NCLEX

NCLEX Case Study: Nursing Care of the Patient With an Endocrine Disorder

By March 18, 2018 No Comments

Endocrine Disorder

The nurse is caring for Maria, who was admitted to the hospital with diabetic ketoaci- dosis (DKA). Maria had a virus for 3 days before hospitalization.

Fill in the blanks:

Name four clinical features of diabetic ketoacidosis (DKA).
1.___________________________________________________________
2.___________________________________________________________
3.___________________________________________________________
4.___________________________________________________________

Colin, the nurse, assesses Maria frequently.The characteristics of DKA and hyperglycemic hyperosmolar nonketotic syndrome (HHNS) are very similar, but it is important to differentiate between the two.

Matching:

Indicate whether each characteristic in Column B is associated with diabetic ketoacidosis (DKA) or hyper-
glycemic hyperosmolar nonketotic syndrome (HHNS), mentioned in Column A:

diabetic ketoacidosis (DKA) or hyper- glycemic hyperosmolar nonketotic syndrome (HHNS)

diabetic ketoacidosis (DKA) or hyper- glycemic hyperosmolar nonketotic syndrome (HHNS)

diabetic ketoacidosis (DKA) or hyper- glycemic hyperosmolar nonketotic syndrome (HHNS)

diabetic ketoacidosis (DKA) or hyper- glycemic hyperosmolar nonketotic syndrome (HHNS)

Select all that apply:

The nurse understands that the initial treatment for Maria would include:
A. Administeringoxygen
B. Establishing an intravenous (IV) line
C. Administering 0.9% normal saline (NS) IV
D. Infusing neutral protamine Hagedorn (NPH) insulin
E. Monitoring potassium levels closely
F. Encouraging intake of Gatorade

Multiple-choice:

The nurse reviews the laboratory reports from blood samples drawn 1 hour after the administration of intravenous (IV) insulin. What would the nurse expect?
A. Hyponatremia
B. Hypercalcemia
C. Hypoglycemia
D. Hypokalemia

Maria is feeling better within 24 hours.The nurse begins to explain to her how to prevent this occurrence in the future.

Select all that apply:

Which sick-day rules should the nurse include in the teaching?
A. Continue eating regular meals if possible
B. Increase the intake of noncaloric fluids
C. Take insulin as prescribed
D. Check glucose once daily
E. Test for ketones if glucose is greater than 240 mg/dL
F. Report moderate ketones to the health care provider (HCP)

TIP: Manifestations of diabetes mellitus

Macrovascular complications occur from early-onset atherosclerosis, causing:
■ Cardiovascular disease
■ Cerebrovascular disease
■ Peripheral vascular disease
Microvascular complications occur from thickening of the vessel membranes in the capillaries and arterioles, causing problems with:
■ Vision (retinopathy)
■ Kidneys (nephropathy)

Multiple-choice:

The night charge nurse is making assignments for the following day shift. The plan is for Maria to be discharged home. It would be best to assign Maria to:
A. An experienced RN pulled from another medical unit
B. A new-graduate RN who has been on the unit for 1 week
C. An experienced RN who has just been transferred from the operating room
D. A licensed practical nurse (LPN) who has been on the unit for 3 months

Matching:

Match the information in Column A with the disease alteration in Column B (an option may be used more than once):

Disease Alteration

Disease Alteration

KEY POINTS:

Diabetes Mellitus

■ Characteristics of type 1 diabetes include an onset of usually less than 30 years of age, thin at diagnosis with recent weight loss, little or no insulin production, needs insulin for life, and ketosis prone (DKA).
■ Characteristics of type 2 diabetes include an onset at any age although many type
2 diabetics are older than 30 years of age, usually obese at diagnosis, problem with either decreased amount of insulin or insulin resistance, treatment focuses on weight loss and oral antidiabetic agents, ketosis is uncommon (HHNS).
■ Risk factors include a family history, obesity, ethnicity, age, HTN, dyslipidemia, and history of gestational diabetes or delivery of babies weighing more than 9 lb
■ The classic clinical manifestations are the three Ps: polyuria, polydipsia, and polyph- agia. Others include fatigue, vision changes, wounds that will not heal, and recur- rent infections.
■ Criteria for diagnosis include symptoms of diabetes plus a casual plasma glucose greater than or equal to 200 mg/dL or a fasting plasma glucose greater than or equal to 126 mg/dL.
■ Management focuses on nutrition, exercise, monitoring, medication, and education.
■ Insulin regimens can be conventional or intensive.The intensive regimen is benefi- cial in reducing the risk of long-term complications, but increases the risk of hypo- glycemia because of tight blood sugar controls.
■ Hypoglycemia is a potentially deadly complication. Early symptoms include sweating, tachycardia, palpitations, and anxiety. As the blood sugar falls further, central nervous system (CNS) symptoms develop, which can significantly impair the patient.
■ Treatment of hypoglycemia involves administration of 15 g of a fast-acting concen- trated source of carbohydrate.
■ The primary features of DKA are hyperglycemia, ketosis, dehydration, electrolyte loss, and acidosis.
■ DKA can occur when diabetic patients are sick and stop taking their insulin.“sick- day rules” are designed to minimize the risk of DKA occurring.
■ Treatment of DKA focuses on treating the hyperglycemia and correcting dehydra- tion, electrolyte loss, and acidosis.
■ HHNS is similar to DKA except there is no ketosis and pH and bicarbonate levels are normal.
■ Long-term complications from diabetes are categorized as macrovascular and microvascular complications.


