You are on page 1of 46

Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

1


DISORDER OF THE THYROID GLAND
Hyperthyroidism
Is excessive thyroid hormone secretion from thyroid gland ( Ignatavicius, 2010)
Graves Disease
An autoimmune disorder. Antibodies activate TSH receptors with in turns thyroid enlargement and
hormone secretion. Develops on young women (Linton 2012).
Cause by an autoimmune disorder such as myasthenia gravis and percutinous anemia (Lemone,
2008)
Toxic Multinodular Goiter
Is a tumor characterized by small discrete, independently functioning nodules in the thyroid glands
tissue that secretes excessive amount of TH. It is known how these nodules grow or become
independent, but a genetic mutation of follicle cells is suspected (Lemone, 2008 )
Assessment
Manifestation
Endocrine- goiter
Respiratory- dyspnea
Gastrointestinal- nausea, vomiting, diarrhea, abdominal pain
Neurologic- hand and eye tremors, nervousness, insomnia, emotional lability, increase refelex
Sensory-blurred vision, photophobia, lacrimation, exophthalmos
Cardiovascular- hypertension, tachycardia, dysrhythmias, palpitation
Reproductive- amenorrhea, fertility, decrease in libido, Impotence
Integumentary- Fine, thin hair, Flushed, moist skin
Metabolic Processes- Hyperthermia, diaphoresis, hunger, weight loss, Fluid Volume deficits











Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

2

Laboratory findings in Hyperthyroidism
Test Normal Values Findings
Serum TA Negative to 1:20 increased
Serum TSH 2-10 mU/ ml Decreased in primary
Serum T
4
5-12 mcg/dL Increased
Serum T
3
80-200 mg/dL Increased
T
3
uptake 25-35 relative
percentage
Increased
Thyroid suppression Increase RAI uptake
and T
4
levels

Nursing Diagnosis and Interventions
Risk for Decreased Cardiac Output
a) Monitor blood pressure, pulse rate and rhythm, RR and breath sounds. Assess the peripheral
edema, jugular vein distention, and increased activity intolerance.
b) Suggest keeping the environment as cool and free of distraction as possible. Decrease stress
by explaining interventions and teaching relaxation procedures.
c) Encourage the client to balance activity with rest periods.

Disturbed sensory Perception: Visual
a) Monitor visual acuity, photophobia, integrity of cornea and lid closure
b) Teach measure for protecting the eye from injury and maintaining visual acuity.

Imbalanced Nutrition: Less than body requirement
a) Ask the client to weigh daily
b) In collaboration with a dietician, teach the client the need for a diet high in carbohydrates and
protein and including between meal snacks. Six small meals a day may be more desirable than
three large meals. Caloric intake may need to be increased to 4000 kcal/day if weight loss
exceeds 10% to 17% for height and frame.
c) Monitor nutritional status through results of laboratory data. Serum albumin, transferring and
total lymphocytes count are commonly lower than normal in nutritional deficits.

Disturbed Body Image
a) Establish a trusting relationship; encourage the client to verbalize feelings about self and to
ask questions about the illness and treatment. Provide reliable information and clarify the
information and clarify misconceptions.
Community Based Care
Clients with hyperthyroidism primarily provide self care at home. Teaching is individualized to meet the
clients need
1. The client taking oral medication must understand the need for lifelong treatment.
2. The client who has thyroidectomy requires information about post operation wound care.
3. The client having radioactive iodine therapy needs to know the symptoms of hypothyroidism
4. Depending on the age of the client and support system available, referral to community
healthcare agencies may necessary
Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

3

5. In addition , suggest the following resources which are accessible via internet
American Thyroid Association
Thyroid Foundation of Canada
Endocrine Society
In the Philippines refer to Philippine Thyroid Association located at Eulogio Amang
Rodriguez Institute of Science and Technology Medical Directors Office, Nagtahan,
Sampaloc, Manila.
Medication
Drugs Purpose Nursing Implication Client Teaching
Anti Thyroid
Methimazole
( Tapazole)
Propylthiouracil
( PTU, Propyl-thyracil)

Inhibits thyroid
Hormone
Production
Monitor for Itching,
Rash, Fever, loss of
sense of taste and
agranulocytosis
Take the same time
each day. If taking
warfarin, report any
signs of bleeding.
Iodine Sources
Strong Iodine Solution
(lugols Solution)
Potassium Iodide (
SSKI, Thyro-Block,
Pima)

Inhibits TH
release.
Decrease
vascularity of
thyroid gland to
make surgery
faster
Check for allergy in
shellfish
Dilute in Milk or Fruit
juice
Beta Adrenergic Blockers
Propanolol
Relieves
Thyrotoxicosis
( Heat
Intolerance,
Palpitation and
Nervousness)
Do not give to client
with asthma
Check Pulse

Radio Iodine Therapy
Radioactive iodine is a medicine that you take one time. After you swallow it, it is taken up by
your thyroid gland. Depending on the dosage used, the radioactivity in the iodine destroys most
or all of the tissue in your thyroid gland, but it does not harm any other parts of your body.
Surgery
A thyroidectomy is a surgical procedure to remove all or part of the thyroid gland. Some
hyperthyroid clients have such enlarge thyroid glands that pressure on the esophagus or trachea
causing breathing or swallowing difficulties (Lemone, 2008).
Subtotal Thyroidectomy- removal of approximately 5-6 of the gland while the remaining thyroid
tissue provides enough hormones for normal function.
Total Thyroidectomy- Total removal of the thyroid gland



Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

4

Pre Operative Nursing Care
Discuss to the client that after surgery, that his voice will experience little hoarse and dysphagia
due to irritation caused by endotracheal catheter.
Post Operative Nursing Care
Position client on a semi fowlers and avoid hyperextension
Encourage client to speak at interval of 30-60 minutes
Watch out for the following post operative complication
Recurrent Laryngeal Nerve Injury
Hemorrhage- keep tracheostomy set inside the room for 48 hours, for emergency use.
Thyroid Crisis (Thyroid Storm)- extreme state of hyperthyroidism resulting from
untreated hyperthyroidism or from hyperthyroidism along with stressor, susch as
infection, untreated DKA, physical or conditional trauma or thyroid surgery.
HYPOTHYROIDISM
Hypothyroidism is a disorder that results when the thyroid glands produces an insufficient
amount of TH (Lemone 2008)
Result from the decrease in metabolism from low level of thyroid hormone. (Ignativicius, 2010).

Iodine Deficiency
It may result from certain goitrogenic drugs (which block TH synthesis). Goitrogenic compounds
in food such as turnips , rutabagas, soy beans may also block TH synthesis if consumed in
sufficient quantities

Hashimotos Thyroiditis
Common cause of goiter and primary hypothyroidism in adults and children. This is auto
immune disorders, antibodies develop that destroy thyroid tissue (Lemone 2008)
Hashimoto's disease is a common thyroid gland disorder. It can occur at any age, but is most
often seen in middle-aged women. It is caused by a reaction of the immune system against the
thyroid gland.( Medline plus)
The disease begins slowly. It may take months or even years for the condition to be detected.
Chronic thyroiditis is most common in women and in people with a family history of thyroid
disease. It affects between 0.1% and 5% of all adults in Western countries.
Cretinism
Congenital condition decreased thyroid hormone production causes defective physical
development, mental retardation
Child generally has large head, short limb, puffy eyes, thick protruding tongue, excessive dry
skin, lack of coordination.


Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

5

Myxedema Coma
Myxedema coma is a loss of brain function as a result of severe, longstanding low level of
thyroid hormone in the blood (hypothyroidism). Myxedema coma is considered a life-threatening
complication of hypothyroidism and represents the far more serious side of the spectrum of
thyroid disease.
Myxedema coma is an extreme complication of hypothyroidism in which patients exhibit multiple
organ abnormalities and progressive mental deterioration. The term myxedema is often used
interchangeably with hypothyroidism and myxedema coma. Myxedema also refers to the
swelling of the skin and soft tissue that occurs in patients who are hypothyroid. Myxedema
coma occurs when the body's compensatory responses to hypothyroidism are overwhelmed by
a precipitating factor such as infection
Assessment
Manifestation



















Fatigue Lethargy Mental impairment
Depression Cold intolerance Weight gain
Changes in menstrual
cycle

Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

6

Laboratory Findings
Test Normal Values Findings
Serum TA None to 1:20 Normal
Serum TSH 2-10 mU/ ml Increase in primary
hypothyroidism
Serum T
4
5-12 mcg/dL decreased
Serum T
3
80-200 mg/dL decreased
T
3
uptake 25-35 relative
percentage
decreased
Thyroid suppression No changes in RAI uptake
and T
4
levels

Medication
Thyroid preparation
o Levothyroxine sodium ( T
4
) ( Levoxyl, Levothroid, Synthroid)
o Liothyronine Sodium (T
3
) ( Cytomel)
o Liotrix (T
3
-T
4
) ( Euthyroid, Thyrolar)
Nursing Diagnosis and Interventions
Decreased Cardiac Output
a. Monitor blood pressure, rate and rhythm and apical and peripheral pulses, RR and
breath sounds
b. Suggest the client avoid chilling increase room temperature, use additional bed covers
and avoid drafts
c. Encourage the client to balance activity with rest periods. Ask the client to report any
breathing difficulties chest pain, heart palpitation or dizziness.

Constipation
a. Encourage fluid intake of up to 2000mL per day. Discussed preferred liquids and best
time for drink fluids. If calorie intake is restricted, ensure that fluids have no kilocalorie or
are low in kilocalorie.
b. Discuss ways to maintain a high fiber diet.

