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Med-Surg Endocrine - Progression Exam

Terms in this set (56)

3. Perform a fingerstick and serum blood glucose test
4. Prepare to administer an IV infusion of regular insulin
5. Start an IV line and administer a bolus of normal saline


Explanation:

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.

The nurse should start an IV and bolus the client with normal saline or 1/2 normal saline to reverse dehydration. This should occur prior to treating the hyperglycemia with regular insulin IV infusion. Because insulin promotes water, potassium, and glucose entrance into the cell, it can exacerbate vascular dehydration and imbalance of electrolytes, particularly potassium. A potassium level (along with other electrolytes) should also be assessed prior to beginning the prescribed insulin therapy.

Other signs associated with DKA include Kussmaul respirations, deep, rapid respirations that have a fruity/acetone smell as the carbon dioxide is exhaled. This compensatory mechanism results in a lowered PaC02 in an attempt to restore the body's normal pH level and should not be reversed (Option 2).

(Option 1) IV dextrose is administered during acute hypoglycemic episodes and would worsen DKA.

Educational objective:
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 and should be treated first with rehydration (normal saline) and then insulin administration
Place blood pressure cuff on arm, inflate to pressure > than systolic BP, and hold in place for 3 minutes

Normal serum calcium is 8.6-10.2 mg /dL (2.15-2.55 mmol/L). Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of parathyroidectomy because the parathyroids regulate calcium levels in the blood. When one or more parathyroids are removed, it may take some time for others that have been dormant during hyperparathyroidism (which causes an increase in serum calcium) to begin regulating serum calcium.

Trousseau's sign may indicate hypocalcemia before other signs and symptoms of hypocalcemia, such as tetany, occur. Trousseau's sign can be elicited by placing the BP cuff on the arm, inflating to a pressure > than systolic BP, and holding in place for 3 minutes. This will occlude the brachial artery and induce a spasm of the muscles of the hand and forearm when hypocalcemia is present.

Chevostek's sign another early indicator of hypocalcemia, should also be assessed. It may be elicited by tapping the face at the angle of the jaw and observing for contraction on the same side of the face.

(Option 1) Phalen's maneuver is used to diagnose carpal tunnel syndrome.

(Option 2) The heel-to-shin test is another means of assessing cerebellar function. An abnormal examination is evident when the client is unable to keep the foot on the shin.

(Option 3) The Romberg test is a component of a neurological examination to assess vestibular function (perception of head position in space), proprioception (perception of the body in space), and vision.

Educational objective:
Normal serum calcium is 8.6-10.2 mg/dL (2.15-2.55 mmol/L). Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of parathyroidectomy. The nurse should check for Trousseau's and Chevostek's signs as early indications of hypocalcemia.
Administer both insulins as prescribed

Glargine (Lantus) is a long-acting (basal) insulin given to prevent hyperglycemia for 24 hours. The drug has no peak, and so timing of administration is not dependent on food intake. However, if the client is NPO for more than 12 hours, the provider may hold it.

Lispro (Humalog) is a rapid-acting insulin with a peak of 30 minutes to 3 hours and should be given only if it is certain the client will eat within 15 minutes. Lispro is prescribed in two ways:

Scheduled prandial (ie, fixed dosage) given to prevent hyperglycemia with consumption of food. Typically, this would not be held unless the blood sugar is below normal (70 mg/dL [3.9 mmol/L]) or according to facility guidelines.

Correctional (ie, sliding-scale dosage) given to correct hyperglycemia. Typically, this would be held when blood glucose is below 150 mg/dL (8.3 mmol/L).

Both glargine and lispro would be given according to schedule, as the client is not NPO and plans to eat immediately, and glucose is above 70 mg/dL [3.9 mmol/L] (Option 1).

(Options 2, 3, and 4) Holding glargine will increase the blood sugar level over 24 hours. Holding lispro will cause blood glucose to rise uncontrollably due to the consumption of food.

Educational objective:
Rapid-acting insulin (eg, scheduled prandial fixed dosing, correctional sliding-scale dosing) is given if a client plans to eat within 15 minutes. Scheduled prandial insulin prevents hyperglycemia after meals and is held when blood glucose is below normal (70 mg/dL [3.9 mmol/L]). Correctional insulin corrects existing hyperglycemia.
Sodium of 120 mEq/L in a client with small cell lung cancer

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is often caused by the ectopic production of ADH by a malignant lung tumor (eg, lung cancer). Increased ADH leads to increased water reabsorption and intravascular volume, which results in dilutional hyponatremia. Severe neurologic dysfunction (eg, confusion, seizures) can occur when serum sodium drops below 120 mEq/L (120 mmol/L) (normal: 135-145 mEq/L [135-145 mmol/L]). Therefore, hyponatremia is the highest priority to report as it poses the greatest threat to survival. Hyponatremia requires immediate evaluation and treatment (eg, seizure precautions, fluid restriction, intravenous hypertonic saline) by the health care provider.

(Option 1) Albumin (normal: 3.5-5.0 g/dL [35-50 g/L]) is a protein formed in the liver. Hepatocytes lose the ability to synthesize albumin when the cells are diseased. Hypoalbuminemia (<3.5 g/dL [<35 g/L]) should be expected in this client.

