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CCRN 42 Practice Questions -
Endocrine
Weakness, fatigue, muscle pain, and abdominal discomfort in a patient receiving metformin would likely be associated with which of the following?
a. Hypoglycemia
b. Hyperglycemia
c. Heart failure
d. Lactic acidosis - ✔ ✔ Correct answer: d
Rationale: These are symptoms that may indicate the serious adverse effect of metformin of lactic acidosis and rhabdomyolysis.
Test-Taking Strategy: Hypoglycemia can cause weakness. Abdominal pain is associated with metabolic acidosis which can occur with hyperglycemia (DKA) and severe heart failure. Weakness and fatigue do occur with heart failure. The symptom that is inconsistent with both hyperglycemia and heart failure is muscle pain. This would lead you to rhabdomyolysis and the resultant lactic acidosis.
Which laboratory values would differentiate diabetic ketoacidosis (DKA) from a hyperosmolar hyperglycemic state (HHS)?
a. Serum glucose of 600 mg/dL
b. Serum potassium of 4 mEq/L
c. Positive serum ketones
d. Serum osmolality of 320 mOsm/L - ✔ ✔ Correct answer:
c
Rationale: In DKA there is an absolute insulin deficiency that causes glycogenolysis and gluconeogenesis. The gluconeogenesis causes the incomplete breakdown of free fatty acids, which results in ketones in the blood and urine. In HHS, there is a relative insulin deficiency that causes glycogenolysis but does not cause gluconeogenesis. Therefore tests for ketones are positive in DKA but typically negative in HHS.
Test-Taking Strategy: A serum glucose of 600 mg/dL is abnormal but could be due to DKA or HHS. A serum potassium of 4 mEq/L could be seen in DKA or HHS. Elevated serum osmolality of 320 mOsm/L could be seen in DKA or HHS and is due to dehydration. Only the serum ketones distinguish between the two hyperglycemic crises.
Which of the following accurately describes a difference between diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS)?
a. Patients with DKA have higher serum glucose levels than patients with HHS.
d. dehydration. - ✔ ✔ Correct answer: c
Rationale: Infection is a common cause of ketoacidosis in the patient with type 1 DM because it increases the need for insulin.
Test-Taking Strategy: Focus on the history. Included information is usually (but not always) important. The fact that the case study says that she has had a cold over the last few days, and your knowledge that infection increases the need for insulin, make option c the most logical choice.
A 16-year-old girl with a history of type 1 diabetes mellitus (DM) is admitted to the critical care unit. Her friend states that she has had a cold for the last few days. She is now lethargic. Which of the following lab results would the nurse expect?
a. Hyperglycemia, hypokalemia, acidosis, elevated serum osmolality
b. Hyperglycemia, hyperkalemia, acidosis, elevated serum osmolality
c. Hyperglycemia, hypernatremia, alkalosis, decreased serum osmolality
d. Hypoglycemia, hyponatremia, acidosis, decreased serum osmolality - ✔ ✔ Correct answer: b
Rationale: The hyperglycemia is caused by insulin deficiency and therefore the inability of insulin to move into the cell. This hyperglycemia causes a hypertonic diuresis, dehydration, and
elevated serum osmolality. Gluconeogenesis causes the breakdown of fats and proteins for energy. This results in an increase in ketone bodies and acidosis. This acidosis causes potassium to move out of the cell and into the serum, causing hyperkalemia.
Test-Taking Strategy: In questions with multiple answers in each option, go with what you know. You know that patients with diabetic ketoacidosis (DKA) are not hypoglycemic, so eliminate option d. It certainly does not make sense for something with the name diabetic ketoacidosis to have alkalosis as a laboratory feature, so eliminate option c. Now you have to know the potassium effect because this is the only difference between options a and b. Remember that acidosis causes potassium to shift out of the cell and into the serum. Although the whole body potassium is low, the serum potassium is high. Choose option b.
A 25-year-old woman is admitted with diabetic ketoacidosis (DKA). The following laboratory values were reported from blood taken at admission: Serum glucose 450 mg/dL Potassium 4.5 mEq/L pH 7.15 She has received regular insulin bolus, and an infusion has been initiated. Two liters of normal saline has been administered. The last serum glucose is 215 mg/dL, and the pH is 7.32. Which therapy would be inappropriate?
a. Changing the intravenous solution to include dextrose
b. Adding potassium to the intravenous solution
potassium 4.5 mEq/L, and serum osmolality 320 mOsm/kg. She is not responding to voice but she does respond to pain. Her mucous membranes are dry and urine output is scant and concentrated. Which of the following would be a teaching priority for this patient when she is well enough to participate?
a. Insulin administration
b. Sick day management
c. Diabetic diet
d. Exercise guidelines - ✔ ✔ Correct answer: b
Rationale: Patients often believe that because they cannot eat, they should not take their insulin. Sick day management is a priority for this patient. While it is important to access current knowledge regarding insulin, diet, and exercise, it is likely that this patient, a
known type 1 diabetic, has significant knowledge regarding those aspects of diabetic management. After assessment, the patient would benefit from reinforcement, clarification, and elaboration on that knowledge.