Risk for Impaired Skin Integrity
a. Monitor skin surfaces for redness or lesions, especially if the clients activity is greatly
reduced. Use a pressure ulcer assessment scale to identify clients at risk.
b. Provide or teach the immobile clients measure to promote optimal circulation
1. Use a turning schedule if the client is on bed rest, or teach the client to change
position every 2 hours
2. Limit the time for sitting in one position; shift weight or the body using arm rest
every 20-30 minutes.
3. Use pillows, pads or sheepskin or foam cushions for bed and/ or chair.
4. Teach and implement ROM


Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

7

c. Provide or teach the client measures to maintain skin integrity.
1. Take baths only as necessary; use war (not hot) water
2. Use gentle motions when washing and drying the skin
3. Use alcohol free skin oils and lotions

Community Based Care
Clients with hypothyroidism primarily provide self care at home. Teaching is individualized to meet the
clients need
1. The client taking oral medication must understand the need for lifelong treatment.
2. Need for periodic dosage reassessments
3. If the client is older or does not have a support system help ful community system
4. In addition , suggest the following resources which are accessible via internet
American Thyroid Association
Thyroid Foundation of Canada
Endocrine Society
In the Philippines refer to Philippine Thyroid Association located at Eulogio Amang
Rodriguez Institute of Science and Technology Medical Directors Office, Nagtahan,
Sampaloc, Manila
















Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

8

DISORDERS OF PARATHYROID GLAND
HYPERPARATHYROIDISM
Result from an increase in secretion of parathyroid hormone (PTH) which regulates normal
serum calcium. The increase in PTH affects the kidney and bones ( Lemone, 2008)
Increased reabsorption of calcium and excretion of phosphate by the kidney, which
increase the risk for hyperglycemia and hypophosphatemia
Increased bicarbonate excretion and decreased acid excretion by the kidney which
increase the risk of metabolic acidosis and hyperkalemia
Increase release of calcium and phosphorus by bones, with resultant bone decalcification.
Deposits of calcium in soft tissues and formation of renal calculi.

Primary Hyperparathyroidism- occurs when there is hyperplasis or adenoma

Secondary hyperparathyroidism- compensatory response by parathyroid glands to chronic
hypocalcemia

Tertiary Hyperparathyroidism- results from the hyperplasia of the gland and loo of response to
serum calcium levels.

The parathyroid glands are located in the neck, near or attached to the back side of the thyroid
gland. They produce parathyroid hormone. This hormone controls calcium, phosphorus, and
vitamin D levels in the blood and bone.

When calcium levels are too low, the body responds by making more parathyroid hormone. This
hormone causes calcium levels in the blood to rise, as more calcium is taken from the bone and
reabsorbed by the intestines and kidney.

One or more of the parathyroid glands may grow larger. This leads to too much parathyroid
hormone (a condition called primary hyperparathyroidism). Most often, the cause is not known.

Manifestation
Musculoskeletal: bone pain (back, joint, shins); pathologic fracture ( women); muscle
weakness; muscle atrophy
Renal effects: renal calculi; polyuria; polydipsia
Gastrointestinal: abdominal pain, peptic ulcers, pancreatitis; nausea; constipation
Cardiovascular: arrhythmias; Hypertension
CNS: parenthesia; depression; psychosis
Metabolic effects: Acidosis; weight loss




Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

9


Diagnosis
Serum electrolytes shows total serum calcium greater than 10.0 mg/dL
Serum PTH levels are measured to identify or rule out hyperathyroidism
ECG changes in hypercalcemia include a shortened QT interval, shortened and depressed ST
segment and wined T wave. Bradycardia or heart block may be identified on ECG
Bone density scan may be done to monitor bone reabsorption and effect of treatment measure
on mineralization.
Medication
The biphosphonate( pamidronate and etidronate) are commonly used to treat hypercalcemia
associated with malignancies. These drug are also used to treat osteoporosis
When a biphosphonate drug is ineffective ,mitramycin a chemotherapeutic agent, may be
used.
Other drug may therapies include the use of IV plimacamaycin (Mithracin ) to inhibits bone
reabsorption
Glucocorticoids (Cortisone) which compete with vitamin D and low calcium diet.

Fluid management
Intravenous fluids usually isotonic saline are administered to client with severe hypercalcemia to
restore vascular volume and promote renal excretion of calcium
Isotonic saline is used because sodium because excretion in accompanied by calcium
excretion.
The client is carefully monitored for evidence of fluid overload during treatment.

Health Promotion
Promote mobility as possible
Assist hospitalized client to ambulate as soon as possible.
In home setting, discuss the regular weight bearing activity with client families and caregivers.
Fluid intake of up to 3-4 quarts per day
Limit milk intake

Nursing Diagnosis and Interventions
Risk for injury
a) Institute safety precaution if confusion or other changes in mental status is noted
b) Observe for manifestation of digitalis toxicity, including visual changes, anorexia, and
changes in heart rate and rhythm
c) Promote fluid intake (oral or intravenous) to keep the client well hydrated and maintain
dilute urine. Encourage fluids such as prune or cranberry juice to keep maintain acidic
urine
d) If excess bone reabsorption has occurred, use caution when turning, positioning,
transferring or ambulating.
Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

10

Risk for Excess Fluid Volume
a) Closely monitor intake and output
b) Assess vital signs, RR, and heart sound
c) Place in semi- Fowlers to Fowlers position
d) Administer diuretics as ordered, monitoring response.

Community Based
Avoid excess intake of calcium rich foods and antacids
Used prescribed drugs to prevent excess calcium resorption.
Increased fluid intake to 3 to 4 quarts per day; increase the take of acid ash foods.
Maintain weight bearing physical activity to prevent hypercalcemia
Report early manifestations of hypercalcemia to care provider.
Follow recommended schedule for monitoring serum electrolytes.

HYPOPARATHYROIDISM
Result from abnormally low PTH levels. The most common cause is damage to or removal of
the parathyroid glands during thyroidectomy. The lack of circulating PTH cause hypocalcemia
and an elevated blood phosphate levels ( Lemone, 2008).

Manifestation
Musculoskeletal system: Muscle spasm; Facial grimacing; carpopedal spasm; tetany or
convulsions
Integumentary system: brittle nails; hair loss; dry, scaly skin
Gastrointestinal; Abdominal cramps; malabsorption
Cardiovascular: Arrhythmias
CNS: Paresthesias; Mood Disorder; Hyperactive reflexes; psychosis; IICP
Chvostek's sign- Contraction of the lateral facial muscles in response to tapping the face in front
of the ear; caused by decreased blood calcium levels.
Trousseau's sign- Contraction of the hand and fingers in response to occlusion of the blood
supply by a blood pressure cuff; caused by decreased blood calcium levels.

Diagnosis
Total serum calcium, Serum albumin, Serum magnesium, Serum phosphate, Parathyroid
hormone (PTH), ECG
Medication
Calcium salts ( Calcium carbonate, calcium chloride, calcium citrate, calcium glubionate,
calcium gluceptate, calcium gluconate, calcium lactate)


Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

11


Nursing Diagnosis and Interventions
Risk for Injury
a. Frequently monitor airway and RR. RT report changes such as respiratory stridor (a high-
pitched, harsh inspiratory sound indicative of upper airway obstruction) or increased RR or
effort to physician.
b. Monitor cardiovascular status including heart rate and rhythm, BP and peripheral pulses.
c. Monitor ECG in client receiving IV calcium preparation, especially if client also taking
digitalis.
d. Provide a quiet environment. Institute seizure precautions such as raising the side rails
and keeping an airway at bedside.
Medical and Surgical Management
Tetany and severe hypoparathyroidism are treated immediately by the administration of IV
calcium salt and calcium gluconate
Long Term treatment after trauma to or inadvergent removal of the parathyroid includes
administration of oral calcium, Vitamin D1 and Vitamin D2 which increases serum calcium level.

















Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

12

DISORDER OF THE ADRENAL GLAND
HYPERCORTISOLISM (Cushings syndrome)
Cushing's syndrome is a disease caused by increased production of cortisol, or by excessive
use of cortisol or other steroid hormones.

Cushing's syndrome is a condition that results from an excess of cortisol, a hormone produced
by the adrenal glands. The most common cause of Cushing's syndrome is Cushing's disease,
caused by excessive production of the hormone ACTH by the pituitary gland. ACTH stimulates
the adrenal glands to produce cortisol.

Cushing's syndrome can be caused by a tumor of the pituitary gland, a tumor of the adrenal
gland, a tumor somewhere other than the pituitary or adrenal glands (ectopic Cushing's
syndrome), or by long-term use of corticosteroids (drugs commonly used to treat conditions
such as rheumatoid arthritis and asthma).

Risk factors for Cushing's syndrome are adrenal or pituitary tumors, long-term therapy with
corticosteroids, and being female.
Manifestation
Musculoskeletal: weakness, Muscle Wasting, osteoporosis
Integumentary: Thin, easily bruised skin, skin Infection, Poor wound Healing, Eccymosis, Purple
striae, Hirsuim
CNS: Emotional lability, Psychoses
GI: Peptic Ulcers
Cardiovascular: Hypertention
Renal: Renal Calculi, Polyuria, Polydipsia, Glycosuria
Metabolic Effect: Hypokalemia, Hypernatremia, truncal Obesity
Reproductive: Oligomenorrhea / amenorrhea, Impotence, Decreased Libido.










Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

13


Laboratory findings
Test Normal Values Findings
Serum

Cortisol 8am-10am
5-23 mcg/dL
4pm-6pm
3-13 mcg/Dl
increased
Blood Urea nitrogen 5-25 mg/dl Normal
Sodium 135-145 mEq/L Increased
Potassium 3.4-5.0 mEq/L Increased
Glucose 70-100 mg/dL Increased
Urine 17-KS Male: 5-25 mg/24h
Female: 5-15 mg/24h
Age 65:4 -
8mg/24h
Increase

Tests to confirm high cortisol level:
Cortisol, urine
dexamethasone suppression test
serial serum cortisol levels

Tests to determine the cause:
ACTH
cranial MRI or cranial CT scan may show pituitary tumor
abdominal CT may show adrenal mass
glucose test is elevated
potassium test may be low
white blood cell count may be elevated

Medication
Mitotate directly suppresses activity of adrenal cortex and decrease peripheral metabolism of
corticosteroid.
Aminoglutemide or ketoconazole
Somastostatin

Nursing Diagnosis and Interventions
Fluid Volume Excess
a) Ask the Client to weigh at the same time each day and maintain a record of results
b) Monitor BP, rate rhythm of pulse, respiratory rate and breath sounds. Assess for
peripheral edema and jugular vein distention
c) Teach the client and family the reason for restricting the fluids and importance of
limiting fluids if ordered.
Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

14


Risk for injury
a. Teach the Client about safety environment

Disturbed Body Image
1) Encourage client to express feelings and ask question about disorder and treatment
2) Discuss strengths and previous coping strategies. Enlist the support of family or
significant others in reaffirming the clients worth
3) Discuss signs of progress in controlling symptoms.

Risk for Infection
a) Place in the private room
b) Monitor vital signs
c) Use standard precautions
d) If wounds are presents assess the color, odor and consistency of wound drainage and
look for increased pain in and around the wound
e) Teach the importance of protein and vitamins C and A.