(Option 2) B-type natriuretic peptide (BNP) (normal: <100 pg/mL [100 pmol/L]) is a substance secreted from the cardiac ventricles in response to increases in ventricular pressures and volume. Therefore, BNP is a marker for heart failure and is elevated in clients with both stable and decompensated heart failure. BNP is an expected finding in this client.

(Option 3) Clients in alcohol withdrawal usually require magnesium supplements. Hypomagnesemia (<1.5 mEq/L [<0.75 mmol/L]) results from poor dietary intake, malnutrition, and increased renal excretion, and is common in clients with chronic alcoholism. This finding is within normal limits (normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]).

Educational objective:
Malignant lung tumors are a common cause of syndrome of inappropriate antidiuretic hormone secretion (SIADH). When serum sodium drops below 120 mEq/L (120 mmol/L), immediate intervention is necessary to prevent severe neurologic dysfunction. Fluid restriction is recommended for clients with SIADH
1."A pregnancy test must be obtained prior to RAIU test administration."
2."All jewelry or metal around the neck area should be removed before the RAIU test."
3."Antithyroid medications should be held for 5-7 days before the RAIU test."

Explanation:

A RAIU test involves administering a low dose of radioactive iodine, in contrast to radioactive iodine treatment for some types of thyroid cancer, which uses a high dose to destroy all thyroid tissue. The thyroid gland is the only tissue that uses iodine, which is a key component of thyroid hormones. A scan is performed at 2, 6, and 24 hours to assess the areas actively absorbing iodine, which can narrow the diagnosis to hyperfunctioning thyroid disorders (eg, Graves' disease).

Important nursing considerations:

Notify the primary health care provider (PHCP) if computerized tomography scan or other recent x-ray using iodine contrast has been performed; the iodine may alter the test results.
Antithyroid or thyroid hormone medication should be held for 5-7 days before undergoing a RAIU test as these can also alter results.
All premenopausal women must take a pregnancy test before the procedure, as radioactive iodine could adversely affect the development of the fetal thyroid gland.
Important aspects of client education:

Maintain nothing by mouth (NPO) status for 2-4 hours prior to the procedure (Option 5). Eating may resume 1-2 hours after swallowing the iodine; a normal diet can be restarted when the test ends. Remove dentures and jewelry/metal around the neck to allow clear visualization during the scan.
Drink plenty of fluids after the procedure to clear RAI from the system. Notify the PHCP if you are allergic to any medications (eg, iodine). However, a RAIU test is generally safe (even in the presence of an iodine allergy) due to the diminutive amount of iodine used.
You will be awake during the procedure but there should be no discomfort (Option 4).
Do not breastfeed immediately after this procedure, and ask your PHCP when breastfeeding may resume.
Educational objective:
RAIU measures the metabolic activity in the thyroid gland in order to differentiate between the many types of thyroid disorders. For an accurate measurement, medications affecting the thyroid should be held 7 days prior to the test date and clients are NPO for 4 hours prior to iodine administration. Premenopausal women must take a pregnancy test. Dentures, metal, and jewelry should be removed.
Administer desmopressin

Explanation:

Diabetes insipidus (DI) is a condition that occurs due to insufficient production/suppression of antidiuretic hormone (ADH). Neurogenic DI is a type of DI that results from impaired ADH secretion, transport, or synthesis. It sometimes occurs after manipulation of the pituitary or other parts of the brain during surgery, brain tumors, head injury, or central nervous system infections.

DI is characterized by polydipsia (increased thirst) and polyuria (increased urine output) with low urine specific gravity (dilute urine). As a result, fluids should be replaced orally/intravenously to prevent dehydration (Option 3).

ADH release is impaired in neurogenic DI. As a result, ADH replacement with vasopressin (Pitressin) can be used to treat DI. However, it also has vasoconstrictive properties. Therefore, desmopressin (DDAVP), an analog without vasopressor activity, is the preferred therapy. Clients on this treatment should be monitored for urine output, urine specific gravity, and serum sodium (to avoid hyponatremia due to excess DDAVP).

(Option 2) DI is not associated with low/high blood glucose and should not be confused with diabetes mellitus (DM) as both DI and DM involve symptoms of excessive urination (polyuria).

(Option 4) The Trendelenburg position (body laid flat and supine with feet higher than the head by at least 15-30 degrees) is contraindicated in most neurological conditions.

Educational objective:
DI occurs when there is insufficient production/suppression of ADH. It is characterized by polydipsia and polyuria with diluted urine. Oral and/or intravenous fluid replacement is imperative to prevent dehydration. DI is treated with ADH replacement drugs (eg, desmopressin acetate [DDAVP]). Clients should be monitored for urine output, urine specific gravity, and serum sodium.
Laryngeal stridor

Explanation:

Stridor is a high-pitched, vibratory, harsh sound during inspiration or expiration that indicates partial airway obstruction. When stridor occurs after a thyroidectomy, a delicate surgery involving a highly vascularized area, the most immediate concern is airway compromise secondary to hemorrhage or laryngeal edema. This is a life-threatening complication requiring immediate intervention. The nurse should ensure that suctioning devices, oxygen, and a tracheostomy tray are readily available in the recovery room as immediate tracheostomy may be necessary.

Respiratory stridor, also observed in epiglottitis, is very different from the minor laryngeal edema that commonly occurs after intubation and results in transient hoarseness in the postoperative period.

