1. The nurse performs medication reconciliation for a 94-year-old client who has type 2 diabetes, hypothyroidism, and heart failure caused by a previous myocardial infarction. Due to risks outweighing benefits, the nurse plans to talk with the health care provider about discontinuing which medication?
A. Aspirin 81 mg PO once a day
B. Furosemide 40 mg PO once a day
C. Glyburide 10 mg PO once a day
D. Levothyroxine 50 mcg PO once a day
- Answer C
- Rationale: Sulfonylureas (eg, glyburide) stimulate insulin release via the pancreas and carry a risk for severe and prolonged hypoglycemia in the geriatric population due to potential delayed elimination. Avoidance of these drugs is recommended by the Beers Criteria. Instead, other medications that are at lower risk for hypoglycemia should be used (eg, metformin)
2. The nurse is planning a client care conference with the parents of a 3-year-old with newly diagnosed type 1 diabetes mellitus. What is the priority outcome for the caregivers?
A. Demonstrating adequate coping skills
B. Knowing how to keep blood sugars stable
C. Understanding how to perform meal planning
D. Understanding the need for periodic follow-up visits
- Answer B
- Rationale: The parents of the newly diagnosed client with type I diabetes mellitus will need education in blood sugar control due to the risk of hypoglycemia and the risk of complications that can arise from hyperglycemia. Since type I is a lifelong condition patient or caregiver education is critical.
3. The school nurse is caring for 4 clients with type 1 diabetes mellitus. Which of these clients should the nurse assess first?
A. A 5-year-old whose capillary blood glucose is 71 mg/dL (3.9 mmol/L).
B. A 7-year-old who is busy drawing pictures and refusing to eat lunch.
C. A 9-year-old who is sweating after recess and irritably states, "I'm so hungry!"
D. An 11-year-old whose prescribed dose of insulin glargine is 30 minutes overdue.
- Answer C
- Rationale: The 9 year old is showing signs of hypoglycemia. A client with symptoms of hypoglycemia (eg, sweating, irritability, tremor, tachycardia, hunger) should be assessed immediately.
4. The nurse is caring for an adolescent client diagnosed with type 1 diabetes. The client exhibits hot, dry skin and a glucose level of 350 mg/dL (19.4 mmol/L). Arterial blood gases show a pH of 7.27. STAT serum chemistry labs have been drawn. Cardiac monitoring shows a sinus rhythm with peaked T waves, and the client has minimal urine output. What is the nurse's next priority action?
A. Administer IV regular insulin
B. Administer normal saline infusion
C. Obtain urine for urinalysis
D. Request prescription for potassium infusion
- Answer B
- This client has diabetic ketoacidosis (DKA). All clients with DKA experience dehydration due to osmotic diuresis. Prompt and adequate fluid therapy restores tissue perfusion and suppresses the elevated levels of stress hormones. The initial hydrating solution is 0.9% saline infusion.
5. The nurse educates a 30-year-old female client who is being evaluated for hyperthyroidism with a radioactive iodine uptake (RAIU) test. Which instruction(s) should the nurse include in the teaching plan? Select all that apply.
A. "A pregnancy test must be obtained prior to RAIU test administration."
B. "All jewelry or metal around the neck area should be removed before the RAIU test."
C. "Anti-thyroid medications should be held for 5-7 days before the RAIU test."
D. "Conscious sedation will be used to help with relaxation during the RAIU test."
E. "It is important to refrain from eating or drinking for at least 12 hours before the RAIU test."
- Answer A, B, C
- Rationale: Radioactive Iodine Uptake, or RAIU, is a test of thyroid function. The test measures the amount of radioactive iodine (taken by mouth) that accumulates in the thyroid gland. It is a type of nuclear test that measures how much radioactive iodine is taken up by the thyroid gland in a given time period. You are asked to ingest (swallow) radioactive iodine (I-123 or I-131) in liquid or capsule form. After a time (usually 6 and 24 hours later), you must return to have the radioactivity measured.
- Pregnancy test would have to be performed because the radioactive test can affect an unborn baby. Any jewelry on the body can react with a radioactive material and cause damage to the skin.
