NR341 Exam 2 Review

A 52-year-old client with newly diagnosed type 2 diabetes mellitus is being discharged with metformin and a plan for lifestyle modifications. Which points should the nurse emphasize to promote effective glycemic control and overall health? Select all that apply.

• Take metformin with meals to reduce gastrointestinal side effects

• Avoid vigorous exercise to reduce the risk of hypoglycemia

• Notify the provider if experiencing unexplained muscle pain

• Limit carbohydrate intake by avoiding all fruits and vegetables

• Monitor blood glucose regularly, including before & after exercise & maintain a consistent meal schedule &portion sizes

Answer explanation

Rationale:

1. ✅ Take metformin with meals – This helps minimize common GI side effects such as nausea and diarrhea, improving medication adherence.

2. ---

   ❌ Avoid vigorous exercise – Regular exercise is encouraged for patients with type 2 diabetes to improve insulin sensitivity and glucose control. While hypoglycemia is less common with metformin alone, blood glucose should be monitored, especially if other glucose-lowering agents are added.

3. ---

   ✅ Notify the provider if experiencing unexplained muscle pain – This may be a rare sign of lactic acidosis, a serious but uncommon adverse effect of metformin, especially in patients with kidney dysfunction.

4. ---

   ---

   ❌ Limit carbohydrate intake by avoiding all fruits and vegetables – This is inaccurate. Patients should choose complex carbs and focus on balanced nutrition. Fruits and vegetables provide fiber, vitamins, and essential nutrients that support metabolic health.

5. ---

   ✅ Monitor blood glucose regularly – Especially around exercise, this helps patients understand how activity affects their blood sugar and adjust accordingly.

6. ---

   ✅ Maintain a consistent meal schedule and portion sizes – Helps prevent spikes or drops in blood glucose and supports weight management.

A 74-year-old client with a history of type 2 diabetes is brought to the emergency department by family members. The family reports the client has been increasingly confused, very weak, and has not been eating or drinking well for several days. Upon assessment, the client is lethargic, severely dehydrated, and has dry mucous membranes. Vital signs:

---

[BP: 90/54 mmHg], [HR: 122 bpm], [RR: 26/min], [Blood glucose: 880 mg/dL], [Serum ketones: Negative], [Arterial pH: 7.38], [Serum osmolality: 350 mOsm/kg]

---

Which condition does the nurse most likely suspect based on the client’s presentation?

• Diabetic Ketoacidosis (DKA)

• Hyperosmolar Hyperglycemic Syndrome (HHS)

• Hypoglycemia

• Septic shock

Answer explanation

✅ Hyperosmolar Hyperglycemic Syndrome (HHS)

---

💡 HHS typically occurs in older adults with type 2 diabetes. It presents with extremely high blood glucose, absent ketones, normal pH, severe dehydration, and altered mental status.

• The absence of metabolic acidosis (normal pH) helps differentiate it from DKA.

A client with diabetic ketoacidosis (DKA) is receiving IV insulin and normal saline infusions. When the client’s blood glucose approaches 250 mg/dL, which IV fluid should the nurse expect to administer?

• Lactated Ringer’s solution

• Total Parenteral Nutrition (TPN)

• Dextrose 5% in 0.45% saline solution (D5½NS)

• 3% Saline solution

Answer explanation

✅ Dextrose 5% in 0.45% saline solution (D5½NS)

• When a client with DKA’s blood glucose drops to ~250 mg/dL, the goal is to prevent hypoglycemia and cerebral edema while continuing to correct acidosis and ketosis. At this point, D5½NS is commonly infused alongside insulin to allow continued glucose control while avoiding rapid drops in blood sugar.

• ---

  ❌ Lactated Ringers: Not appropriate once glucose approaches 250 mg/dL; it lacks dextrose.

  ---

  ❌ TPN: Not indicated in acute DKA management.

  ---

  ❌ 3% Saline: Hypertonic solution used for severe hyponatremia or cerebral edema, not standard in DKA.