Persistent hoarseness and the inability to raise one's voice more than 24 hours postoperatively may indicate damage to the laryngeal nerve, a frequent complication of thyroid surgery.

(Option 1) This calcium level is normal (8.6-10.2 mg/dL [2.15-2.55 mmol/L]). However, hypocalcemia is a potential complication of a thyroidectomy as the parathyroid glands that regulate calcium levels in the blood are often inadvertently removed or damaged during surgery. The nurse should ensure that calcium gluconate is available.

(Options 2 and 4) Although the pain and tachycardia warrant action by the nurse, these are not as high a priority as the life-threatening complication of airway obstruction.

Educational objective:
Stridor indicates airway obstruction, and abrupt onset is a medical emergency. Stridor after thyroidectomy requires immediate action by the nurse to maintain airway patency. Suctioning devices, oxygen, and a tracheostomy tray should be available for rapid surgical intervention.
Administer hydromorphone IV PRN for pain
Administer intravenous fluids
Insert a nasogastric tube for nasogastric suction


Supportive care for symptom relief and prevention of complications are the major goals in clients with acute pancreatitis. These strategies include:

NPO status - The client is maintained on NPO status as any ingestion of food will stimulate the excretion of pancreatic enzymes. A nasogastric tube is used to suction out gastric secretions; this will reduce nausea and lessen stimulation of the pancreas as these juices will move to the duodenum.
Pain management - Intravenous opioids (eg, hydromorphone, fentanyl) are frequently utilized for pain management. Morphine can also be used; worsening pancreatitis due to increase in sphincter of Oddi pressure has not been proven in studies.
IV fluids - Aggressive fluid replacement to prevent hypovolemic shock is critical. Inflammation of the pancreas releases chemical mediators that increase capillary permeability and cause third spacing (fluid going into empty spaces).
(Option 4) The client should maintain positions that flex the trunk and draw the knees up to the abdomen (semi-Fowler's) to decrease tension on the abdomen. A side-lying position with the head elevated to 45 degrees will help relieve the pain even better.

(Option 5) NPO status is maintained to inhibit stimulation of pancreatic enzymes.

Educational objective:
The major goals in acute pancreatitis are symptom management (eg, opioids, NPO status, nasogastric suction) and monitoring and prevention of complications (eg, IV fluids), giving the pancreas time to heal.
Assess the client's level of orientation

Explanation:

Change in mental status and confusion is a common presenting symptom of sepsis in the elderly. The nurse should assess the client's cognitive status and level of orientation and consciousness. Diminished mental acuity, side effects of medication, and impairment related to a medical condition during hospitalization affect the client's ability to manage the insulin pump safely.

Mental status is the key to safe insulin pump use, so if the client is not competent to operate the pump, the nurse should notify the health care provider (HCP) and document the findings in the client's electronic medical record. The HCP will determine if continuing the use of the pump during hospitalization is appropriate.

(Option 2) Assessing the infusion pump site for signs of infection and intactness of the infusion set is important, but it is not the priority action.

(Option 3) The HCP prescribes the basal insulin along with the parameters for bolus and correction doses while the client is hospitalized. The nurse should check and document the make and model, pump settings, type of insulin, and the date that the infusion site and set were changed. However, this is not the priority action.

(Option 4) Consulting with the diabetic resource nurse or educator to determine the client's competency and ability to manage a specific type of pump and provide ongoing client education is an appropriate action. However, this is not the priority.

Educational objective:
When caring for a hospitalized client wearing an insulin pump, the priority nursing action is to assess the client's mental capacity to determine the ability to self-manage the pump safely.
1. Hyperglycemia
2. Hypertension
4. Truncal obesity

Cushing syndrome is the result of prolonged exposure to excess corticosteroids, especially glucocorticoid steroids. The most common cause is the administration of corticosteroids, such as prednisone or hydrocortisone, for other conditions. However, pituitary adenomas can secrete adrenocorticotropic hormone (ACTH), which in turn causes the adrenal glands to produce too much cortisol.

Clinical manifestations include:

Androgen excess from adrenal gland stimulation can result in acne, hirsutism, and menstrual irregularities (eg, oligomenorrhea).
Metabolic complications include truncal obesity (subsequently causing peripheral insulin resistance), hypertension, and hyperglycemia (ie, excess cortisol stimulating gluconeogenesis). Fat accumulation in the face (ie, moon face) and the back of neck (ie, buffalo hump) is common (Options 1, 2, and 4).
Dermatological changes are possible and include easy bruising, purple striae, and skin atrophy; these result from loss of collagen.
Proximal muscle weakness and bone loss (ie, osteoporosis) due to steroid catabolism on muscles and bone can develop in untreated clients.
(Options 3 and 5) Hyponatremia and weight loss are associated with adrenocortical insufficiency, or Addison disease.

Educational objective:
Clinical manifestations of Cushing syndrome include weight gain, truncal obesity, moon face, skin atrophy, easy bruising, purple striae on the abdomen, muscle weakness, hypertension, and hyperglycemia. Associated androgen excess can result in acne, hirsutism, and menstrual irregularities.
Start an IV line and infuse normal saline as prescribed

DKA is a life-threatening complication of type I diabetes characterized by hyperglycemia (>250 mg/dL) that results in ketosis, a metabolic acidosis. Glucose cannot be taken out of the bloodstream and used for energy without insulin. The body begins to break down fat stores into ketones, as it does in a state of starvation, causing a metabolic acidosis (low pH and low HCO3). The lack of insulin also results in increased glucose production in the liver, worsening the hyperglycemia.

