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CCRN PRACTICE QUESTIONS – ENDOCRINE
VERIFIED CORRECT ANSWERS 2025 GRADED
A+.
Which of the following is true regarding the difference between diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS)? a. There is less dehydration in HHS than there is in DKA. b. DKA occurs in type 1 diabetes mellitus (DM), and HHS occurs in type 2 DM. c. Less insulin usually is needed in HHS than is needed in DKA. d. Potassium is low in DKA and normal or high in HHS. - correct answer>>Correct answer: b Rationale: Patients with HHS have more dehydration and azotemia than patients with DKA. Although patients with HHS have higher serum glucose levels, it takes less insulin to normalize their glucose metabolism. Patients with DKA have elevated potassium levels because they are acidotic. Patients with HHS are not acidotic, and their potassium levels are not skewed by acidosis. Therefore they have a normal or low (because of loss in diuresis) potassium. Patients with type 1 DM develop DKA, but patients with type 2 DM develop HHS. Test-Taking Strategy: Always be logical. Remember that insulin need is absolute in type 1 DM and that the hyperglycemia that occurs in DKA is accompanied by acidosis because gluconeogenesis occurs with liberation and incomplete breakdown of free fatty acids. The insulin deficiency in type 2 DM is relative. In the hyperglycemia that occurs in HHS, there is enough insulin to prevent gluconeogenesis and therefore acidosis. Choose option b as the correct answer.
Patients with hyperglycemic hyperosmolar state (HHS) are susceptible to thrombosis and pulmonary embolism because: a. they are dehydrated. b. they are hyperglycemic. c. they have vascular changes. d. they are immobile - correct answer>>Correct answer: a Rationale: Patients with HHS are extremely dehydrated, which makes them hypercoagulable. Test-Taking Strategy: Imagine the diuresis that would be caused by a serum glucose of 1100 mg/dL (and this is average in HHS; some patients have even higher serum glucose levels). This causes a tremendous osmotic diuresis and dehydration. Dehydration causes hypercoagulability and predisposes the patient to thrombosis and pulmonary embolism. Remember that hypercoagulability is one component of Virchow's triad. Choose option a. A newly diagnosed diabetic patient who is on insulin complains of feeling nervous and afraid that she is going to faint. She is diaphoretic and has a tremor. Nursing actions might include all of the following except: a. giving her a glass of juice to drink. b. administering 50% dextrose in water (D50W) if she cannot drink. c. administering potassium. d. checking her serum glucose. - correct answer>>Correct answer: c Rationale: Although her clinical signs and symptoms indicate that she is hypoglycemic, a serum glucose level would confirm hypoglycemia. She should be given 10 to 15 g of carbohydrates. If she is unconscious, she should be given one ampule of D50W. Potassium should be checked, especially if you have given her dextrose intravenously, because potassium moves into the cell with insulin and dextrose. Dextrose should not be given without knowledge of the potassium level. Test-Taking Strategy: Because her clinical symptoms indicate that she is hypoglycemic, any action with glucose in it probably would be appropriate. This is an except question, so the answer is except option c.
Rationale: Diabetes insipidus is due to a decreased amount or effect of antidiuretic hormone. Without the effect of antidiuretic hormone, massive diuresis occurs. Because antidiuretic hormone causes the retention of water but not the retention of sodium, urine in diabetes insipidus is low in sodium and specific gravity. The sodium concentrates in the blood, so hypernatremia and hyperosmolality occur. Test-Taking Strategy: Always start with what you know. You know that diabetes insipidus causes polyuria, so eliminate options a and c. Next, remember that the patient becomes very dehydrated, so serum osmolality would be high. That is as far as you need to go. Choose option b A patient is receiving morning and evening doses of NPH Humulin. He refused his nighttime snack last night and is hyperglycemic this morning. The physician has requested a 3 AM serum glucose to confirm Somogyi phenomenon. The physiologic reason for the Somogyi phenomenon is: a. counterregulatory hormones. b. insulin resistance. c. dehydration after hyperglycemia. d. hypoglycemia after dehydration - correct answer>>Correct answer: a Rationale: Insulin resistance does not occur with Humulin as it did with pork or beef insulin. Dehydration is not a component of Somogyi phenomenon. Remember that Somogyi phenomenon is suspected when the morning serum glucose is unexpectedly elevated. This hyperglycemia is due to the release of counterregulatory hormones (epinephrine, glucagon, glucocorticoids, and growth hormone) after hypoglycemia. Test-Taking Strategy: None Which of the following would be inappropriate for a patient with diabetic ketoacidosis? a. Rapid infusion of normal saline (NS) b. Regular insulin intravenous injection followed by infusion
c. Potassium replacement d. 50 mL of 50% dextrose in water (D50W) if blood glucose falls to less than 250 mg/dL - correct answer>>Correct answer: d Rationale: Dextrose should be added to the NS or ½NS (depending on serum osmolality) when the blood glucose decreases to less than 250 mg/dL, but only in a concentration of 5% (D5W). D50W would be too much and would cause more hyperglycemia.
