graves’ disease. Which statement
by the student indicates an accurate understanding of this disorder?
1. “It is an autoimmune disorder associated with sustained thyroid overactivity.”
2. “It is an autoimmune disorder associated with sustained thyroid underactivity.”
3. “It is a disorder that is associated with a tumor on the thyroid, which leads to
thyroid overactivity”
4. “It is a disorder that is associated with long-term use of amiodarone, a cardiac
medication.”
Answer: 1
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Rationale: Graves’ disease is an autoimmune disorder associated with sustained thyroid
overactivity. Option 2 is incorrect. Options 3 and 4 are potential causes of
hyperthyroidism, but not Graves’ disease in particular.
Application; Physiological Integrity: Assessment
19.23•A student nurse is caring for a patient with new-onset atrial fibrillation. Which of
the following lab values might the student nurse find documented?
1. TSH 18 mU/ml
2. TSH 0.25 mU/ml
3. Hgb 13.8 g/dl
4. Hgb 11.0 g/dl
Answer: 1
Rationale: New-onset atrial fibrillation is a potential symptom of hyperthyroidism. A
TSH level above 5 mU/ml is considered high. Option 2 is indicative of hypothyroidism.
Options 3 and 4 are both normal hemoglobin levels.
19.24•A graduate nurse is preparing a care plan for an 88-year-old female admitted with
type 2 diabetes mellitus. Which of the following nursing diagnoses would be most
appropriate for this patient?
1. Risk for infection
2. Risk for fall
3. Tissue perfusion, Altered: circulatory
4. Tissue integrity, Impaired
Answer: 1
Rationale: A client with diabetes mellitus is at risk for infection. No other information is
given in the question to support options 2, 3, and 4 as potential nursing diagnoses.
Analysis; Physiological Integrity; Planning
19.25•A student nurse has presented an educational program on health maintenance for
older persons with diabetes. Which statement by a participant after the program suggests
the need for further education?
1. “If I start to feel nervous, sweaty, or shaky, I will lie down and take a nap.”
2. “I will keep some hard candy with me at all times.”
3. “If I get sick and can’t eat, I will continue to take my insulin as my physician
prescribed.”
4. “I will start a walking program with my neighbors.”
Answer: 1
Rationale: Nervousness and diaphoresis can be suggestive of hyperglycemia. The client
should check his blood glucose level and if low, ingest 10 to 15 g of carbohydrates.
Options 2, 3, and 4 are correct information for a client with diabetes.
Analysis; Health Promotion and Maintenance; Assessment
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