Hyperglycemia causes osmotic diuresis, and clients are severely dehydrated. The cardinal signs of dehydration are poor skin turgor, dry mucosal membranes, tachycardia, orthostatic hypotension, weakness, and lethargy. Despite laboratory values showing hyperkalemia on admission, clients with DKA have a net potassium deficiency and will need careful replacement after fluid resuscitation.

(Option 1) Although it is important to insert an indwelling catheter to monitor fluid balance, rehydrating the client is a life-saving measure with higher priority.

(Option 2) Although it is important to monitor serum potassium results before and during insulin administration, rehydrating the client is the highest priority. Dilution will also improve the hyperkalemia.

(Option 3) The priority intervention in DKA is to start an IV infusion for bolus rehydration therapy with normal saline. This should occur before insulin infusion as insulin will result in water, potassium, and glucose entering the cells, worsening the dehydration and electrolyte imbalances.
55-year-old woman with waist circumference of 37 inches, triglycerides of 190 mg/dL, and fasting blood glucose of 120 mg/dL.

Metabolic syndrome is the presence of ≥3 metabolic health factors that increase a client's risk for stroke, diabetes mellitus, and cardiovascular disease. Criteria include:

Abdominal obesity: Waist circumference (≥40 inches [102 cm] in men, ≥35 inches [89 cm] in women)
High serum triglycerides >150 mg/dL (1.7 mmol/L) or hypertriglyceridemia drug treatment
Low levels of high-density lipoprotein (HDL) cholesterol (<40 mg/dL [1.0 mmol/L] in men, <50 mg/dL [1.3 mmol] in women)
Hypertension ≥130/85 mm Hg or hypertension drug treatment
Fasting blood glucose ≥100 mg/dL (5.6 mmol/L) or hyperglycemia drug treatment
The 55-year-old woman (waist circumference 37 inches [94 cm], triglycerides 190 mg/dL [2.2 mmol/L], fasting blood glucose 120 mg/dL [6.7 mmol/L]) is at highest risk for metabolic syndrome with 3 of 5 criteria (obesity, high triglycerides, hyperglycemia) (Option 3).

(Option 1) The 27-year-old woman (triglycerides 210 mg/dL [2.4 mmol/L]) has only 1 metabolic syndrome-associated condition (hypertriglyceridemia).

(Option 2) The 45-year-old man (fasting blood glucose 118 mg/dL [6.6 mmol/L]) has only 1 metabolic syndrome-associated condition (hyperglycemia).

(Option 4) The 82-year-old man (blood pressure 148/88 mm Hg, fasting blood glucose 104 mg/dL [5.8 mmol/L]) has only 2 metabolic syndrome-associated conditions (hypertension, hyperglycemia). His HDL is within normal limits.

Educational objective:
Clients with metabolic syndrome are at increased risk for stroke, diabetes mellitus, and cardiovascular disease. Criteria for metabolic syndrome include at least 3 of 5 conditions: abdominal obesity, hyperglycemia, low levels of high-density lipoprotein, high serum triglycerides, and hypertension.
Fluid restriction
Seizure precautions
Strict record of fluid intake and output

SIADH is an endocrine condition in which antidiuretic hormone overproduction leads to water retention, increased total body water, and dilutional hyponatremia (low serum sodium). Hyponatremia can cause confusion, seizures, or other neurologic complications. It is important for the nurse to anticipate these problems and institute seizure precautions.

SIADH treatment includes:

Fluid restriction to <1000 mL/day
Oral salt tablets to increase serum sodium (Option 3)
Hypertonic saline (3%) during the first few hours for clients with markedly decreased serum sodium and severe neurologic manifestations
Vasopressin receptor antagonists (eg, conivaptan)
The nurse should also maintain a strict fluid intake and output chart and daily weights and carefully monitor neurologic status to evaluate for improvement or deterioration.

(Option 1) Normal saline fluid bolus would worsen the hyponatremia as the client already has excess fluid volume. Symptoms are caused by a low sodium level. If the sodium level must be raised, the client will need hypertonic (3%) saline or salt tablets as these contain mainly sodium and little free fluid.

Educational objective:
SIADH can occur due to lung cancer and is characterized by water retention, increased total body water, and dilutional hyponatremia. Hyponatremia may cause neurologic complications (eg, confusion, seizures). SIADH treatment includes fluid restriction, oral salt tablets, and administration of 3% saline IV and/or vasopressin receptor antagonists.
Deficient fluid volume related to osmotic diuresis

DKA is a life-threatening emergency caused by a relative or absolute insulin deficiency. The condition is characterized by hyperglycemia, ketosis, metabolic acidosis, and dehydration. The most likely contributing factors in this client include stress associated with illness and infection (elevated temperature) and inadequate insulin dosage and self-management.

Deficient fluid volume related to osmotic diuresis secondary to hyperglycemia as evidenced by dry mucous membranes and client report of frequent urination, thirst, and weakness is the priority ND. Hyperglycemia leads to osmotic diuresis, dehydration, electrolyte imbalance, and possible hypovolemic shock and renal failure. Therefore, this condition requires rapid correction through the infusion of isotonic intravenous fluids and poses the greatest risk to the client's survival (Option 1).