Community Based
Safety measure to prevent falls if fatigue, weakness and osteoporosis
Taking medications as prescribed, with information about side effects/ clients often require
medication for the rest of their lives and dosage changes are highly likely
Having regular health assessment
Wearing a medical ID indicating the client has Cushing syndrome
Providing helpful resources
1) Refer to Philippine Society of Endocrinology and Metabolism: Unit 1701, 17/F Medical
Plaza Ortigas, San Miguel Avenue, Ortigas Center, Pasig City 1605
ADDISONS DISEASE
Addison's disease is a disorder that occurs when the adrenal glands do not produce enough of
their hormones
Addison's disease results from damage to the adrenal cortex. The damage causes the cortex to
produce less of its hormones.

This damage may be caused by the following:
The immune system mistakenly attacking the gland (autoimmune disease)
Infections such as tuberculosis, HIV, or fungal infections
Hemorrhage, blood loss
Tumors
Use of blood-thinning drugs (anticoagulants)


Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

15


Manifestation
Integumentary: Delayed wound healing, Hyperpigmentation
Cardiovascular: Postural Hypotension, tachycardia, arrhythmias
CNS: Lethargy; tremors, Emotional lability, Confusion
Musculoskeletal: Weakness, muscle wasting, joint and muscle pain
Gastrointestinal: Anorexia, nausea and vomiting, diarrhea
Reproductive: Menstrual Changes
Metabolic: Hyperkalemia, Hyponatremia, Hypoglycemia











Laboratory Findings










Test Normal Values Findings
Serum

Cortisol 8am-10am
5-23 mcg/dL
4pm-6pm
3-13 mcg/dL
Decreased
Blood Urea nitrogen 5-25 mg/dl Increased
Sodium 135-145 mEq/L Decreased
Potassium 3.4-5.0 mEq/L Increased
Glucose 70-100 mg/dL Decreased
Urine 17-KS Male: 5-25 mg/24h
Female: 5-15
mg/24h
Age 65:4 -
8mg/24h
Low or absent
Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

16


Medication
The primary medical treatment of Addisons disease is replacement of corticosteroid,
accompanied by increase sodium diet. Hydrocortisone is given orally to replace cortisol.
Fludrocortisone is given orally to replace mineralocorticoids.
Nursing Diagnosis and Interventions
Deficient Fluid Volume
a) Monitor Input and Output and assess for signs of dehydration: dry mucous membranes;
thirst; poor skin turgor; sunken eyes
b) Monitor for cardiovascular status
c) Weight the client daily at the same time and in the same clothing
d) Encourage the oral fluid intake of 3000 mL per day and increase salt intake
e) Teach to sit and stand slowly and provide assistance as necessary

Risk for Ineffective regimen management
a) Teach the effect of illness and treatment. Discuss client and family concerns.
b) Include the following in teaching the plan
i. Self-administration of steroids
ii. The importance of carrying at all times an emergency kit
iii. Wearing a Medic-alert bracelet that says adrenal insufficiency- takes
Hydrocortisone
iv. Increased oral fluid
c) Maintaining a diet in sodium and low potassium
d) The necessary altering the medication dose when experiencing emotional or physical
stressors
e) The importance of continuing health care











Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

17


PHEOCHROMOCYTOMA
Rare disease characterized by paroxysmal or sustain hypertension due to excessive secretion
of epinephrine and norepinephrine
Hypertension, unrelenting headache and profuse diaphroresis
Pheochromocytoma is a rare tumor of adrenal gland tissue. It results in the release of too much
epinephrine and norepinephrine, hormones that control heart rate, metabolism, and blood
pressure.
Pheochromocytoma may occur as a single tumor or as more than one growth. It usually
develops in the center (medulla) of one or both adrenal glands. Rarely, this kind of tumor occurs
outside the adrenal gland, usually somewhere else in the abdomen
The tumors may occur at any age, but they are most common from early to mid-adulthood.
Pheochromocytoma is a tumor of chromaffin cells, which secrete catecholamines,
predominantly norepinephrine, as well as epinephrine, and rarely dopamine
Clinical features result from excessive catecholamine levels; the most common of these
features is hypertension
The majority of pheochromocytomas are sporadic, however recent studies suggest that up to
25% of cases are hereditary
Treatment is surgical excision of the tumor, following preoperative treatment of hypertension
Assessment
Elevated Blood Pressure
Tremors and nervousness
Sweating, Head ache, Vertigo
Nausea and Vomiting
Hyperglycemia
Polyuria
Medical and Surgical Treatment
Treatment involves surgical removal of tumor by means of unilateral adrenalectomy
Phentolamine is given before and during surgery to control hypertension
Medical management includes administration of metyrosine (Demser) an enzyme inhibitor that
reduces synthesis of cathecolamines to decrease hypertensive attacks.
Nursing Management
The nurse monitors the BP closely when initiating drug therapy or during dose changes. He/
She should notify physician of sudden decrease in Blood Pressure. If the client undergoes
adrenalectomy, the nurse should monitor signs and symptoms of acute adrenal insufficiency.




Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

18

DISORDER OF THE PITUITARY GLANDS
1. Anterior Pituitary Gland
Hyper function of the pituitary gland, characterized by excess production and secretion
of one or more tropic hormones is usually the result of pituitary tumor or pituitary
hyperplasia.
Hypo function of anterior glands results in deficiency of one or more of the glands
hormone.
GIGANTISM
Gigantism is abnormally large growth due to an excess of growth hormone during childhood,
before the bone growth plates have closed.
Occurs when GH secretion begins before puberty and enclosure of epiphyseal plates. The
person becomes abnormally tall, often exceeding 7ft in height but body proportions are
normal Lemone (2008).
ACROMEGALY
Enlarge extremities when sustained GH hyper secretion begins during adulthood, most
commonly because of pituitary tumors. As a result of constant stimulation bone and tissue
continue to grow ( Lemone 2008).
Acromegaly is a long-term condition in which there is too much growth hormone and the
body tissues get larger over time.

Acromegaly occurs in about 6 of every 100,000 adults. It is caused by abnormal production
of growth hormone after the skeleton and other organs finish growing.

Excessive production of growth hormone in children causes gigantism rather than
acromegaly.

The cause of the increased growth hormone release is usually a noncancerous (benign)
tumor of the pituitary gland. The pituitary gland, which is located just below the brain,
controls the production and release of several different hormones, including growth
hormone.
Manifestation
Body odor, Carpal tunnel syndrome
Decreased muscle strength (weakness)
Easy fatigue
Excessive height (when excess growth hormone production begins in childhood)
Excessive sweating
Headache
Hoarseness
Joint pain
Large bones of the face
Large feet
Large hands
Large glands in the skin (sebaceous glands)
Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

19

Large jaw (prognathism) and tongue
Limited joint movement
Sleep apnea
Laboratory Findings
High growth hormone level
High insulin-like growth factor 1 (IGF-1) level
Spine x-ray shows abnormal bone growth
Pituitary MRI may show a pituitary tumor
Echocardiogram may show an enlarged heart, leaky mitral valve, or leaky aortic valve
Fasting plasma glucose
Glucose tolerance test
Treatment
Surgery to remove the pituitary tumor that is causing this condition usually corrects the
abnormal growth hormone release in most patients. Sometimes the tumor is too large to remove
completely. People who do not respond to surgery will have radiation of the pituitary gland.
However, the reduction in growth hormone levels after radiation is very slow.
Octreotide (Sandostatin) or bromocriptine (Parlodel) may control growth hormone release in
some people.
Pegvisomant (Somavert) directly blocks the effects of growth hormone, and has been shown to
improve symptoms of acromegaly.

Nursing Care
Client with anterior pituitary disorder require intervention to help in coping with physical and
emotional changes, as well as to prevent complication involving other organs and functions of
endocrine system.

2. Posterior Pituitary Gland

SYNDROME OF THE INAPPROPRIATE ADH PRODUCTION
High levels of ADH in the absence of serum hypo-osmolality. This order is often caused by the
ectopic production of ADH by malignant tumors ( Lemone 2008).
Depending on the magnitude and rate of development, hyponatremia may or may not cause
symptoms. The history should take into account the following considerations:
In general, slowly progressive hyponatremia is associated with fewer symptoms than is a rapid
drop of serum sodium to the same value







Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

20


Manifestation
Signs and symptoms of acute hyponatremia do not precisely correlate with the severity or the acuity of
the hyponatremia
Patients may have symptoms that suggest increased secretion of ADH, such as chronic pain,
symptoms from central nervous system or pulmonary tumors or head injury, or drug use
Sources of excessive fluid intake should be evaluated
The chronicity of the condition should be considered
After the identification of hyponatremia, the approach to the patient depends on the clinically
assessed volume status. Prominent physical findings may be seen only in severe or rapid-onset
hyponatremia and can include the following:
Confusion, disorientation, delirium
Generalized muscle weakness, myoclonus, tremor, asterixis, hyporeflexia, ataxia, dysarthria,
Cheyne-Stokes respiration, pathologic reflexes
Generalized seizures, coma
Medical Management
Treatment aims to eliminating the underlying causes. The following are needed to correct water
retention.
Osmotic diuretic (Mannitol)
Loop diuretics (Lasix)

Severe hyponatremia is treated with IV administration of a 3% hypertonic Sodium Chloride
solution.
Nursing Management
Assess the vital signs
Monitoring of fluid intake and output
Assessment of Level of Consciousness
Monitor and check for signs and symptoms of Fluid overload (Confusion, Dyspnea, Pulmonary
Congestion, Hypertension)
Monitor for signs and symptoms of Hyponatremia







Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

21


DIABETES INSIPIDUS
Result of ADH insufficiency
a) Neurogenic Diabetes Insipidus: disruption of Hypothalamus and pituitary gland
b) Neprogenic Diabetes Insipidus: renal tubules are sensitive to ADH.
May result to a brain tumor or infections of pituitary surgery, cerebral vascular accidents and
renal and organ failure.
Manifestation
Extreme Polyuria
Extreme thirst, preferring cold beverages
Weight loss, dizziness, Weakness and fatigue, Constipation, Nocturia
Assessment Findings
Urine Output maybe as high as 20 L/24 hours
Urinalysis revels virtually colorless urine, diluted with specific gravity of 1.002 or less
Weakness, Dehyration, Weight loss
Medical Management
SIADH is treated by correcting underlying causes, treating the hyponatremia with intravenous
hypertonic saline, and restricting oral fluids to less than 800 mL/day
Diabetes Insipidus is also treated by correcting the underlying cause. If possible. Other medical
intervention includes administering IV hypotonic saline, Increase Fluid intake and replacing ADH
hormone. Desmopressin acetate, administration intranasal orally, or parenterally.
Nursing Management
Closely monitoring of IV Fluid infusion to ensure that the prescribe amount is given over the
required period
Measuring Intake and Output
Notifying the physician for steady weight gain or loss








Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

22


DISORDER IN PANCREAS
DIABETES MELLITUS
Diabetes mellitus is a disorder of carbohydrate, fat, and protein metabolism brought about by
impaired beta cell synthesis or release of insulin, or the inability of tissues to use glucose (Porth,
2010).
1. Type 1 diabetes results from loss of beta cell function and an absolute insulin deficiency.
2. Type 2 diabetes results from impaired ability of the tissues to use insulin (insulin
resistance) accompanied by a relative lack of insulin or impaired release of insulin in
relation to blood glucose levels (beta cell dysfunction).