A client with hypothyroidism is starting levothyroxine. Which points should the nurse emphasize to ensure safe and effective therapy? SATA

• Take levothyroxine with food to reduce stomach upset

• Have thyroid function rechecked in about 6-8 weeks & expect to take this medication for life

• Report palpitations or chest pain promptly

• Store the medication in the refrigerator

• Take levothyroxine first thing in the morning on an empty stomach

Answer explanation

Rationale:

---

❌ Take levothyroxine with food to reduce stomach upset
Incorrect. Levothyroxine should be taken on an empty stomach, ideally 30–60 minutes before breakfast, because food can interfere with absorption.

---

✅ Have thyroid function rechecked in about 6–8 weeks -- Correct. It takes several weeks for TSH levels to stabilize, so thyroid function should be rechecked to assess dosing effectiveness and make adjustments if needed.

✅ Expect to take this medication for life
Correct. Hypothyroidism is typically a lifelong condition, and levothyroxine therapy is usually continued indefinitely.

---

✅ Report palpitations or chest pain promptly
Correct. These could indicate overmedication or thyrotoxicosis, which can stress the cardiovascular system, especially in older adults.

---

❌ Store the medication in the refrigerator
Incorrect. Levothyroxine should be stored at room temperature, away from moisture and direct sunlight—not refrigerated.

---

✅ Take levothyroxine first thing in the morning on an empty stomach
Correct. This ensures optimal absorption, improving therapeutic effectiveness.

The nurse is assessing a patient with hypothyroidism. Which of the following are risk factors for developing myxedema coma? Select all that apply.

• Discontinuation of thyroid hormone therapy

• Exposure to cold temperatures

• Use of sedatives or narcotics

• Hyperthyroidism

• Acute infection or illness

Answer explanation

• ✅ Stopping thyroid meds can trigger crisis

  ---

  ✅Cold exposure suppresses already slow metabolism

  ---

  ✅ Sedatives/narcotics depress CNS and respiratory drive

  ---

  ❌ Hyperthyroidism is the opposite problem (risk for thyroid storm)

  ---

  ✅ Infection or systemic illness can precipitate decompensation

---

Myxedema coma is a life-threatening complication of hypothyroidism known as decompensated hypothyroidism. Though this complication contains the word coma, patients may or may not be actually comatose. Either way, this is a medical emergency. Myxedema coma can be caused by long-term untreated hypothyroidism, abrupt discontinuation of thyroid medication, or infection or illness. It can also be a combination of these. For example, in untreated hypothyroidism, the body comes up with adaptive mechanisms to maintain homeostasis, and if a bad infection occurs, these mechanisms can fail, and the body can fall into myxedema coma.

The nurse is reviewing assessment findings for clients with thyroid disorders. Which of the following are clinical manifestations associated with hyperthyroidism? Select all that apply.

• Heat intolerance

• Bradycardia and cold, dry skin

• Weight loss despite increased appetite

• Diarrhea, insomnia and restlessnessI

• Exophthalmos

Answer explanation

✅ Heat intolerance – Due to increased basal metabolic rate.

---

❌ Bradycardia – More common in hypothyroidism; hyperthyroidism causes tachycardia. ❌ Cold, dry skin – Associated with hypothyroidism due to decreased circulation and metabolism.

---

✅ Weight loss with increased appetite – Classic sign of hyperthyroidism.

---

• ✅ Diarrhea – GI motility increases in hyperthyroidism. ✅ Insomnia and restlessness – Nervous system is overstimulated.

---

✅ Exophthalmos – Eye bulging is specific to Graves' disease, a form of hyperthyroidism.