(Option 2) When the supply of insulin is insufficient and glucose cannot be metabolized for energy, the body breaks down fat stores leading to ketosis (fruity breath) and metabolic acidosis. However, it does not pose the greatest risk to survival and is not the priority ND.

(Option 3) Tachypnea and deep labored respirations (ie, Kussmaul) are the body's attempt to eliminate excess acid (pCO2) through hyperventilation and normalize the pH. However, it does not pose the greatest risk to survival and is not the priority ND.

(Option 4) Ineffective health maintenance related to inability to manage a condition during illness (evidenced by DKA development in this client) is an appropriate ND. However, it does not pose the greatest risk to survival at this time and is not the priority ND.

Educational objective:
Hyperglycemia associated with DKA leads to osmotic diuresis, dehydration, electrolyte imbalance, and possible hypovolemic shock and renal failure. Deficient fluid volume related to osmotic diuresis is an appropriate ND for a client with DKA.
Administer artificial tears to moisten the conjunctiva
If eyelids don't close during sleep, lightly tape them shut
Recommend the use of dark glasses to prevent irritation
Teach about the importance of smoking cessation

Exophthalmos is a complication of hyperthyroidism (hypermetabolic state due to thyroid hormone overproduction) from Graves' disease. It is defined as a protrusion of the eyeballs caused by increased orbital tissue (connective, adipose, muscular) expansion and can be irreversible. The exposed cornea is at risk for dryness, injury, and infection.

Nursing care for a client with exophthalmos includes:

Maintaining the head of the bed in a raised position to facilitate fluid drainage from the periorbital area
Using artificial tears or other similar products to moisten the eyes to prevent corneal drying (causes abrasions/ulcers)
Taping the client's eyelids shut during sleep if they do not close on their own
Teaching the client the following:
Regular visits to the ophthalmologist are necessary to measure eyeball protrusion and evaluate condition.
If recommended, anti-thyroid drugs should be taken to prevent further exacerbation of exophthalmos.
Smoking cessation is necessary as smoking increases the risk of Graves' disease and associated eye problems.
Restrict salt intake to decrease periorbital edema.
Use dark glasses to decrease glare and prevent external irritants and infection.
Perform intraocular muscle exercises (turning the eyes using complete range of motion) to maintain flexibility.
Educational objective:
Exophthalmos is a complication of hyperthyroidism from Graves' disease leading to increased orbital tissue (connective, adipose, muscular) expansion that can be irreversible. Nursing care to keep eyes moist and protected is needed to prevent corneal ulcers and infection.
"I will make sure my flip flops are made of leather."

Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet due to the chronic complication of peripheral neuropathy. Peripheral neuropathy results from damage to the nerves in the extremities. Clients may be unable to feel injuries if they occur and must take extra measures in caring for their feet. Clients should be taught to wear closed-toed, leather-based shoes to prevent injury.

Careful, daily attention to foot care can prevent long-term complications. The following instructions can be used in teaching diabetic foot care:

Proper footwear - Wear shoes that are comfortable, supportive, and well-fitting (preferably leather). Avoid high-heeled, open-heeled, and open-toed shoes. Wear clean, absorbent (eg, cotton) socks.
Daily hygiene and inspection - Use a mild soap and warm water; dry feet thoroughly, especially between toes. Apply lanolin lotion to prevent drying (but not between toes) (Option 1). Inspect for any break in skin integrity using a mirror or a second person to visualize the bottom of the feet. Trim toenails straight across; file edges along contour of the toes.
Injury avoidance - Do not walk barefoot, use hot water or heating pads, wear restrictive shoes or clothing, or cross the legs for extended periods (Options 3 and 4).
Report problems - Do not self-treat corns, calluses, or ingrown toenails. Cleanse cuts or abrasions with mild soap and water; report non-healing or infected injuries to the health care provider immediately.
Educational objective:
Careful, daily attention to foot care can prevent long-term complications. Clients with diabetes should be taught to wear closed-toed, leather-based shoes to prevent injury. Clients should also receive instruction regarding daily hygiene and inspection, injury avoidance, and prompt reporting of problems.
To request a prescription for insulin lispro

Type 1 diabetes mellitus is an endocrine disorder characterized by the absence of insulin production in the pancreas, causing hyperglycemia and intracellular energy deficits. Clients with type 1 diabetes mellitus require consistent insulin administration, typically of both short- or rapid-acting and intermediate- or long-acting insulins, to prevent hyperglycemia and provide energy to the cells.

The nurse should contact the health care provider (HCP) to report the serum glucose (270 mg/dL [14.9 mmol/L]) and request an additional insulin prescription (Option 4). The client requires rapid-acting insulin (eg, lispro, aspart) before eating to correct the hyperglycemia; long-acting insulins are not effective for immediate correction.

(Option 1) Detemir is a long-acting (basal) insulin, prescribed once or twice daily. Long-acting insulins are given to prevent, not correct, hyperglycemia. However, if the blood glucose remains elevated, the detemir dose may need to be increased.