Lisa has been feeling extremely nervous and has come to the clinic for an evaluation. She is 34 years old, has three children, and works full time.The laboratory results indicate that she has hyperthyroidism.The most common cause of hyperthyroidism is Graves’ disease.

Select all that apply:

Which health alterations can cause hyperthyroidism?
A. Toxic nodular goiter B. Thyroiditis
C. Cancer of the tongue
D. Thyroidcancer
E. Hyperfunction of the adrenal glands
F. Exogenous iodine intake

Matching:

Match the clinical manifestations in Column A with the disease alteration in Column B:

Disease alteration matching

Disease alteration matching

Two days after being diagnosed with Graves’ disease, Lisa presents to the emergency room with palpitations, chest pain, and extreme anxiety. Her BP is elevated and the EKG shows a rhythm of sinus tachycardia with a rate of 134. Lisa states that she has been very anxious since being told of her diagnosis.

Multiple-choice:

Lisa is being admitted with the diagnosis of thyrotoxic crisis. When making a room assignment for this patient, the charge nurse knows it would be best to assign:
A. A room in which the roommate is not infected
B. A room that is directly across from the nursing station
C. A private room
D. A room in which the roommate is very pleasant and talkative

KEY POINTS:

Thyroid Disorders

■ The most common cause of hypothyroidism in adults is Hashimoto’s disease, which occurs when the immune system attacks the thyroid gland.
■ Thyroid deficiency can affect all body functions.
■ Clinical manifestations include fatigue, hair loss, brittle nails, dry skin, and consti- pation. Later symptoms are progressively worse and include subdued emotional responses, cold intolerance, weight gain, bradycardia, and hypotension. Myxedema coma is the most extreme stage of hypothyroidism.
■ Normal metabolism is restored by replacing the missing hormone with synthetic hormone. Dosages are based on serum thyroid-stimulating hormone (TSH) levels.
■ The most common cause of hyperthyroidism is the autoimmune disorder Graves’ disease.
■ Symptoms of hyperthyroidism may occur after an emotional shock, stress, or
infection.
■ Clinical manifestations include nervousness, irritability, palpitations, rapid HR, ele- vated BP, heat intolerance, excessive perspiration, weight loss, tremors of the hands and tongue, and exophthalmos.Thyroid storm is an abrupt onset of severe hyper- thyroidism.
■ Management involves several options, including radioactive iodine-131 therapy, antithyroid drug therapy, or thyroidectomy.


Marilyn, age 70 years, has been taking corticosteroids intermittently for many years to treat rheumatoid arthritis.These high amounts of corticosteroids can cause many physi- ological and psychological changes; in Marilyn’s case, they have caused Cushing’s disease.

Select all that apply:

Which of the following clinical manifestations are present in Cushing’s disease?
A. Buffalohump
B. Hypovolemia
C. Weightloss
D. Hyperpigmentation of skin
E. Moonface
F. Muscle wasting in the extremities
G. Purple striae on the abdomen

The treatment of Cushing’s disease is related to the cause, which may be a tumor of the pituitary or adrenal gland or excessive secretion of adrenocorticotropic hormone (ACTH) from carcinoma of the lung. Some patients may need surgery to remove the tumor that is causing these symptoms. In Marilyn’s case, Cushing’s has developed as a result of long-term corticosteroid use.

Multiple-choice:

In order to manage Cushing’s disease, the health care provider (HCP) recommends:
A. Discontinuing the corticosteroid therapy immediately
B. Weaning her off the corticosteroid medication slowly
C. Using the corticosteroid only as needed for severe pain
D. Administering the corticosteroid before bedtime

Select all that apply:

Select the information that should be included in the teaching session for this patient.
A. Keep a medical identification device with you
B. Keep a list of medications and doses with you
C. Increase the sodium in your diet
D. Avoid exposure to infection
E. Hold the medication if side effects occur
F. Monitor for excessive weight gain

Musculoskeletal changes can occur with Cushing’s disease, which may result in kyphosis and compression fractures of the vertebrae.