Chapter Review
Type 2 DM has a hereditary link and is characterized by obesity and sedentary lifestyles.
Unlike type 1 DM, in which the onset is often sudden, the development of symptoms that
bring clients to their healthcare providers for evaluation is slow; it is estimated that 50% of
newly diagnosed type 2 DM clients have already developed complications secondary to
hyperglycemia.
The risk factors for acute and chronic complications are known, but clinical practice has not
integrated these factors thoroughly into assessment and planning.
Tighter, more intensive glycemic control is increasingly the focus of care for hospitalized
clients with hyperglycemia. Correcting hyperglycemia is considered a benefit to diabetics
and no diabetics alike.
New products for clients with DM include insulin, noninsulin hypoglycemics, and blood
glucose monitoring devices. Nurses must be familiar with these products and help clients
become proficient in their use.
Motivation for self-care by the client with diabetes continues to be a challenge because
treatment commonly includes lifestyle changes. Through education and support, clients can
achieve control of DM and avoid complications.

OVERVIEW OF ENDOCRINE PANCREATIC HORMONES AND GLUCOSE HOMEOSTASIS
Hormones
The endocrine pancreas produces hormones necessary for the metabolism and cellular
utilization of carbohydrates, proteins, and fats. The cells that produce these hormones are
clustered in groups of cells called the islets of Langerhans. These islets have three different
types of cells:
1. Alpha cells produce the hormone Glucagon, which stimulates the breakdown of glycogen in
the liver, the formation of carbohydrates in the liver, and the breakdown of lipids in both the liver
and adipose tissue. The primary function of glucagon is to decrease glucose oxidation and to
increase blood glucose levels. Through glycogenolysis (the break- down of liver glycogen) and
gluconeogenesis (the forma- tion of glucose from fats and proteins), glucagon prevents blood
glucose from decreasing below a certain level when the body is fasting or in between meals.
Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

23

The action of glucagon is initiated in most people when blood glucose falls below about 70
mg/dL.
2. Beta cells secrete the hormone insulin, which facilitates the movement of glucose across cell
membranes into cells, de- creasing blood glucose levels. Insulin prevents the excessive
breakdown of glycogen in the liver and in muscle, facilitates lipid formation while inhibiting the
breakdown of stored fats, and helps move amino acids into cells for protein synthesis. After
secretion by the beta cells, insulin enters the portal circulation, travels directly to the liver, and is
then released into the general circulation. Circulating insulin is rapidly bound to receptor sites on
peripheral tissues (especially muscle and fat cells) or is destroyed by the liver or kidneys. Insulin
re- lease is regulated by blood glucose; it increases when blood glucose levels increase, and it
decreases when blood glucose levels decrease. When a person eats food, insulin levels be- gin
to raise in minutes, peak in 30 to 60 minutes, and return to baseline in 2 to 3 hours.
3. Delta cells produce Somatostatin, which is believed to be a neurotransmitter that inhibits the
production of both glucagon and insulin.
Metabolic Effect of Insulin
A. Carbohydrates Metabolism
Increase glucose transport into skeletal muscle and adipose tissue
Increase glycogen synthesis
Decrease gluconeogenesis
B. Protein Metabolism
Increase active transport of AA into cells
Increase protein synthesis and storage
Decrease protein metabolism
C. Fat Metabolism
Increase glucose transport into fat cells
Metabolic Effects of Glucagon
A. Carbohydrates Metabolism
Decrease glycogen synthesis/ Increase glycogenolysis
Increase gluconeogenesis
B. Protein Metabolism
Increase Protein Catabolism
Increase conversion of Amino Acids into glucose precursors
C. Fat Metabolism
Enhance Lypolysis in adipose tissue (Fatty acids Conversion on GLYCEROL)
Metabolic Effect of Epinephrine
A. Increase Release of Insulin
B. Promotes glycogenolysis
C. Inhibits transport of Glucose into muscle cells
D. Mobilize fatty acids from adipose tissue




Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

24




Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

25


Laboratory Findings
Symptoms of diabetes plus casual plasma glucose (PG) concentration>200mg/dL (11.1mmol/L)
defined as any time of day without regard to time since last meal.
Fasting plasma glucose (FPG) > 126 mg/dL(7.0 mmol/L). Fasting is defined as no caloric intake
for 8 hours
Two-hour PG > 200 mg/dL(11.1 mmol/L) during an oral glucose tolerance test (OGTT). The test
should be performed with a glucose load containing the equivalent of 75 anhydrous glucose
dissolved in water.

DIAGNOSTIC TESTS TO MONITOR DIABETES MANAGEMENT
a. Fasting blood glucose (FBG).This test is often ordered, especially if the client is experiencing
symptoms of hypoglycemia or hyperglycemia. In most people, the normal range is 70 to 110
mg/dL.
b. Glycosylated hemoglobin (c) (A1c)- the average blood glucose level over approximately the
previous 2 to 3 months. When glucose is elevated or control of glucose is erratic, glucose
attaches to the hemoglobin molecule and remains attached for the life of the hemoglobin, which
is about 120 days. The normal level depends on the type of as- say done, but values above 7%
to 9% are considered elevated. The ADA recommends that A1c be performed at the initial
assessment, and then at regular intervals, individualized to the medical regimen used.
c. Urine glucose and ketone levels. These are not as accurate in monitoring changes in blood
glucose as blood levels. The presence of glucose in the urine indicates hyperglycemia. Most
people have a renal threshold for glucose of 180 mg/dL; that is, when the blood glucose
exceeds 180 mg/dL, glucose is not reabsorbed by the kidney and spills over into the urine. This
number varies highly, however. Ketonuria (the presence of ketones in the urine) occurs with the
breakdown of fats and is an indicator of DKA; however, fat breakdown and ketonuria also occur
in states of less than normal nutrition.
d. Urine test for the presence of protein as albumin (albuminuria). If albuminuria is present, a 24-
hour urine test for creatinine clearance is used to detect the early onset of nephropathy.
e. Serum cholesterol and triglyceride levels. These are indicators of atherosclerosis and an
increased risk of cardiovascular impairments. The ADA (2005) recommends treatment goals to
lower LDL cholesterol to <100 mg/dL, raise HDL cholesterol to >45 mg/dL, and lower
triglycerides to <150 mg/dL.
f. Serum electrolytes. Levels are measured in clients who have DKA or hyperosmolar
hyperglycemic state (HHS) to determine imbalances.





Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

26


Health Promotion
Health promotion activities primarily focus on preventing the complications of diabetes. The
prevention of the disease has not been determined, although it is recommended that all people
should prevent or decrease excess weight, follow a sensible and well-balanced diet, and
maintain a regular physical exercise program. Blood glucose screening at 3-year intervals
beginning at age 45 is recommended for those in the high-risk groups. These same activities,
when combined with medications and self-monitoring, are also beneficial in reducing the onset
of complications.
Nursing Diagnosis and Interventions (Lemone 2008).
Risk for impaired skin integrity
Conduct baseline and ongoing assessments of the feet, including:
a) Musculoskeletal assessment that includes foot and ankle joint range of motion, bone
abnormalities (bunions, hammertoes, overlapping digits), gait patterns, use of assistive
devices for walking, and abnormal wear patterns on shoes.
b) Neurologic assessment that includes sensations of touch and position, pain, and
temperature.
c) Vascular examination that includes assessment of lower extremity pulses, capillary refill,
color and temperature of skin, lesions, and edema.
d) Hydration status, including dryness or excessive perspiration. Lesions, fissures between
toes, corns, calluses, plantar warts ,ingrown or overgrown toenails, redness over
pressure points, blisters, cellulitis, or gangrene.
e) Teach foot hygiene. Wash the feet daily with lukewarm water and mild hand soap; pat
dry, and dry well between the toes. Apply a very thin coat of lubricating cream if dryness
is present (but not between the toes).
f) Discuss the importance of not smoking if client smokes.
g) Discuss the importance of maintaining blood glucose levels through prescribed diet,
medication, and exercise. Hyperglycemia promotes the growth of microorganisms.
h) Conduct foot care teaching sessions as often as necessary information about proper
shoe fit and composition, avoiding clothing or activities that decrease circulation to the
feet, foot inspections, the care of toenails, and the importance of obtaining medical care
for lesions. If the person has visual deficits, is obese, or cannot reach the feet, teach the
caregiver how to inspect and care for the feet. Feet should be inspected daily.

Risk for Infection
Use and teach meticulous hand washing.
a. Monitor for manifestations of infection: increased temperature, pain, malaise, swelling,
redness, discharge, cough.
b. Discuss the importance of skin care. Keep the skin clean and dry, using lukewarm water
and mild soap
c. Teach dental health measures:
Obtain a dental examination every 4 to 6 months.
Maintain careful oral hygiene, which includes brushing the teeth with a soft
toothbrush and fluoridated toothpaste at least twice a day and flossing as
recommended.
Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

27

Be aware of the symptoms requiring dental care: bad breath; unpleasant taste in
the mouth; bleeding, red, or sore gums; and tooth pain.
If dental surgery is necessary, monitor for need to make adjustments in insulin.
All people with diabetes need to be taught proper oral hygiene, the risk of
periodontal disease, and the importance of obtaining dental care for symptoms of
oral or dental problems.
d. Teach women with diabetes the symptoms and preventive measures for vaginitis caused
by Candida albicans. The symptoms are an odorless, white or yellow cheeselike
discharge and itching. Sexual transmission is unlikely, but discomfort may cause the
client to avoid sexual activity.