(Option 2) Spironolactone is a potassium-sparing diuretic that counteracts potassium loss caused by other diuretics. It is often prescribed in combination with thiazide diuretics to treat hypertension and in combination with loop diuretics to treat ascites associated with liver disease. The nurse would question this prescription if the client were hyperkalemic.

(Option 3) Serum potassium is within the normal range of 3.5-5.0 mEq/L (3.5-5.0 mmol/L), so it does not need to be reported to the HCP.

Educational objective:
Rapid-acting insulin preparations are administered to correct hyperglycemia, whereas long-acting insulin preparations prevent hyperglycemia. The nurse should question a spironolactone prescription and notify the health care provider if the client is hyperkalemic.
"The increase in glucose is a normal response to stress by the body. We give insulin to keep the level at 140 - 180 mg/dL."

Stress-induced hyperglycemia (gluconeogenesis) can occur in hospitalized clients in relation to surgery, trauma, acute illness, and infection. Hyperglycemia (glucose level >140 mg/dL [7.8 mmol/L]) affects both diabetic and non-diabetic hospitalized clients, especially those who are critically ill. Approximately 80% of clients in the intensive care unit who develop hyperglycemia have no history of diabetes before admission.

Hyperglycemia is associated with increased risk of complications (eg, health care-associated infection, increased length of stay, acute kidney injury). To minimize complications and avoid hypoglycemia, the recommended glucose target range for critically ill clients is 140-180 mg/dL [7.8-10.0 mmol/L]. For non-critically ill clients, <140 mg/dL [7.8 mmol/L] fasting and <180 mg/dL [10.0 mmol/L] random blood glucose are recommended.

(Option 1) Hospital hyperglycemia is not a direct cause of type II diabetes mellitus. In the non-diabetic client, the glucose level usually returns to normal after resolution of the disease process and/or discontinuation of steroid medications. A target glucose range of <140 mg/dL [7.8 mmol/L) is not recommended for this client.

(Option 2) The prevalence of diabetes in hospitalized clients is high (about 1 in 4) and may be an undiagnosed pre-existing condition. A normal-range glucose level (70-110 mg/dL [3.9-6.1 mmol/L]) is not the recommended target range in this client due to the risk of hypoglycemia (with aggressive control) and worse outcomes.

(Option 4) Although hyperglycemia does affect the ability to fight infection, 70-110 mg/dL [3.9-6.1 mmol/L] is not the recommended target range for this client.

Educational objective:
Stress-induced hyperglycemia causes complications in the hospitalized client. To minimize complications, the recommended target glucose range for critically ill clients is 140-180 mg/dL [7.8-10.0 mmol/L]. For non-critically ill clients, <140 mg/dL (7.8 mmol/L) fasting and <180 mg/dL (10.0 mmol/L) random blood glucose are recommended.
Start nitroprusside infusion at 0.5 mcg/kg/min

Explanation:

Pheochromocytoma is a condition caused by a tumor in the adrenal medulla. This results in excess release of catecholamines such as epinephrine and norepinephrine, leading to paroxysmal hypertensive crisis.

Important points to note when caring for these clients include the following:

Hypertension is difficult to treat and is often resistant to multiple drugs.
The client should avoid activities that can precipitate a hypertensive crisis (eg, bending, lifting, Valsalva maneuver).
Abdominal palpation should be avoided as manipulation of the adrenal gland and release of catecholamines can precipitate a hypertensive crisis.
Hypertensive crisis puts the client at risk for stroke and so has the highest priority for treatment. Nitroprusside (Nitropress, Nipride) is a vasodilator given via infusion and can be titrated to keep the BP within a desired parameter.

(Options 1, 2, and 3) Administration of acetaminophen and use of a fan may help relieve symptoms. Drawing an electrolyte panel is appropriate. However, these are not life-saving interventions and so are not the highest priority.

Educational objective:
Pheochromocytoma is a condition caused by a tumor in the adrenal medulla that causes release of catecholamines such as epinephrine and norepinephrine, resulting in paroxysmal hypertensive crisis. Hypertensive crisis puts the client at risk for stroke and should be treated promptly with intravenous nitroprusside or another vasodilator (eg, phentolamine, nicardipine). Abdominal palpation should be avoided in these clients.
Female with a waist circumference of 38 inches (96.5 cm)
Female with blood pressure of 148/90 mm Hg
Male with a triglyceride level of 201 mg/dL (2.3 mmol/L)

Individuals with metabolic syndrome (insulin resistance syndrome) have an increased risk of diabetes and coronary artery disease. The presence of abdominal obesity causes increased insulin production (hyperinsulinemia); this excess insulin leads to insulin resistance, the primary feature of metabolic syndrome. Metabolic syndrome is characterized by the presence of 3 or more of the following criteria:

Increased waist circumference: ≥40 in (102 cm) in men, ≥35 in (89 cm) in women (Option 2)
Blood pressure: ≥130 mm Hg systolic or ≥85 mm Hg diastolic or drug treatment for hypertension (Option 3)
Triglyceride level: >150 mg/dL (1.7 mmol/L) or drug treatment for elevated triglycerides (Option 5)
High-density lipoprotein (HDL) levels: <40 mg/dL (1.04 mmol/L) in men and <50 mg/dL (1.3 mmol/L) in women or drug treatment for low HDL-C
Fasting glucose levels: ≥100 mg/dL (5.6 mmol/L) or drug treatment for elevated blood glucose (Option 4)
The mnemonic for metabolic syndrome is "We Better Think High Glucose" (Waist circumference, Blood pressure, Triglyceride, HDL, Glucose).