Test-Taking Strategy: This crisis is related to this patient's poor sick day management. She likely does not understand these very important principles.
A 30-year-old woman with type 1 diabetes mellitus is admitted with complaints of nausea, vomiting, and diarrhea. She has not
been eating and she has not taken her insulin for 2 days. She has been taking glargine (Lantus) 45 units daily and aspart (NovoLog) with meals (5 units with breakfast, 8 units with lunch, and 10 units with dinner). Her blood pressure is 92/ mm Hg, heart rate is 112/min, respiratory rate is 40/min and deep, temperature is 99.2º F. Laboratory results include serum glucose 420 mg/dL, pH 7.1, potassium 4.5 mEq/L, and serum osmolality 320 mOsm/kg. She is not responding to voice but she does respond to pain. Her mucous membranes are dry and urine output is scant and concentrated. A gradual reduction in serum glucose is planned to prevent what
serious complication?
a. Pulmonary edema
b. Cerebral edema
c. Acute kidney injury
d. Acute pancreatitis - ✔ ✔ Correct answer: b
Rationale: The goal is to reduce the serum glucose by 50- mg/dL/hr to prevent cerebral edema. When the serum glucose is rapidly reduced, it reduces the intravascular osmolality so that fluid moves into the more hypertonic brain cells.
Test-Taking Strategy: Consider the effects of high or low serum glucose and note that the brain is much more likely to be affected than the lung, kidney, or pancreas, so choose option b.
Test-Taking Strategy: Remember that people do not die from hyperglycemia, but they do die from hypovolemia, and this patient is presenting with indications of significant dehydration.
A 30-year-old woman with type 1 diabetes mellitus is admitted with complaints of nausea, vomiting, and diarrhea. She has not been eating and she has not taken her insulin for 2 days. She has been taking glargine (Lantus) 45 units daily and aspart (NovoLog) with meals (5 units with breakfast, 8 units with lunch, and 10 units with dinner). What is insulin aspart's onset of action?
a. 5 to 10 minutes
b. 30 minutes to 2 hours
c. 3 to 4 hours
d. 6 to 10 hours - ✔ ✔ Correct answer: a
Rationale: This insulin is given immediately prior to a meal because it has a very short onset of action. The patient is advised to eat within 5 minutes of insulin administration.
Test-Taking Strategy: Notice from the case study that this insulin is given with meals, so choose the option that is a very short time span, option a.
Which of the following would not be prescribed in SIADH?
a. Fluid restriction
b. Diuretics
c. Hypertonic (3%) saline
d. D5W - ✔ ✔ Correct answer: d
Rationale: This patient is already hypoosmolar. While D5W is isotonic in the bottle, the dextrose is rapidly metabolized, leaving free water. A hypoosmolar solution, such as water, would make things worse by further reducing the serum osmolality.
Test-Taking Strategy: Note that all of the options except option d would result in a decrease in body fluid either by decreasing water gain (option a) or cause a water loss (options b and c).
Which of the following would support the nurse's suspicion that a patient is exhibiting signs of SIADH?
a. Elevated potassium levels
b. Hyponatremia
c. Increased serum osmolality
d. Elevated serum glucose - ✔ ✔ Correct answer: b
Rationale: SIADH is excessive ADH (or excessive response to ADH) causing retention of water and potentially water intoxication. This dilutes the serum sodium causing dilutional hyponatremia. This is sometimes referred to as hypervolemic hyponatremia.
urine output is less than 10 mL/hr. What laboratory data would the nurse
expect to find in this patient?
a. Urine specific gravity less than 1.
b. Serum osmolality greater than 295 mOsm/L
c. Serum sodium less than 125 mEq/L
d. Low serum levels of ADH - ✔ ✔ Correct answer: c
Rationale: SIADH is due to an increase in the amount or effect of ADH. Antidiuretic hormone will cause the renal tubule to hold onto water. Water intoxication occurs and serum sodium decreases due to hemodilution.
Test-Taking Strategy: ADH levels are high, so eliminate option d. Also remember that most tumors hypersecrete and this patient has an adenoma (glandular tumor). Too much of antidiuresis causes water retention; urine specific gravity is high and serum osmolality is low, so eliminate a and b. Sodium is decreased due to hemodilution. Choose c.
A 54-year-old male patient was initially admitted to the medical- surgical unit with diagnosis of oat cell carcinoma of the lung. He was scheduled for a thoracotomy tomorrow but became very lethargic this evening. During report from the nurse on the
medical-surgical unit, the critical care nurse hears that he has voided only scant amounts since yesterday. Which of the
following are clinical indications of SIADH that the nurse may see in this patient?
a. Lethargy, diuresis, and hyperreflexia
b. Lethargy, headache, and nausea and vomiting
c. Nervousness, hyperglycemia, dehydration
d. Headache, dehydration, hyperreflexia - ✔ ✔ Correct answer: b
Rationale: Lethargy and headache are due to water intoxication and cerebral edema. Nausea and vomiting result from GI tract edema.