Risk for Injury
a. Assess for the presence of contributing or causative factors that increase the risk of
injury: blurred vision, cataracts, decreased adaptation to dark, decreased tactile
sensitivity, hypoglycemia, hyperglycemia, hypovolemia, joint immobility, unstable gait
b. Reduce environmental hazards in the healthcare facility, and teach the client about
safety in the home and in the community.

IN THE HEALTHCARE FACILITY
Orient the client to new surroundings on admission.
Keep the bed at the lowest level.
Keep the floors free of objects.
Use a night-light.
Check the temperature of the bath or shower water before the client uses it.
Instruct the client to wear shoes or slippers when out of bed.
Monitor blood glucose levels regularly.
Monitor for side effects of prescribed medications, such as dizziness or
drowsiness.

IN THE HOME AND COMMUNITY
Use a night-light, preferably one with a soft, nonglare bulb.
Turn the head away when switching on a bright light.
Avoid directly looking into headlights when driving at night.
Test the temperature of the bath or shower water before use.
Conduct a daily foot inspection.
Wear shoes and slippers with nonskid soles.
Do not use throw rugs.
Install hand grips in the tub and shower and next to the toilet.
Wear a seat belt when driving or riding in a car.

c. Monitor for and teach the client and family to recognize and seek care for the
manifestations of DKA in the client with type 1 DM: hyperglycemia, thirst, headaches,
nausea and vomiting, increased urine output, ketonuria, dehydration, and decreasing
level of consciousness.
d. Monitor for and teach the client and family to recognize and seek care for the
manifestations of HHS in the client with type 2 DM: extreme hyperglycemia, increased
urinary output, thirst, dehydration, hypotension, seizures, and decreasing level of
consciousness. HHS is a life-threatening condition requiring recognition and treatment.
Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

28

e. Monitor for and teach the client and family to recognize and treat the manifestations of
hypoglycemia: low blood glucose, anxiety, headache, uncoordinated movements,
sweating, rapid pulse, drowsiness, and visual changes. Teach client and family to carry
some form of rapid-acting sugar source at all times.
f. Recommend that the client wear a Medic-Alert bracelet or necklace identifying self as a
person with diabetes. In case of sudden, severe illness or accident, a Medic-Alert
bracelet can allow immediate medical attention for diabetes to be instituted.

Sexual Dysfunction

a. Include a sexual history as a part of the initial and ongoing assessment of the client with
diabetes. A specific history form may be used that addresses sexual development,
personal and family values, current sexual practices and concerns, and changes
desired. Ask a nonthreatening, open-ended question to elicit information, such as Tell
me about your experience with sexual function since you have been diagnosed with
diabetes.

b. Provide information about the actual and potential physical effects of diabetes on sexual
function. Include the effect of poor control of blood glucose on sexual function as part of
any teaching plan. Clients benefit from basic information about male and female
anatomy and the sexual response cycle, and how diabetes can affect this part of the
body.

c. Provide counseling or make referrals as appropriate. The nurse is responsible for
knowing about sexuality and sexual health throughout the life span and provides
information based on knowledge of the effects of illness and treatment on sexual
function. For example, men who are impotent may regain the ability to have sexual
intercourse through penile implants, suction apparatus, the use of sildenafil citrate
(Viagra), or injections of medications (such as yohimbine, an alpha-2 adrenergic blocker)
that increase vascular blood flow into the corpus of the penis. Women with decreased
vaginal lubrication can decrease painful intercourse by using vaginal lubricants (such as
K-Y Jelly) or estrogen creams.

Ineffective Coping
a. Assess the clients psychosocial resources, including emotional resources, support
resources, lifestyle, and communication skills. Chronic illness affects all dimensions
of a persons life, as well as the lives of family members and significant others
b. Explore with the client and family the effects (actual and perceived) of the diagnosis
and treatment of diabetes on finances, occupation, energy levels, and relationships.
Common frustrations associated with diabetes are the disease itself, the treatment
modalities, and the healthcare system.
c. Teach constructive problem-solving techniques
d. Provide information about support groups and resources, such as suppliers of
products, journals, books, and cookbooks for people with diabetes

Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

29


Community Based Care






Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

30


Medication
Type 1 DM must have insulin; type 2 usually is able to control glucose levels with Oral
Hypoglycemic Agent , But they require insulin when control is inadequate
Drug Action Nursing Implication Client Education
Sulfonylureas
Glyburide
(DiaBeta)
Glypizide
(Glucotrol)

Increase release of
Insulin from pancreas
and increase tissue
response to insulin
Assess for allergy to
sulfonamides.
Assess for side effects
of nausea, heartburn or
diarrhea
Take at the same time
each day.
Take before meals,
Except glucotrol XL,
which must be taken
with food.
Biguanides
Metformin
(Glucophage)

Improves glucose use
in skeletal muscle
Monitor renal function
Signs of lactic acidosis
such s rapid RR,
drowsiness or malaise
must be reported
Take at the same time
each day.
Do not double the dose
if missed
Alpha- Glucoside
Inhibitors
Miglitol (Precose)
Slow digestion and
absorption of CHO to
decrease rise in blood
glucose after meals
Do not give to client
with intestinal disorder
Take with first bite of a
meal.
May cause gas and
diarrhea
Meglitides
Repaglitide
(Prandin)
Stimulates pancreas to
secrete insulin
Monitor for
hypoglycemia
Monitor for
hypoglycemia
D- Phenylalanine
Derivatives
Nateglinide
(Starlix)
Stimulates pancreas to
secrete insulin
Monitor for
hypoglycemia
Monitor for
hypoglycemia
Thiazolidinediones
Rosiglitazone
(Avandia)
Pioglitazone
(Actos)
Increase insulin
sensitivity at receptor
site on liver, muscle
and fat cells
Assess for sign of liver
toxicity
Avandia may increase
risk for MI
Call MD if signs of
toxicity is observed and
report chest pain in
clients receiving
Avandia

Insulin site








Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

31

Insulin Therapy
Derived from pork pancreas as synthetically produced from altered pork insulin or through
genetic engineering using of strain of E. Coli to form biosynthetic human insulin.
Dispensed in two concentrations: 100 Units/ mL (U-100) is standard concentration; or 500 Units/
mL used in rare cases in insulin resistance.
Regular insulin may be given either subcutaneous or IV; all others are given only subcutaneous.
Rapid-acting (e.g Lispro), Regular and Lantus insulin appears Clear. All other insulin appear
cloudy.
Types of Insulin Onset (HR) Peak (HR) Duration (HR)
Rapid Acting
Lispro (Humalog)

0.25

0.5- 2.5

3-6.5
Short- Acting
Regular Novolin-R
Humulin- R


0.5-1


2-3


4-6
Intermediate- Acting
NHP Novolin-N
Humulin-N
Novolin NPH
70/regular 30


1.2
0.5


6-14
4-8


16-24
24
Long-Acting
Glargine lantus
2 Not define 24










Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

32



Bibliography
References:
LeMone, P., Burke K. (2008) Medical Surgical Nursing Critical Thinking in Client Care 4
th
ed.
Linton, A (2012) Introduction to Medical- Surgical Nursing 5
th

Wysolmerski JJ, Insogna KL. The parathyroid glands, hypercalcemia, and hypocalcemia. In: Goldman
L, Schafer AI, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 253.

Webliography
References:
http://www.nlm.nih.gov/medlineplus/ency/article/000358.htm
http://thyroid.org/
https://www.philippinemedicalassociation.org/affiliate-societies-details.php?AffiliateID=24



































Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

33


PHYSIOLOGIC ADAPTATION: DISTURBANCE IN METABOLISM- RESPONSES TO ALTERED
ENDOCRINE FUNCTION
SAMPLE 50 ITEMS NCLEX QUESTION

1. Nurse Ronn is assessing a client with possible Cushings syndrome. In a client with Cushings
syndrome, the nurse would expect to find:
a. Hypotension.
b. Thick, coarse skin.
c. Deposits of adipose tissue in the trunk and dorso cervical area.
d. Weight gain in arms and legs.
Rationale: Answer C. Because of changes in fat distribution, adipose tissue accumulates in the trunk,
face (moonface), and dorsocervical areas (buffalo hump). Hypertension is caused by fluid retention.
Skin becomes thin and bruises easily because of a loss of collagen. Muscle wasting causes muscle
atrophy and thin extremities.

2. A male client with primary diabetes insipidus is ready for discharge on desmopressin (DDAVP).
Which instruction should nurse Lina provide?
a. Administer desmopressin while the suspension is cold.
b. Your condition isnt chronic, so you wont need to wear a medical identification bracelet.
c. You may not be able to use desmopressin nasally if you have nasal discharge or blockage.
d. You wont need to monitor your fluid intake and output after you start taking desmopressin.

Rationale: Answer C. Desmopressin may not be absorbed if the intranasal route is compromised.
Although diabetes insipidus is treatable, the client should wear medical identification and carry
medication at all times to alert medical personnel in an emergency and ensure proper treatment. The
client must continue to monitor fluid intake and output and receive adequate fluid replacement.

3. Nurse Wayne is aware that a positive Chvosteks sign indicate?
a. Hypocalcemia
b. Hyponatremia
c. Hypokalemia
d. Hypermagnesemia

Rationale: Answer A. Chvosteks sign is elicited by tapping the clients face lightly over the facial
nerve, just below the temple. If the clients facial muscles twitch, it indicates hypocalcemia.
Hyponatremia is indicated by weight loss, abdominal cramping, muscle weakness, headache, and
postural hypotension. Hypokalemia causes paralytic ileus and muscle weakness. Clients with
hypermagnesemia exhibit a loss of deep tendon reflexes, coma, or cardiac arrest.

4. In a 29-year-old female client who is being successfully treated for Cushings syndrome, nurse
Lyzette would expect a decline in:
a. Serum glucose level.
b. Hair loss.
c. Bone mineralization.
d. Menstrual flow.
Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

34

Rationale: Answer A. Hyperglycemia, which develops from glucocorticoid excess, is a manifestation of
Cushings syndrome. With successful treatment of the disorder,serum glucose levels decline. Hirsutism
is common in Cushings syndrome; therefore, with successful treatment, abnormal hair growth also
declines. Osteoporosis occurs in Cushings syndrome; therefore, with successful treatment, bone
mineralization increases. Amenorrhea develops in Cushings syndrome. With successful treatment, the
client experiences a return of menstrual flow, not a decline in it.