(Option 1) The normal LDL level is <100 mg/dL (2.6 mmol/L); therefore, this client's LDL level is within normal limits. LDL level is not a criterion for diagnosing metabolic syndrome, although a normal level is important for cardiovascular health.

Educational objective:
Features of metabolic syndrome include increased waist circumference, elevated blood pressure, increased triglycerides, decreased HDL, and increased fasting blood glucose. The mnemonic is "We Better Think High Glucose" (Waist circumference, Blood pressure, Triglyceride, HDL, Glucose).
Provide 4 oz of regular soft drink

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.

Educational objective:
Clients with diabetes should be monitored for signs of hypoglycemia (eg, shakiness, sweating, alterations in mental status). Conscious clients experiencing hypoglycemia should receive a snack of 15 g quick-acting carbohydrates.
Cut toenails straight across and file along the curves of the toes
Use a mild foot powder on perspiring feet
Use cotton or lamb's wool to separate overlapping toes

Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet. This is due to the chronic complication of peripheral neuropathy, which results from nerve damage in the extremities.

Instructions for diabetic foot care include:

Wash feet daily with warm water and mild soap; test water temperature with thermometer beforehand. Gently pat feet dry, particularly between the toes (Option 2). Use lanolin to prevent dry and cracked skin, but do not apply between the toes.
Inspect for abrasions, cuts, or sores. Have others inspect the feet if eyesight is poor.
To prevent injury, use cotton or lamb's wool to separate overlapping toes. Cut toenails straight across and use a nail file to file along the curves of the toes. Avoid going barefoot and wear sturdy leather shoes. Use mild foot powder to absorb perspiration and wear clean, absorbent socks with seams aligned (Options 1, 3, and 4).
Avoid using over-the-counter products (eg, iodine, alcohol, strong adhesives) on cuts or abrasions (Option 5).
To improve circulation, do not sit with legs crossed or for extended periods, avoid tight-fitting garments, and perform daily exercise.
Report other types of problems such as infections or athlete's foot immediately.
Educational objective:
Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet due to the chronic complication of peripheral neuropathy. Clients should keep feet clean, dry, and free from irritation.
Obtain a serum calcium level

Normal serum calcium is 8.6-10.2 mg /dL (2.15-2.55 mmol/L). Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of thyroidectomy because the parathyroids that regulate calcium levels in the blood are accidentally removed during this surgical procedure. The nurse should monitor the client closely for signs of hypocalcemia, which include tetany (overactive neurological responses such as tingling in the hands, feet, and around the mouth; spasms or cramps that can occur even in the larynx; positive Trousseau or Chvostek sign). A serum calcium level should be drawn, and the nurse should ensure that calcium gluconate is readily available in case this complication occurs.

(Option 1) Monitoring for bleeding is an important assessment. However, when bleeding occurs post thyroidectomy, blood typically trickles and pools behind the client's neck. This client's symptoms are more consistent with hypocalcemia.

(Option 2) It is important to document findings in the electronic medical record, but the nurse should do this after taking action to help the client.

(Option 3) If laryngeal spasm occurs as a result of hypocalcemia, hypoxia may be evident in arterial blood gases. However, the client will also exhibit signs of hypoxemia (eg, stridor, respiratory distress, low pulse oximetry reading). Checking the calcium level so that effective treatment can begin is the highest priority.

Educational objective:
Normal serum calcium is 8.6-10.2 mg /dL (2.15-2.55 mmol/L). Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of thyroidectomy. The nurse should monitor for signs and symptoms of tetany (tingling of hands, toes, and circumoral region; positive Trousseau or Chvostek sign), confirm with serum calcium results, and administer calcium gluconate as prescribed. Untreated clients can develop life-threatening laryngeal spasm.
Assess frequently for facial or extremity numbness or tingling

Ensuring that a tracheostomy insertion kit is at the bedside at all times

Maintaining the HOB 30 - 45 degrees

Monitor client's voice strength and quality.

Thyroidectomy is a surgery involving partial or complete removal of the thyroid, often to treat hyperthyroidism or thyroid cancer. Clients undergoing a thyroidectomy require close monitoring as they are at increased risk for airway compromise due to potential neck swelling, hypocalcemia, and nerve damage. Nurses planning care following a thyroidectomy promote client recovery and monitor for and prevent complications by:

Assessing for and immediately reporting signs of hypocalcemia (eg, facial or extremity numbness or tingling, stridor, Trousseau and Chvostek signs), which may occur from parathyroid gland trauma during surgery (Option 1)

Assessing for stridor and new or worsening changes in voice strength and quality (eg, hoarseness, whispering), which may indicate laryngeal nerve damage that can result in respiratory arrest (Option 5)

Keeping emergency airway equipment (eg, tracheostomy kit, suction, oxygen) at the bedside in case respiratory distress develops (Option 3)

Maintaining the client in semi-Fowler position, which promotes drainage of surgical site edema around the neck and reduces the risk of respiratory distress (Option 4)

(Option 2) Postoperatively, the client should avoid excessive neck flexion and extension, which may strain and cause disruption of the incision site, leading to hemorrhage. Encourage the client to maintain neutral head and neck alignment.