- Since anti-thyroid medications are meant to suppress thyroid production, they should be held because using the medication before the test may interfere with the results of the test.
6. The nurse provides medication teaching to a client with primary adrenal insufficiency (Addison's disease) who is prescribed hydrocortisone 10 mg by mouth 3 times a day. Which instructions should be included in the client's teaching plan? Select all that apply.
A. "Discontinue hydrocortisone if you note mood changes or disruptions in behavior."
B. "Make an appointment with an optometrist yearly to assess for cataracts."
C. "Report even a low-grade fever to the health care provider (HCP) immediately."
D. "Report signs of hyperglycemia, including increased urine, hunger, and thirst."
E. "Take the medication on an empty stomach."
F. "The dose of hydrocortisone may need to be decreased during times of stress."
- Answer: B, C, D.
- Rationale: Corticosteroids are immunosuppressants used to manage certain conditions including adrenal insufficiency. In addition to suppressing the immune system, they also increase intraocular pressure which can lead to glaucoma, as well as increase in blood sugar levels. Hence it is necessary to monitor for signs of infection, intraocular pressure, and hyperglycemia.
7. The nurse in an outpatient clinic receives a blood test report of moderately elevated thyroid-stimulating hormone (TSH) and markedly decreased T3 and T4 levels. Which signs and/or symptoms should be expected in the client's evaluation? Select all that apply
A. Cold intolerance
D. Hair loss
E. Warm, moist skin
F. Weight loss
- Answer: A,B, C, D
- Rationale: Very low levels of T3 and T4 levels means the client is suffering from hypothyroidism. Some early symptoms of hypothyroidism include:
- Cold intolerance
- Extreme fatigue (difficult for person to complete full days of work)
- Hair loss, receding hairline
- Brittle nails
- Dry skin
- Numbness & tingling of fingers
8. The nurse prepares to administer a dose of radioactive iodine (RAI) to a 39-year- old female client with Graves' disease. Which action is most important for the nurse to take?
A. Ask client when her last menstrual cycle occurred
B. Confirm pregnancy test result is negative
C. Obtain a baseline assessment of the mouth and throat
D. Teach the client the signs and symptoms of hypothyroidism
- Answer B
- Rationale: RAI is the primary treatment for nonpregnant adults with hyperthyroid disorders such as Graves' disease (a type of autoimmune hyperthyroid disease). The use of RAI is contraindicated in pregnancy and could cause harm to a fetus. Pregnancy results should therefore be confirmed using a valid pregnancy test in all clients who still have menstrual cycles rather than using a subjective form of assessment such as asking when the last menstrual period occurred (Option 1).
9. The nurse is caring for a client with diabetes who is being discharged with a prescription for glyburide. Which statement by the client indicates a need for further instruction?
A. "I should avoid alcohol intake with this new medication."
B. "I should call my primary health care provider if my morning blood glucose is below 60 mg/dL (3.3 mmol/L)."
C. "I should read the labels on all foods I eat, including those that say 'sugarless'."
D. "This medication will help me lose weight."
- Answer: D
- Rationale: Glyburide is an adjunct therapy for type II diabetes It belongs to a class of medications called sulfonylureas (e.g., glyburide, glipizide, glimepiride). Some side effects of glyburide include hypoglycemia, weight gain, and photosensitivity which can cause sunburn. Therefore option 4 is not correct.
The school nurse evaluates a 9-year-old client who is sweating, trembling, and slurring while speaking. The client has type 1 diabetes managed with insulin glargine and NPH. What is the most appropriate action by the nurse?
A. Administer scheduled dose of NPH insulin
B. Give emergency glucagon IM injection
C. Give peanut butter and crackers
D. Provide 4 oz of regular soft drink
- Answer D
- Rationale: Clients experiencing hypoglycemia may develop shakiness, palpitations, sweating, and altered mental status (eg, difficulty speaking, confusion). If manifestations of hypoglycemia are present, the nurse should check the client's blood glucose level (BGL) immediately. A BGL <70 mg/dL (3.9 mmol/L) requires treatment; however, if glucose testing is not readily available, the client should be treated based on symptoms.