Test-Taking Strategy: Go with what you know. You know that dehydration does not occur in SIADH, so eliminate options c and d. You know that diuresis does not occur in SIADH, so eliminate option a. Choose option b.
A 55-year-old man has been prescribed acarbose (Precose) to control his type 2 diabetes mellitus. When you teach him about the drug, which of the following would you tell him to use for hypoglycemia?
a. Orange juice
b. Fresh fruit
c. Cheese and crackers
d. Glucose tablets - ✔ ✔ Correct answer: d
A friend brings a 22-year-old woman to the emergency department. She says that the patient is a diabetic and takes insulin. She reports that they were out exercising and the patient became agitated and argumentative and then lost consciousness. The friend called an ambulance. When you measure the serum glucose, it is 25 mg/dL. What should you do?
a. Administer 25 g of glucose intravenously.
b. Administer 12.5 g of glucose intravenously.
c. Administer 10 g of glucose by mouth.
d. Administer glucagon intramuscularly. - ✔ ✔ Correct answer: a
Rationale: She is unconscious, so 25 g should be given. Because she cannot take anything by mouth, it should be given intravenously. D50W is 50% dextrose, which has 50 g/100 mL. An ampule is 50 mL, so it supplies 25 g of dextrose. Glucagon is a hormone that causes the body to mobilize glucose. Glucagon is an indirect way to increase the serum glucose and will take longer than giving the glucose directly.
Test-Taking Strategy: None
A newly diagnosed diabetic patient who is on insulin complains of feeling nervous and afraid that she is going to faint. She is diaphoretic and has a tremor. Nursing actions might include all of the following except:
a. giving her a glass of juice to drink.
b. administering 50% dextrose in water (D50W) if she cannot drink.
c. administering potassium.
d. checking her serum glucose. - ✔ ✔ Correct answer: c
Rationale: Although her clinical signs and symptoms indicate that she is hypoglycemic, a serum glucose level would confirm hypoglycemia. She should be given 10 to 15 g of carbohydrates. If she is unconscious, she should be given one ampule of D50W. Potassium should be checked, especially if you have given her dextrose intravenously, because potassium moves into the cell with insulin and dextrose. Dextrose should not be given without knowledge of the potassium level.
Test-Taking Strategy: Because her clinical symptoms indicate that she is hypoglycemic, any action with glucose in it probably would be appropriate. This is an except question, so the answer is except option c.
A patient develops diabetes insipidus after a craniotomy. Which group of findings would be most characteristic of diabetes insipidus?
a. Oliguria, low serum osmolality, hyponatremia, and high urine specific gravity
d. glucose causing an osmotic diuresis. - ✔ ✔ Correct answer: d
Rationale: Remember that osmolality and osmotic pull are increased by the addition of solutes such as sodium or glucose. The high serum glucose in diabetic ketoacidosis causes an increase in osmotic pull in the renal tubules and an osmotic diuresis.
Test-Taking Strategy: Ketones do not cause diarrhea, but they do cause the acidosis that causes Kussmaul's respirations. This form of hyperpnea may increase insensible loss via the respiratory tract, but not nearly as much as the loss from the osmotic effect of the glucose on the renal tubules and water loss by diuresis. Diffusion is an equalizer to equilibrate solutes. Diffusion does not cause a diuresis. Choose option d.
A 16-year-old girl with a history of type 1 diabetes mellitus (DM) is admitted to the critical care unit. Her friend states that she has had a cold for the last few days. She is now lethargic. The intravenous solution most appropriate for initial fluid replacement would be:
a. 5% dextrose in water.
b. normal saline.
c. half-normal (0.45%) saline.
d. 10% dextrose in water. - ✔ ✔ Correct answer: b
Rationale: Isotonic solutions are needed initially to replace the vascular space. Dextrose solutions generally are not used until the serum glucose is down to 250 mg/dL.
Test-Taking Strategy: Eliminate anything with dextrose because this patient does not need any more dextrose right now. So eliminate options a and d. Hypotonic solutions leave the vascular space more readily than do isotonic solutions, and right now this patient needs to have the vascular space replaced as a priority, so eliminate option c. Choose option b.
A patient had a craniotomy 2 days ago for removal of a tumor. He is awake and talking to the nurse and demonstrates no neurologic deficit. Blood pressure is 110/80 mm Hg, pulse is 92 beats/min, and respiratory rate is 22 breaths/min. Urine outputs have been approximately 60 mL/hr over the last 2 days, but he has had a recent change. He has had 300 to 400 mL/hr of urine output over the last several hours. The urine has a specific gravity of 1.002. The nurse checks his serum glucose and finds that it is 100 mg/dL. The cause of hypernatremia in this patient is:
a. sodium retention.
b. water loss.
c. water gain.
d. aldosterone excess. - ✔ ✔ Correct answer: b