---

💡 Tips & Mnemonics

→ “Hashimoto's Slow and Cold” = Hypothyroid

→ “Grave's Hot and Fast” = Hyperthyroid

🔺 Hyperthyroidism (Graves’ Disease)

→ 🚨 Clinical Manifestations: Weight loss despite increased appetite; Heat intolerance, sweating; Tachycardia, palpitations; Anxiety, insomnia; Diarrhea; Exophthalmos (bulging eyes); Goiter (enlarged thyroid)

→ 🩺 Nursing Interventions: Administer antithyroid meds: propylthiouracil (PTU), methimazole; Administer beta blockers (propranolol) for tachycardia; Prepare for radioactive iodine therapy or thyroidectomy; Monitor for thyroid storm

→ Thyroid Storm S/S Mnemonic: "STORM"

• S: Sweating, T: Tachycardia, O: Outbursts (agitation), R: Restlessness, M: Mental status changes

🔻 Hypothyroidism (Hashimoto’s Thyroiditis)

→ 🚨 Clinical Manifestations: Fatigue, cold intolerance; Weight gain, constipation; Bradycardia, hypotension; Depression, dry skin, hair thinning; Menstrual irregularities

• Myxedema (severe form: coma, respiratory failure)

• → 🩺 Nursing Interventions: Monitor vital signs & respiratory effort; Administer levothyroxine on an empty stomach in the morning; Monitor for signs of myxedema coma; Educate on lifelong therapy adherence

→ Myxedema Coma Mnemonic: "HYPO"

• H: Hypothermia, Y: Your HR is low (bradycardia), P: Poor perfusion, O: Output decreased (urine, LOC)

The nurse is caring for two clients: one with diabetes insipidus (DI) and one with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which statements reflect correct clinical reasoning for each condition? SATA

• “The SIADH client is likely to have higher urine output.”

• “The DI client is at risk for hypovolemia due to excessive fluid loss and may have very low urine specific gravity..”

• “The SIADH client often shows hyponatremia due to dilution.”

• “Desmopressin (DDAVP) is commonly used to treat SIADH.”

• “Hypertonic saline could be used in severe cases of SIADH with critical hyponatremia.”

Answer explanation

Rationale:

---

❌ “The SIADH client is likely to have higher urine output.”
Incorrect. SIADH involves excess antidiuretic hormone (ADH), causing the kidneys to retain water, leading to low urine output and fluid retention.

---

✅ “The DI client is at risk for hypovolemia due to excessive fluid loss.”
Correct. In diabetes insipidus (DI), there is a lack of ADH, leading to large amounts of dilute urine, which can cause hypovolemia and dehydration.

✅ “The DI client may have very low urine specific gravity.”
Correct. DI leads to very dilute urine, so urine specific gravity is typically <1.005.

---

✅ “The SIADH client often shows hyponatremia due to dilution.”
Correct. SIADH causes water retention, which dilutes serum sodium levels, resulting in dilutional hyponatremia.

---

❌ “Desmopressin (DDAVP) is commonly used to treat SIADH.”
Incorrect. Desmopressin (DDAVP) is used to treat DI, not SIADH. In SIADH, fluid restriction and sometimes demeclocycline or loop diuretics are used.

---

✅ “Hypertonic saline could be used in severe cases of SIADH with critical hyponatremia.”
Correct. In severe or symptomatic hyponatremia (e.g., seizures), hypertonic (3%) saline may be cautiously administered to correct sodium levels.

A client with type 1 diabetes asks about managing blood glucose when ill. Which instructions should the nurse include? Select all that apply.

• Continue taking insulin or antidiabetic medications normally

• Monitor blood glucose every 6-8 hours

• Stay hydrated and take mild analgesic for fever or malaise.

• Notify the provider if blood glucose is consistently elevated

• If blood sugar < 60, take 30 grams of carbohydrate and recheck blood sugar in 30 minutes

Answer explanation

Correct Answers:
✅ Continue taking insulin or antidiabetic medications normally
✅ Stay hydrated and take mild analgesic for fever or malaise
✅ Notify the provider if blood glucose is consistently elevated

---

Incorrect Answers:

❌ Monitor blood glucose every 6–8 hours

Incorrect – During illness, clients with type 1 diabetes should monitor blood glucose every 3–4 hours, not every 6–8 hours. Illness can increase insulin needs and raise the risk for diabetic ketoacidosis (DKA).