5. A male client has recently undergone surgical removal of a pituitary tumor. Dr. Wong prescribes
corticotropin (Acthar), 20 units I.M. q.i.d. as a replacement therapy. What is the mechanism of action of
corticotropin?
a. It decreases cyclic adenosine monophosphate (cAMP) production and affects the metabolic rate of
target organs.
b. It interacts with plasma membrane receptors to inhibit enzymatic actions.
c. It interacts with plasma membrane receptors to produce enzymatic actions that affect protein, fat,
and carbohydrate metabolism.\
d. It regulates the threshold for water resorption in the kidneys.

Rationale: Answer C. Corticotropin interacts with plasma membrane receptors to produce enzymatic
actions that affect protein, fat, and carbohydrate metabolism. It doesnt decrease cAMP production. The
posterior pituitary hormone, antidiuretic hormone, regulates the threshold for water resorption in the
kidneys.

6. Capillary glucose monitoring is being performed every 4 hours for a female client diagnosed with
diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose
results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of
regular insulin. Nurse Vince should expect the doses:
a. Onset to be at 2 p.m. and its peak to be at 3 p.m.
b. Onset to be at 2:15 p.m. and its peak to be at 3 p.m.
c. Onset to be at 2:30 p.m. and its peak to be at 4 p.m.
d. Onset to be at 4 p.m. and its peak to be at 6 p.m.
Rationale: Answer C. Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes
and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be
from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.

7. A female client with Cushings syndrome is admitted to the medical-surgical unit. During the
admission assessment, nurse Tyzz notes that the client is agitated and irritable, has poor memory, reports
loss of appetite, and appears disheveled. These findings are consistent with which problem?
a. Depression
b. Neuropathy
c. Hypoglycemia
d. Hyperthyroidism
Rationale: Answer A. Agitation, irritability, poor memory, loss of appetite, and neglect of ones
appearance may signal depression, which is common in clients with Cushings syndrome. Neuropathy
affects clients with diabetes mellitus not Cushings syndrome. Although hypoglycemia can cause
Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

35

irritability, it also produces increased appetite, rather than loss of appetite. Hyperthyroidism typically
causes such signs as goiter, nervousness, heat intolerance, and weight loss despite increased appetite.

8. Nurse Ruth is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and
tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which
complication?
a. Tetany
b. Hemorrhage
c. Thyroid storm
d. Laryngeal nerve damage
Rationale: Answer A. Tetany may result if the parathyroid glands are excised or damaged during
thyroid surgery. Hemorrhage is a potential complication after thyroid surgery but is characterized by
tachycardia, hypotension, frequent swallowing, feelings of fullness at the incision site, choking, and
bleeding. Thyroid storm is another term for severe hyperthyroidism not a complication of
thyroidectomy. Laryngeal nerve damage may occur postoperatively, but its signs include a hoarse voice
and, possibly, acute airway obstruction.

9. After undergoing a subtotal thyroidectomy, a female client develops hypothyroidism. Dr. Smith
prescribes levothyroxine (Levothroid), 25 mcg P.O. daily. For which condition is levothyroxine the
preferred agent?
a. Primary hypothyroidism
b. Graves disease
c. Thyrotoxicosis
d. Euthyroidism
Rationale: Answer A. Levothyroxine is the preferred agent to treat primary hypothyroidism and
cretinism, although it also may be used to treat secondary hypothyroidism. It is contraindicated in
Graves disease and thyrotoxicosis because these conditions are forms of hyperthyroidism.
Euthyroidism, a term used to describe normal thyroid function, wouldnt require any thyroid
preparation.

10. Which of these signs suggests that a male client with the syndrome of inappropriate antidiuretic
hormone (SIADH) secretion is experiencing complications?
a. Tetanic contractions
b. Neck vein distention
c. Weight loss
d. Polyuria
Rationale: Answer B. SIADH secretion causes antidiuretic hormone overproduction, which leads to
fluid retention. Severe SIADH can cause such complications as vascular fluid overload, signaled by
neck vein distention. This syndrome isnt associated with tetanic contractions. It may cause weight gain
and fluid retention (secondary to oliguria).





Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

36


11. A female client with a history of pheochromocytoma is admitted to the hospital in an acute
hypertensive crisis. To reverse hypertensive crisis caused by pheochromocytoma, nurse Lyka expects to
administer:
a. phentolamine (Regitine).
b. methyldopa (Aldomet).
c. mannitol (Osmitrol).
d. felodipine (Plendil).

Rationale: Answer A. Pheochromocytoma causes excessive production of epinephrine and
norepinephrine, natural catecholamines that raise the blood pressure. Phentolamine, an alpha-adrenergic
blocking agent given by I.V. bolus or drip, antagonizes the bodys response to circulating epinephrine
and norepinephrine, reducing blood pressure quickly and effectively. Although methyldopa is an
antihypertensive agent available in parenteral form, it isnt effective in treating hypertensive
emergencies. Mannitol, a diuretic, isnt used to treat hypertensive emergencies. Felodipine, an
antihypertensive agent, is available only in extended-release tablets and therefore doesnt reduce blood
pressure quickly enough to correct hypertensive crisis.

12. A male client with a history of hypertension is diagnosed with primary hyperaldosteronism. This
diagnosis indicates that the clients hypertension is caused by excessive hormone secretion from which
of the following glands?
a. Adrenal cortex
b. Pancreas
c. Adrenal medulla
d. Parathyroid
Rationale: . Answer A. Excessive secretion of aldosterone in the adrenal cortex is responsible for the
clients hypertension. This hormone acts on the renal tubule, where it promotes reabsorption of sodium
and excretion of potassium and hydrogen ions. The pancreas mainly secretes hormones involved in fuel
metabolism. The adrenal medulla secretes the catecholamines epinephrine and norepinephrine. The
parathyroids secrete parathyroid hormone.

13. Nurse Troy is aware that the most appropriate for a client with Addisons disease?
a. Risk for infection
b. Excessive fluid volume
c. Urinary retention
d. Hypothermia
Rationale: Answer A. Addisons disease decreases the production of all adrenal hormones,
compromising the bodys normal stress response and increasing the risk of infection. Other appropriate
nursing diagnoses for a client with Addisons disease include Deficient fluid volume and Hyperthermia.
Urinary retention isnt appropriate because Addisons disease causes polyuria.

14. Acarbose (Precose), an alpha-glucosidase inhibitor, is prescribed for a female client with type 2
diabetes mellitus. During discharge planning, nurse Pauleen would be aware of the clients need for
additional teaching when the client states:
a. If I have hypoglycemia, I should eat some sugar, not dextrose.
Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

37

b. The drug makes my pancreas release more insulin.
c. I should never take insulin while Im taking this drug.
d. Its best if I take the drug with the first bite of a meal.
Rationale: Answer A. Acarbose delays glucose absorption, so the client should take an oral form of
dextrose rather than a product containing table sugar when treating hypoglycemia. The alpha-
glucosidase inhibitors work by delaying the carbohydrate digestion and glucose absorption. Its safe to
be on a regimen that includes insulin and an alpha-glucosidase inhibitor. The client should take the drug
at the start of a meal, not 30 minutes to an hour before.


15. A female client whose physical findings suggest a hyperpituitary condition undergoes an extensive
diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transphenoidal
hypophysectomy. The evening before the surgery, nurse Jacob reviews preoperative and postoperative
instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?
a. You must lie flat for 24 hours after surgery.
b. You must avoid coughing, sneezing, and blowing your nose.
c. You must restrict your fluid intake.
d. You must report ringing in your ears immediately.

Rationale: Answer B. After a transsphenoidal hypophysectomy, the client must refrain from coughing,
sneezing, and blowing the nose for several days to avoid disturbing the surgical graft used to close the
wound. The head of the bed must be elevated, not kept flat, to prevent tension or pressure on the suture
line. Within 24 hours after a hypophysectomy, transient diabetes insipidus commonly occurs; this calls
for increased, not restricted, fluid intake. Visual, not auditory, changes are a potential complication of
hypophysectomy.

16. Dr. Kennedy prescribes glipizide (Glucotrol), an oral antidiabetic agent, for a male client with type
2 diabetes mellitus who has been having trouble controlling the blood glucose level through diet and
exercise. Which medication instruction should the nurse provide?
a. Be sure to take glipizide 30 minutes before meals.
b. Glipizide may cause a low serum sodium level, so make sure you have your sodium level checked
monthly.
c. You wont need to check your blood glucose level after you start taking glipizide.
d. Take glipizide after a meal to prevent heartburn.
Rationale: Answer A. The client should take glipizide twice a day, 30 minutes before a meal, because
food decreases its absorption. The drug doesnt cause hyponatremia and therefore doesnt necessitate
monthly serum sodium measurement. The client must continue to monitor the blood glucose level
during glipizide therapy.

17. For a diabetic male client with a foot ulcer, the physician orders bed rest, a wet-to-dry dressing
change every shift, and blood glucose monitoring before meals and bedtime. Why are wet-to-dry
dressings used for this client?
a. They contain exudate and provide a moist wound environment.
b. They protect the wound from mechanical trauma and promote healing.
c. They debride the wound and promote healing by secondary intention.
d. They prevent the entrance of microorganisms and minimize wound discomfort.
Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

38


Rationale: Answer C. For this client, wet-to-dry dressings are most appropriate because they clean the
foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by secondary intention.
Moist, transparent dressings contain exudate and provide a moist wound environment. Hydrocolloid
dressings prevent the entrance of microorganisms and minimize wound discomfort. Dry sterile dressings
protect the wound from mechanical trauma and promote healing.

18. When instructing the female client diagnosed with hyperparathyroidism about diet, nurse Gina
should stress the importance of which of the following?
a. Restricting fluids
b. Restricting sodium
c. Forcing fluids
d. Restricting potassium

Rationale: Answer C. The client should be encouraged to force fluids to prevent renal calculi formation.
Sodium should be encouraged to replace losses in urine. Restricting potassium isnt necessary in
hyperparathyroidism.