Multiple-choice:

In order to prevent injuries, it is a priority to teach the patient to:
A. Increase protein in his or her diet
B. Begin an aerobics exercise class
C. Use assistive devices as much as possible
D. Establish a protective environment

KEY POINTS:

Cushing’s Disease

■ Although overproduction of endogenous corticosteroids can lead to Cushing’s, it is more commonly caused by chronic use of synthetic corticosteroid medications.
■ Clinical manifestations include central-type obesity, fatty buffalo hump in the neck area, moon face, thin skin, muscle wasting, retention of sodium and water, weight gain, hyperglycemia, virilization in females, and changes in mood and mental activity.
■ Treatment is directed at the cause.
■ To minimize the risk of Cushing’s, corticosteroids are best taken around 8:00 a.m.,
in the lowest dose possible, for the shortest period of time.
■ Corticosteroids should never be abruptly stopped because of the risk of causing adrenal insufficiency.


Isabella is admitted to the hospital in Addisonian crisis. She has a history of Addison’s disease.

Multiple-choice:

After Isabella arrives on the unit, the nursing team begins the admission process. What role can be dele- gated to the licensed practical nurse (LPN)?
A. Perform the initial physical assessment
B. Obtain the patient’s weight
C. Hang a new bag of intravenous (IV) fluids
D. Educate the patient on the plan of care

Fill in the blanks:

What three hormones does the adrenal cortex produce and what is their primary function?
1.________________________________________________________
2.________________________________________________________
3.________________________________________________________

Matching:

Match the hormones in Column A with the related clinical manifestations of deficiency in Column B:

Match Hormones

Match Hormones

Isabella states that she was taking her medications as prescribed and she does not under- stand why she had this problem.

Fill in the blanks:

List four causes of Addisonian crisis.
1._______________________________________________________
2._______________________________________________________
3._______________________________________________________
4._______________________________________________________

The nurse explains that hormone replacement will always be needed, but the doses of med- ication must be increased when there are events that cause psychological or physical stress.

Select all that apply:

Which symptoms would indicate that Isabella is in Addisonian crisis?
A. Hypertension(HTN)
B. Bradycardia
C. Dehydration
D. Hyperkalemia
E. Nausea and vomiting
F. Weakness

KEY POINTS:

Addisonian crisis

The collaborative care includes:
■ Restoring fluid volume deficit with normal saline 0.9% IV
■ Administering hydrocortisone replacement
■ Monitoring and treating hyperkalemia and hypoglycemia
■ Evaluating vital signs and cardiac rhythm frequently to assess for fluid volume defi- cit and hyperkalemia

Gabriel had a craniotomy to remove a benign brain tumor.Two days after surgery,he began putting out copious amounts of very dilute urine. He was subsequently diagnosed with diabetes insipidus (DI) and transferred back to the intensive care unit. On arrival, Gabriel is hypotensive, tachycardic, and complaining of intense thirst.

Multiple-choice:

After receiving transfer orders on Gabriel, the nurse knows that the priority intervention is to:
A. Draw all laboratory tests before starting any treatment
B. Administer fluid-replacement therapy
C. Fill up the patient’s water pitcher as requested
D. Obtain the patient’s baseline weight

Fill in the blank:

Which type of diabetes insipidus (DI) does Gabriel have? Explain.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Select all that apply:

Which clinical manifestations would be present in a patient with diabetes insipidus (DI)?
A. Polydipsia
B. Polyuria
C. Urine output less than 100 mL in 24 hours
D. Specific gravity less than 1.005
E. Weightloss
F. Hypertension (HTN)

The patient’s BP remains low and the urine output continues to increase. Gabriel is feeling very weak.

Select all that apply:

The nurse understands that appropriate treatment for a patient with diabetes insipidus (DI) includes:
A. Titrating intravenous (IV) fluids to replace urine output
B. Administering thiazide diuretics
C. Initiating a low-sodium diet
D. Administering desmopressin acetate (DDAVP)
E. Monitoring a strict input and output (I&O)
F. Allowing the patient to drink as desired

KEY POINTS:

Diabetes Insipidus

■ DI is characterized by a deficiency of antidiuretic hormone (ADH ; vasopressin).
■ The three types are neurogenic, nephrogenic, and psychogenic.
■ An output of very large amounts of dilute urine can quickly lead to a fluid volume deficit.
■ Other signs and symptoms are related to the fluid volume deficit that results; these include weight loss, poor skin turgor, dry mucous membranes, increased HR, and hypotension.
■ The patient experiences an intense thirst and may drink up to 20 L/d. Limiting the fluid intake will not alter the high volume loss of urine.
■ Medical management includes identifying and correcting the cause if possible, ensuring adequate fluid replacement, and administering desmopressin, which is synthetic vasopressin.

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