- Hypoglycemia treatment in a conscious client is administration of 15 g of a quick-acting carbohydrate (Option 4). After treatment, the nurse should retest BGL every 15 minutes, repeating treatment if BGLs remain low. Quick-acting carbohydrate options include:
- 4 oz (120 mL) of regular soft drink or fruit juice
- 8 oz (240 mL) low-fat milk
- 1 tablespoon (15 mL) of honey or syrup
- 6 hard candies
- Commercial dextrose products
- (Option 1) The nurse should hold the client's scheduled insulin until the client's BGL is normal and the symptoms resolve.
- (Option 2) An emergency glucagon injection is indicated if the client is somnolent, unconscious, or seizing.
- (Option 3) After the client's BGL improves, the client should eat a meal. However, if the next meal is more than an hour away, the nurse should give the client a serving of carbohydrate plus protein or fat (eg, peanut butter, cheese) to maintain glucose levels.
11. The nurse evaluates the effectiveness of desmopressin use for diabetes insipidus in a client with a pituitary tumor. Which client assessment finding indicates that the medication is having the desired effect?
A. Appetite has improved
B. Blood glucose is 110 mg/dL (6.1 mmol/L)
C. Urine output has decreased
D. Urine specific gravity is lower
- Answer C.
- Rationale: Desmopressin is often used to treat central diabetes insipidus, a disease characterized by reduced antidiuretic hormone (ADH) levels that may result in dehydration and hypernatremia. Desmopressin mimics the effects of naturally occurring ADH, which increases renal water resorption and concentrates urine leading to decreased urine output. However, this effect also increases the risk for water intoxication.
12. The nurse is assessing a group of clients in the community health clinic for metabolic syndrome. Which clients exhibit features of the syndrome? Select all that apply.
A. Female with a low-density lipoprotein (LDL) level of 96 mg/dL (2.5 mmol/L)
B. Female with a waist circumference of 38 inches (96.5 cm)
C. Female with blood pressure of 148/90 mm Hg
D. Male with a fasting blood glucose of 99 mg/dL (5.5 mmol/L)
E. Male with a triglyceride level of 201 mg/dL (2.3 mmol/L)
- Answer 2, 3, 5
- Rationale: Metabolic syndrome is a cluster of conditions that occur together, increasing the risk of heart disease, stroke and type 2 diabetes. These conditions include increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels.
13. A client with type I diabetes mellitus is brought to the emergency department by his wife. The client has fruity breath with rapid, deep respirations at 36 breaths per minute, reports abdominal pain, and appears weak. The nurse should anticipate implementation of which prescription(s)? Select all that apply.
A. Administer dextrose 50 mg intravenous (IV) push
B. Instruct client to breathe into a paper bag to treat hyperventilation
C. Perform a fingerstick and serum blood glucose test
D. Prepare to administer an IV infusion of regular insulin
E. Start an IV line and administer a bolus of normal saline.
- Answer 3, 4, 5
- Rationale: The client is exhibiting the cardinal signs and symptoms of diabetic ketoacidosis (DKA). DKA is an acute life-threatening complication, typically of type I diabetes, characterized by hyperglycemia, ketosis, and acidosis. It is caused by an intense deficit of insulin. Glucose cannot be used properly for energy when this deficit occurs and the body begins to break down fat stores, producing ketones, a byproduct of fat metabolism, resulting in metabolic acidosis. The lack of insulin also results in increased production of glucose in the liver, further exacerbating hyperglycemia. Because some of the symptoms of hypoglycemia and DKA overlap, a blood glucose level should be checked to ensure that hyperglycemia is present.
- Hyperglycemia can cause osmotic diuresis, leading to dehydration. In addition, ketones are excreted in the urine as the body tries to restore its pH balance. Vital electrolytes such as sodium, potassium, chloride, phosphate, and magnesium become depleted during the process. Cardinal signs of dehydration such as poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension, weakness, and lethargy can occur.