19. Which nursing diagnosis takes highest priority for a female client with hyperthyroidism?
a. Risk for imbalanced nutrition: More than body requirements related to thyroid hormone excess
b. Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing
c. Body image disturbance related to weight gain and edema
d. Imbalanced nutrition: Less than body requirements related to thyroid hormone excess

Rationale: Answer D. In the client with hyperthyroidism, excessive thyroid hormone production leads
to hypermetabolism and increased nutrient metabolism. These conditions may result in a negative
nitrogen balance, increased protein synthesis and breakdown, decreased glucose tolerance, and fat
mobilization and depletion. This puts the client at risk for marked nutrient and calorie deficiency,
making Imbalanced nutrition: Less than body requirements the most important nursing diagnosis.
Options B and C may be appropriate for a client with hypothyroidism, which slows the metabolic rate.

20. A male client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome
(HHNS) has a history of type 2 diabetes that is being controlled with an oral diabetic agent, tolazamide
(Tolinase). Which of the following is the most important laboratory test for confirming this disorder?
a. Serum potassium level
b. Serum sodium level
c. Arterial blood gas (ABG) values
d. Serum osmolarity

Rationale: Answer D. Serum osmolarity is the most important test for confirming HHNS; its also used
to guide treatment strategies and determine evaluation criteria. A client with HHNS typically has a
serum osmolarity of more than 350 mOsm/L. Serum potassium, serum sodium, and ABG values are also
measured, but they arent as important as serum osmolarity for confirming a diagnosis of HHNS. A
client with HHNS typically has hypernatremia and osmotic diuresis. ABG values reveal acidosis, and
the potassium level is variable.

Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

39

21. A male client has just been diagnosed with type 1 diabetes mellitus. When teaching the client and
family how diet and exercise affect insulin requirements, Nurse Joy should include which guideline?
a. Youll need more insulin when you exercise or increase your food intake.
b. Youll need less insulin when you exercise or reduce your food intake.
c. Youll need less insulin when you increase your food intake.
d. Youll need more insulin when you exercise or decrease your food intake.
Rationale: Answer B. Exercise, reduced food intake, hypothyroidism, and certain medications decrease
the insulin requirements. Growth, pregnancy, greater food intake, stress, surgery, infection, illness,
increased insulin antibodies, and certain medications increase the insulin requirements.

22. Nurse Noemi administers glucagon to her diabetic client, then monitors the client for adverse drug
reactions and interactions. Which type of drug interacts adversely with glucagon?
a. Oral anticoagulants
b. Anabolic steroids
c. Beta-adrenergic blockers
d. Thiazide diuretics
Rationale: Answer A. As a normal body protein, glucagon only interacts adversely with oral
anticoagulants, increasing the anticoagulant effects. It doesnt interact adversely with anabolic steroids,
beta-adrenergic blockers, or thiazide diuretics.

23. Which instruction about insulin administration should nurse Kate give to a client?
a. Always follow the same order when drawing the different insulins into the syringe.
b. Shake the vials before withdrawing the insulin.
c. Store unopened vials of insulin in the freezer at temperatures well below freezing.
d. Discard the intermediate-acting insulin if it appears cloudy.

Rationale: Answer A. The client should be instructed always to follow the same order when drawing
the different insulins into the syringe. Insulin should never be shaken because the resulting froth
prevents withdrawal of an accurate dose and may damage the insulin protein molecules. Insulin also
should never be frozen because the insulin protein molecules may be damaged. Intermediate-acting
insulin is normally cloudy.

24. Nurse Perry is caring for a female client with type 1 diabetes mellitus who exhibits confusion,
light-headedness, and aberrant behavior. The client is still conscious. The nurse should first administer:
a. I.M. or subcutaneous glucagon.
b. I.V. bolus of dextrose 50%.
c. 15 to 20 g of a fast-acting carbohydrate such as orange juice.
d. 10 U of fast-acting insulin.
Rationale: Answer C. This client is having a hypoglycemic episode. Because the client is conscious, the
nurse should first administer a fast-acting carbohydrate, such as orange juice, hard candy, or honey. If
the client has lost consciousness, the nurse should administer either I.M. or subcutaneous glucagon or an
I.V. bolus of dextrose 50%. The nurse shouldnt administer insulin to a client whos hypoglycemic; this
action will further compromise the clients condition.

Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

40

25. For the first 72 hours after thyroidectomy surgery, nurse Jamie would assess the female client for
Chvosteks sign and Trousseaus sign because they indicate which of the following?
a. Hypocalcemia
b. Hypercalcemia
c. Hypokalemia
d. Hyperkalemia
Rationale: Answer A. The client who has undergone a thyroidectomy is at risk for developing
hypocalcemia from inadvertent removal or damage to the parathyroid gland. The client with
hypocalcemia will exhibit a positive Chvosteks sign (facial muscle contraction when the facial nerve in
front of the ear is tapped) and a positive Trousseaus sign (carpal spasm when a blood pressure cuff is
inflated for a few minutes). These signs arent present with hypercalcemia, hypokalemia, or
hyperkalemia.

26. An agitated, confused female client arrives in the emergency department. Her history includes type 1
diabetes mellitus, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache,
and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute
hypoglycemic reaction. After recovery, nurse Lily teaches the client to treat hypoglycemia by ingesting:
a. 2 to 5 g of a simple carbohydrate.
b. 10 to 15 g of a simple carbohydrate.
c. 18 to 20 g of a simple carbohydrate.
d. 25 to 30 g of a simple carbohydrate.

Rationale: Answer B. To reverse hypoglycemia, the American Diabetes Associationrecommends
ingesting 10 to 15 g of a simple carbohydrate, such as three to five pieces of hard candy, two to three
packets of sugar (4 to 6 tsp), or 4 oz of fruit juice. If necessary, this treatment can be repeated in 15
minutes. Ingesting only 2 to 5 g of a simple carbohydrate may not raise the blood glucose level
sufficiently. Ingesting more than 15 g may raise it above normal, causing hyperglycemia.

27. A female adult client with a history of chronic hyperparathyroidism admits to being noncompliant.
Based on initial assessment findings, nurse Julia formulates the nursing diagnosis of Risk for injury. To
complete the nursing diagnosis statement for this client, which related-to phrase should the nurse add?
a. Related to bone demineralization resulting in pathologic fractures
b. Related to exhaustion secondary to an accelerated metabolic rate
c. Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces
d. Related to tetany secondary to a decreased serum calcium level

Rationale: Answer A. Poorly controlled hyperparathyroidism may cause an elevated serum calcium
level. This, in turn, may diminish calcium stores in the bone, causing bone demineralization and setting
the stage for pathologic fractures and a risk for injury. Hyperparathyroidism doesnt accelerate the
metabolic rate. A decreased thyroid hormone level, not an increased parathyroid hormone level, may
cause edema and dry skin secondary to fluid infiltration into the interstitial spaces. Hyperparathyroidism
causes hypercalcemia, not hypocalcemia; therefore, it isnt associated with tetany.

28. Nurse John is assigned to care for a postoperative male client who has diabetes mellitus. During the
assessment interview, the client reports that hes impotent and says hes concerned about its effect on his
marriage. In planning this clients care, the most appropriate intervention would be to:
a. Encourage the client to ask questions about personal sexuality.
b. Provide time for privacy.
Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

41

c. Provide support for the spouse or significant other.
d. Suggest referral to a sex counselor or other appropriate professional.
Rationale: Answer D. The nurse should refer this client to a sex counselor or other professional.
Making appropriate referrals is a valid part of planning the clients care. The nurse doesnt normally
provide sex counseling.

29. During a class on exercise for diabetic clients, a female client asks the nurse educator how often to
exercise. The nurse educator advises the clients to exercise how often to meet the goals of planned
exercise?
a. At least once a week
b. At least three times a week
c. At least five times a week
d. Every day

Rationale: Answer B. Diabetic clients must exercise at least three times a week to meet the goals of
planned exercise lowering the blood glucose level, reducing or maintaining the proper weight,
increasing the serum high-density lipoprotein level, decreasing serum triglyceride levels, reducing blood
pressure, and minimizing stress. Exercising once a week wouldnt achieve these goals. Exercising more
than three times a week, although beneficial, would exceed the minimum requirement.

30. Nurse Oliver should expect a client with hypothyroidism to report which health concerns?
a. Increased appetite and weight loss
b. Puffiness of the face and hands
c. Nervousness and tremors
d. Thyroid gland swelling

Rationale: Answer B. Hypothyroidism (myxedema) causes facial puffiness, extremity edema, and
weight gain. Signs and symptoms of hyperthyroidism (Graves disease) include an increased appetite,
weight loss, nervousness, tremors, and thyroid gland enlargement (goiter).

31. A female client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg
P.O. daily. Which finding should nurse Hans recognize as an adverse drug effect?
a. Dysuria
b. Leg cramps
c. Tachycardia
d. Blurred vision
Rationale: Answer C. Levothyroxine, a synthetic thyroid hormone, is given to a client with
hypothyroidism to simulate the effects of thyroxine. Adverse effects of this agent include tachycardia.
The other options arent associated with levothyroxine.

32, A 67-year-old male client has been complaining of sleeping more, increased urination, anorexia,
weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these
assessment findings, nurse Richard would suspect which of the following disorders?
a. Diabetes mellitus
b. Diabetes insipidus
c. Hypoparathyroidism
d. Hyperparathyroidism
Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

42

Rationale: Answer D. Hyperparathyroidism is most common in older women and is characterized by
bone pain and weakness from excess parathyroid hormone (PTH). Clients also exhibit hypercaliuria-
causing polyuria. While clients with diabetes mellitus and diabetes insipidus also have polyuria, they
dont have bone pain and increased sleeping. Hypoparathyroidism is characterized by urinary frequency
rather than polyuria.

33. When caring for a male client with diabetes insipidus, nurse Juliet expects to administer:
a. vasopressin (Pitressin Synthetic).
b. furosemide (Lasix).
c. regular insulin.
d. 10% dextrose.
Rationale: Answer A. Because diabetes insipidus results from decreased antidiuretic hormone
(vasopressin) production, the nurse should expect to administer synthetic vasopressin for hormone
replacement therapy. Furosemide, a diuretic, is contraindicated because a client with diabetes insipidus
experiences polyuria. Insulin and dextrose are used to treat diabetes mellitus and its complications, not
diabetes insipidus.

34. The nurse is aware that the following is the most common cause of hyperaldosteronism?
a. Excessive sodium intake
b. A pituitary adenoma
c. Deficient potassium intake
d. An adrenal adenoma
Rationale: Answer D. An autonomous aldosterone-producing adenoma is the most common cause of
hyperaldosteronism. Hyperplasia is the second most frequent cause. Aldosterone secretion is
independent of sodium and potassium intake as well as of pituitary stimulation.