❌ If blood sugar < 60, take 30 grams of carbohydrate and recheck blood sugar in 30 minutes

Incorrect – The standard hypoglycemia treatment is 15 grams of fast-acting carbohydrate, then recheck in 15 minutes, not 30g or 30 minutes.

---

Teaching Points for Sick-Day Management:

• Always continue insulin – even if not eating much; stress hormones increase glucose.

• Monitor blood glucose q3–4h

• Check urine ketones if glucose is >240 mg/dL

• Hydration – drink plenty of fluids (sugar-free or carb-containing depending on glucose level)

• Call the provider for:

  • Vomiting or diarrhea >6 hours

  • Blood glucose >300 mg/dL for >24 hours

  • Moderate to large ketones

A client has just returned from surgery after a total thyroidectomy. Which interventions should the nurse implement to prevent complications and ensure safety? Select all that apply.

• Keep a tracheostomy tray at the bedside and monitor for signs of hypocalcemia

• Maintain the client in a supine position with no pillows

• Monitor VS for symptoms of thyroid storm

• Encourage vigorous coughing exercises every hour

• Assess for hoarseness or difficulty speaking

Answer explanation

Rationale:

✅ Keep a tracheostomy tray at the bedside

• Airway compromise is a critical post-op risk due to swelling or hematoma.

• A tracheostomy tray allows for emergency airway access.

✅ Monitor for signs of hypocalcemia

• The parathyroid glands may be damaged or removed during surgery, leading to low calcium levels.

• Look for tingling, numbness, muscle cramps, or positive Chvostek’s and Trousseau’s signs.

✅ Assess for hoarseness or difficulty speaking

• Indicates possible recurrent laryngeal nerve damage, which can affect vocal cord function.

---

❌ Why not the others?

• Supine position with no pillows – Incorrect. The client should be in semi-Fowler’s to reduce neck strain and swelling.

• Monitor VS for thyroid storm – This is not typically a priority after a total thyroidectomy since the gland is removed. Thyroid storm is more of a concern before or during surgery in cases of uncontrolled hyperthyroidism.

• Encourage vigorous coughing – Avoid vigorous coughing as it increases pressure on the surgical site and risk of bleeding.

A client with known Addison’s disease arrives in the emergency department with severe hypotension, confusion, and hypoglycemia. Which interventions are priority? Select all that apply.

• Rapid infusion of IV normal saline & high-dose IV corticosteroids

• Restrict fluids to stabilize electrolyte levels

• Frequent blood pressure monitoring

• Obtain serum electrolyte and cortisol levels

• Place the client in Trendelenburg position

Answer explanation

Rationale:

The client is experiencing an Addisonian crisis (acute adrenal insufficiency), a life-threatening emergency characterized by hypotension, hypoglycemia, electrolyte imbalances, and confusion due to cortisol deficiency.

---

✅ Rapid infusion of IV normal saline

• Immediate fluid replacement is critical to correct hypovolemia and hypotension.

• Normal saline helps restore circulatory volume and BP.

✅ High-dose IV corticosteroids

• Replaces the missing cortisol, the core treatment for Addisonian crisis. IV hydrocortisone or dexamethasone is typically used.

---

❌ Restrict fluids to stabilize electrolyte levels

• Incorrect – The client is hypotensive and likely volume-depleted. Fluid restriction would worsen their condition.

---

✅ Frequent blood pressure monitoring

• Necessary to assess response to fluids and steroids.

• Hypotension can be severe and unresponsive without prompt treatment.

---

✅ Obtain serum electrolyte and cortisol levels

• Helps confirm diagnosis and guide further treatment (expect hyponatremia, hyperkalemia, low cortisol).

---

❌ Place the client in Trendelenburg position

• No longer recommended as a treatment for hypotension.

• May impair breathing and increase intracranial pressure without improving perfusion.