Educational objective:
Following a thyroidectomy, place the client in semi-Fowler position with a neutral head and neck position. Keep a tracheostomy kit, suction, and oxygen at the bedside in case airway compromise develops. Monitor frequently for signs of hypocalcemia and changes in voice strength and quality.
Initiate potassium IV when serum potassium is 3.5- 5.0 mEq/L (3.5 - 5.0 mmol/L)

Diabetic ketoacidosis (DKA) is an acute, serious complication generally due to lack of insulin in clients with type 1 diabetes. DKA is characterized by hyperglycemia, ketosis, and acidosis. Hyperglycemia causes osmotic diuresis, resulting in profound dehydration. Clients with DKA may initially develop hyperkalemia as a compensatory response to acidosis despite having a total body potassium deficit from urinary loss.

Management of DKA includes fluid resuscitation, IV insulin, and hourly blood glucose monitoring. When serum glucose is <250 mg/dL (13.9 mmol/L), D5W is administered to prevent hypoglycemia until ketoacidosis is resolved. Hypokalemia often occurs with resolution of acidosis and administration of IV insulin, which shifts potassium from the intravascular to the intracellular space. Therefore, potassium is administered even when the client is normokalemic (3.5-5.0 mEq/L [3.5-5.0 mmol/L]) to prevent hypokalemia and subsequent life-threatening arrhythmias (Option 4).

(Option 1) Serum potassium, glucose, and anion gap or bicarbonate levels are regularly monitored in DKA to monitor treatment effectiveness. Although serum creatinine and BUN levels may be elevated due to dehydration and may be monitored, hourly monitoring is not indicated.

(Option 2) IV insulin infusion may be discontinued on resolution of acidosis and ketosis, which generally occurs with a blood glucose level of <200 mg/dL (11.1 mmol/L).

(Option 3) As blood glucose is reduced, the insulin infusion rate is decreased to prevent a hypoglycemic event.

Educational objective:
Hypokalemia often occurs with resolution of diabetic ketoacidosis and administration of IV insulin, which shifts potassium from the intravascular to the intracellular space. Potassium is administered even when the client is normokalemic (3.5-5.0 mEq/L [3.5-5.0 mmol/L]) to prevent life-threatening arrhythmias.
0.45% sodium chloride (NaCl) solution prescribed for a client with SIADH secretion who has a sodium level of 120 mEq/L

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is associated with increased water reabsorption and excessive intra- and extracellular fluid, which result in hypervolemia from fluid retention and dilutional hyponatremia. In the setting of SIADH, the nurse should question a prescription for a hypotonic solution (eg, 0.45% NaCl; or dextrose water) as it would worsen the fluid and electrolyte imbalance. A prescription for fluid restriction and a hypertonic IV solution (eg, 3% NaCl) administered in small quantities would be appropriate to shift fluid back into the vascular compartment and correct hyponatremia.

(Option 2) Isotonic fluids (eg, normal saline) are appropriate for clients with volume deficit such as those with gastrointestinal bleeding.

(Option 3) Septic shock involves an inflammatory response to pathogens that leads to massive vasodilation and increased capillary permeability, resulting in intravascular hypovolemia and severe hypotension. An isotonic solution (eg, 0.9% NaCl) bolus is prescribed to expand intravascular volume and increase blood pressure.

(Option 4) A burn injury causes tissue damage and increased capillary permeability; this leads to fluid and electrolyte losses related to evaporation and intravascular fluid shifts into the interstitial tissue, which result in hypovolemia, hemoconcentration (eg, hematocrit >53% [0.53]), and hypotension. An isotonic solution (eg, lactated Ringer's) is prescribed to replace fluid and electrolyte losses.

Educational objective:
Syndrome of inappropriate antidiuretic hormone secretion is associated with hypervolemia and dilutional hyponatremia. Fluid restriction and hypertonic IV solutions (eg, 3% saline) are prescribed to correct hyponatremia.
Fluid restriction
Seizure precautions
Strict record of fluid intake and output

SIADH is an endocrine condition in which antidiuretic hormone overproduction leads to water retention, increased total body water, and dilutional hyponatremia (low serum sodium). Hyponatremia can cause confusion, seizures, or other neurologic complications. It is important for the nurse to anticipate these problems and institute seizure precautions.

SIADH treatment includes:

Fluid restriction to <1000 mL/day
Oral salt tablets to increase serum sodium (Option 3)
Hypertonic saline (3%) during the first few hours for clients with markedly decreased serum sodium and severe neurologic manifestations
Vasopressin receptor antagonists (eg, conivaptan)
The nurse should also maintain a strict fluid intake and output chart and daily weights and carefully monitor neurologic status to evaluate for improvement or deterioration.

(Option 1) Normal saline fluid bolus would worsen the hyponatremia as the client already has excess fluid volume. Symptoms are caused by a low sodium level. If the sodium level must be raised, the client will need hypertonic (3%) saline or salt tablets as these contain mainly sodium and little free fluid.

Educational objective:
SIADH can occur due to lung cancer and is characterized by water retention, increased total body water, and dilutional hyponatremia. Hyponatremia may cause neurologic complications (eg, confusion, seizures). SIADH treatment includes fluid restriction, oral salt tablets, and administration of 3% saline IV and/or vasopressin receptor antagonists.