35. A male client with type 1 diabetes mellitus has a highly elevated glycosylated hemoglobin (Hb) test
result. In discussing the result with the client, nurse Sharmaine would be most accurate in stating:
a. The test needs to be repeated following a 12-hour fast.
b. It looks like you arent following the prescribed diabetic diet.
c. It tells us about your sugar control for the last 3 months.
d. Your insulin regimen needs to be altered significantly.
Rationale: Answer C. The glycosylated Hb test provides an objective measure of glycemic control over
a 3-month period. The test helps identify trends or practices that impair glycemic control, and it doesnt
require a fasting period before blood is drawn. The nurse cant conclude that the result occurs from poor
dietary management or inadequate insulin coverage.

36. Following a unilateral adrenalectomy, nurse Betty would assess for hyperkalemia shown by which of
the following?
a. Muscle weakness
b. Tremors
c. Diaphoresis
d. Constipation
Rationale: Answer A. Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands,
feet, tongue, and face are findings associated with hyperkalemia, which is transient and occurs from
transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation
arent seen in hyperkalemia.
Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

43


37. Nurse Louie is developing a teaching plan for a male client diagnosed with diabetes insipidus. The
nurse should include information about which hormone lacking in clients with diabetes insipidus?
a. antidiuretic hormone (ADH).
b. thyroid-stimulating hormone (TSH).
c. follicle-stimulating hormone (FSH).
d. luteinizing hormone (LH).
Rationale: Answer A. ADH is the hormone clients with diabetes insipidus lack. The clients TSH, FSH,
and LH levels wont be affected.

38. Early this morning, a female client had a subtotal thyroidectomy. During evening rounds, nurse Tina
assesses the client, who now has nausea, a temperature of 105 F (40.5 C), tachycardia, and extreme
restlessness. What is the most likely cause of these signs?
a. Diabetic ketoacidosis
b. Thyroid crisis
c. Hypoglycemia
d. Tetany
Rationale: Answer B. Thyroid crisis usually occurs in the first 12 hours after thyroidectomy and causes
exaggerated signs of hyperthyroidism, such as high fever, tachycardia, and extreme restlessness.
Diabetic ketoacidosis is more likely to produce polyuria, polydipsia, and polyphagia; hypoglycemia, to
produce weakness, tremors, profuse perspiration, and hunger. Tetany typically causes uncontrollable
muscle spasms, stridor, cyanosis, and possibly asphyxia.

39. For a male client with hyperglycemia, which assessment finding best supports a nursing diagnosis of
Deficient fluid volume?
a. Cool, clammy skin
b. Distended neck veins
c. Increased urine osmolarity
d. Decreased serum sodium level

Rationale: Answer C. In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the
urine) increases as glucose particles move into the urine. The client experiences glucosuria and polyuria,
losing body fluids and experiencing fluid volume deficit. Cool, clammy skin; distended neck veins; and
a decreased serum sodium level are signs of fluid volume excess, the opposite imbalance.

40. When assessing a male client with pheochromocytoma, a tumor of the adrenal medulla that secretes
excessive catecholamine, nurse April is most likely to detect:
a. a blood pressure of 130/70 mm Hg.
b. a blood glucose level of 130 mg/dl.
c. bradycardia.
d. a blood pressure of 176/88 mm Hg.

Rationale: Answer D. Pheochromocytoma, a tumor of the adrenal medulla that secretes excessive
catecholamine, causes hypertension, tachycardia, hyperglycemia, hypermetabolism, and weight loss. It
isnt associated with the other options.

41. A male client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone
(SIADH). Which nursing intervention is appropriate?
a. Infusing I.V. fluids rapidly as ordered
Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

44

b. Encouraging increased oral intake
c. Restricting fluids
d. Administering glucose-containing I.V. fluids as ordered
Rationale: Answer C. To reduce water retention in a client with the SIADH, the nurse should restrict
fluids. Administering fluids by any route would further increase the clients already heightened fluid
load.

42. A female client has a serum calcium level of 7.2 mg/dl. During the physical examination, nurse
Noah expects to assess:
a. Trousseaus sign.
b. Homans sign.
c. Hegars sign.
d. Goodells sign.

Rationale: Answer A. This clients serum calcium level indicates hypocalcemia, an electrolyte
imbalance that causes Trousseaus sign (carpopedal spasm induced by inflating the blood pressure cuff
above systolic pressure). Homans sign (pain on dorsiflexion of the foot) indicates deep vein thrombosis.
Hegars sign (softening of the uterine isthmus) and Goodells sign (cervical softening) are
probable signs of pregnancy.
43. Which outcome indicates that treatment of a male client with diabetes insipidus has been effective?
a. Fluid intake is less than 2,500 ml/day.
b. Urine output measures more than 200 ml/hour.
c. Blood pressure is 90/50 mm Hg.
d. The heart rate is 126 beats/minute.
Rationale: Answer A. Diabetes insipidus is characterized by polyuria (up to 8 L/day), constant thirst,
and an unusually high oral intake of fluids. Treatment with the appropriate drug should decrease both
oral fluid intake and urine output. A urine output of 200 ml/hour indicates continuing polyuria. A blood
pressure of 90/50 mm Hg and a heart rate of 126 beats/minute indicate compensation for the continued
fluid deficit, suggesting that treatment hasnt been effective.

44. Jemma, who weighs 210 lb (95 kg) and has been diagnosed with hyperglycemia tells the nurse that
her husband sleeps in another room because her snoring keeps him awake. The nurse notices that she has
large hands and a hoarse voice. Which of the following would the nurse suspect as a possible cause of
the clients hyperglycemia?
a. Acromegaly
b. Type 1 diabetes mellitus
c. Hypothyroidism
d. Deficient growth hormone
Rationale: Answer A. Acromegaly, which is caused by a pituitary tumor that releases excessive growth
hormone, is associated with hyperglycemia, hypertension, diaphoresis, peripheral neuropathy, and joint
pain. Enlarged hands and feet are related to lateral bone growth, which is seen in adults with this
disorder. The accompanying soft tissue swelling causes hoarseness and often sleep apnea. Type 1
diabetes is usually seen in children, and newly diagnosed persons are usually very ill and thin.
Hypothyroidism isnt associated with hyperglycemia, nor is growth hormone deficiency.

45. Nurse Kate is providing dietary instructions to a male client with hypoglycemia. To control
hypoglycemic episodes, the nurse should recommend:
a. Increasing saturated fat intake and fasting in the afternoon.
Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

45

b. Increasing intake of vitamins B and D and taking iron supplements.
c. Eating a candy bar if light-headedness occurs.
d. Consuming a low-carbohydrate, high-protein diet and avoiding fasting.

Rationale: Answer D. To control hypoglycemic episodes, the nurse should instruct the client to
consume a low-carbohydrate, high-protein diet, avoid fasting, and avoid simple sugars. Increasing
saturated fat intake and increasing vitamin supplementation wouldnt help control hypoglycemia.

46. An incoherent female client with a history of hypothyroidism is brought to the emergency
department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation,
respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area.
Knowing that these findings suggest severe hypothyroidism, nurse Libby prepares to take emergency
action to prevent the potential complication of:
a. Thyroid storm.
b. Cretinism.
c. myxedema coma.
d. Hashimotos thyroiditis.

Rationale: Answer C. Severe hypothyroidism may result in myxedema coma, in which a drastic drop in
the metabolic rate causes decreased vital signs, hypoventilation (possibly leading to respiratory
acidosis), and nonpitting edema. Thyroid storm is an acute complication of hyperthyroidism. Cretinism
is a form of hypothyroidism that occurs in infants. Hashimotos thyroiditis is a common chronic
inflammatory disease of the thyroid gland in which autoimmune factors play a prominent role.


47. A male client with type 1 diabetes mellitus asks the nurse about taking an oral antidiabetic agent.
Nurse Jack explains that these medications are only effective if the client:
a. prefers to take insulin orally.
b. has type 2 diabetes.
c. has type 1 diabetes.
d. is pregnant and has type 2 diabetes.

Rationale: Answer B. Oral antidiabetic agents are only effective in adult clients with type 2 diabetes.
Oral antidiabetic agents arent effective in type 1 diabetes. Pregnant and lactating women arent
prescribed oral antidiabetic agents because the effect on the fetus is uncertain.

48. When caring for a female client with a history of hypoglycemia, nurse Ruby should avoid
administering a drug that may potentiate hypoglycemia. Which drug fits this description?
a. sulfisoxazole (Gantrisin)
b. mexiletine (Mexitil)
c. prednisone (Orasone)
d. lithium carbonate (Lithobid)

Rationale: Answer A. Sulfisoxazole and other sulfonamides are chemically related to oral antidiabetic
agents and may precipitate hypoglycemia. Mexiletine, an antiarrhythmic, is used to treat refractory
ventricular arrhythmias; it doesnt cause hypoglycemia. Prednisone, a corticosteroid, is associated with
hyperglycemia. Lithium may cause transient hyperglycemia, not hypoglycemia.

49. After taking glipizide (Glucotrol) for 9 months, a male client experiences secondary failure. Which
of the following would the nurse expect the physician to do?
Physiologic Adaptation: Disturbance in Metabolism-Responses to Altered Endocrine Function

46

a. Initiate insulin therapy.
b. Switch the client to a different oral antidiabetic agent.
c. Prescribe an additional oral antidiabetic agent.
d. Restrict carbohydrate intake to less than 30% of the total caloric intake.
Rationale: Answer B. Many clients (25% to 60%) with secondary failure respond to a different oral
antidiabetic agent. Therefore, it wouldnt be appropriate to initiate insulin therapy at this time. However,
if a new oral antidiabetic agent is unsuccessful in keeping glucose levels at an acceptable level, insulin
may be used in addition to the antidiabetic agent.

50. During preoperative teaching for a female client who will undergo subtotal thyroidectomy, the nurse
should include which statement?
a. The head of your bed must remain flat for 24 hours after surgery.
b. You should avoid deep breathing and coughing after surgery.
c. You wont be able to swallow for the first day or two.
d. You must avoid hyperextending your neck after surgery.

Rationale: Answer D. To prevent undue pressure on the surgical incision after subtotal thyroidectomy,
the nurse should advise the client to avoid hyperextending the neck. The client may elevate the head of
the bed as desired and should perform deep breathing and coughing to help prevent pneumonia. Subtotal
thyroidectomy doesnt affect swallowing.

You might also like