- Taking Strategy: None A friend brings a 22-year-old woman to the emergency department. She says that the patient is a diabetic and takes insulin. She reports that they were out exercising and the patient became agitated and argumentative and then lost consciousness. The friend called an ambulance. When you measure the serum glucose, it is 25 mg/dL. What should you do? a. Administer 25 g of glucose intravenously. b. Administer 12.5 g of glucose intravenously. c. Administer 10 g of glucose by mouth. d. Administer glucagon intramuscularly. - correct answer>>Correct answer: a Rationale: She is unconscious, so 25 g should be given. Because she cannot take anything by mouth, it should be given intravenously. D50W is 50% dextrose, which has 50 g/100 mL. An ampule is 50 mL, so it supplies 25 g of dextrose. Glucagon is a hormone that causes the body to mobilize glucose. Glucagon is an indirect way to increase the serum glucose and will take longer than giving the glucose directly. Test-Taking Strategy: None A 75-year-old woman is admitted with pneumonia. She is started on enteral feedings. Over the last several hours, her urine output has been increasing. Which laboratory test is most important at this time? a.
c. Specific gravity of urine 1. d. Serum sodium 165 mEq/L - correct answer>>Correct answer: d Rationale: Diabetes insipidus is characterized by diuresis of hypotonic urine. Urine output increases, specific gravity of urine decreases, serum osmolality increases, and serum sodium increases. Test-Taking Strategy: None A 55-year-old man has been prescribed acarbose (Precose) to control his type 2 diabetes mellitus. When you teach him about the drug, which of the following would you tell him to use for hypoglycemia? a. Orange juice b. Fresh fruit c. Cheese and crackers d. Glucose tablets - correct answer>>Correct answer: d Rationale: Acarbose (Precose) is an alpha-glucosidase inhibitor. It delays digestion of ingested carbohydrates, resulting in a smaller rise in serum glucose after meals. Simple sugar must be given for hypoglycemia. The patient should be instructed to carry glucose tablets and to use them for indications of hypoglycemia. Test-Taking Strategy: None Which of the following is the appropriate first intervention for someone with symptoms of hypoglycemia? a. Immediately replace fluids. b. Assess the patient's glucose level. c. Assess and adjust the patient's insulin level. d. Administer three glucose tablets. - correct answer>>Correct answer: b Rationale: First confirm that there is hypoglycemia before initiating treatment. Test-Taking Strategy: None
A 34-year-old woman is admitted to the critical care unit with a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH) secondary to pituitary adenoma. She is lethargic and urine output is less than 10 mL/hr. What laboratory data would the nurse expect to find in this patient? a. Urine specific gravity less than 1. b. Serum osmolality greater than 295 mOsm/L c. Serum sodium less than 125 mEq/L d. Low serum levels of ADH - correct answer>>Correct answer: c Rationale: SIADH is due to an increase in the amount or effect of ADH. Antidiuretic hormone will cause the renal tubule to hold onto water. Water intoxication occurs and serum sodium decreases due to hemodilution. Test-Taking Strategy: ADH levels are high, so eliminate option d. Also remember that most tumors hypersecrete and this patient has an adenoma (glandular tumor). Too much of antidiuresis causes water retention; urine specific gravity is high and serum osmolality is low, so eliminate a and b. Sodium is decreased due to hemodilution. Choose c. Which of the following would be contraindicated for a patient with SIADH? a. Seizure precautions b. Fluid restrictions c. D5W at 50 mL/hr d. Diuretics - correct answer>>Correct answer: c Rationale: D5W is essentially water after the body has metabolized the dextrose. It will add to the water intoxication even in the small amount identified (50 mL/hr). Fluid restrictions to less than 1000 mL/24 hr and seizure precautions are important aspects of care for this patient due to the serious nature of the neurologic effects of hyponatremia. Seizure precautions should be instituted for patients with sodium levels of less than 125 mEq/L. Diuretics may also be administered to eliminate excess volume. Test-Taking Strategy: Remember that this question is negatively stated. You want to choose what not to do. Note that D5W is water with dextrose. This
sodium causing dilutional hyponatremia. This is sometimes referred to as hypervolemic hyponatremia. Test-Taking Strategy: SIADH is an excess of ADH or an increase in the effect of ADH. ADH does not directly affect potassium, so eliminate option a. SIADH causes water intoxication and decreased serum osmolality, so eliminate option c. The serum glucose is not affected in SIADH, so eliminate option d. The sodium is diluted by so much water, so serum sodium is decreased. Choose option b. Treatment of SIADH might include all of the following except: a. hypertonic saline and diuretics. b. vasopressin in oil IM. c. fluid restriction. d. lithium. - correct answer>>Correct answer: b Rationale: Vasopressin is another name for ADH. This would certainly worsen SIADH, which is increased amount or action of ADH. Fluid restriction is the usual first treatment for SIADH. Diuretics may be used to eliminate excess water. Hypertonic saline is used if hyponatremia is at dangerously low levels. Lithium is used especially for ectopic ADH because it interferes with the action of ADH at the renal tubule. Test-Taking Strategy: Note that this question is negatively stated. The question asks what you would not do for this patient. You would not give a patient with increased ADH levels more ADH. Vasopressin (option b) is ADH. A patient with small cell carcinoma of the lung has developed syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would monitor this patient closely for: a. tetany. b. shock. c. seizures. d. hypoglycemia. - correct answer>>Correct answer: c Rationale: Hyponatremia may lead to cerebral edema and seizures. TestTaking Strategy: Tetany is associated with low calcium or magnesium
levels, so eliminate option a. This patient has increased fluid volume, including in the vascular space, so eliminate option b. ADH does not affect serum glucose levels, so eliminate option d. Choose option c. A patient with small cell (i.e., oat cell) carcinoma develops SIADH. The physician prescribes demeclocycline. What does this drug do in SIADH? a. Blocks the action of ADH or ADH-like hormone on the renal tubule b. Decreases the release of ADH from the posterior pituitary c. Decreases the release of an ADH-like hormone associated with the malignancy d. Increases the retention of sodium by the renal tubule - correct answer>>Correct answer: a Rationale: SIADH frequently occurs in oat cell carcinoma of the lung as well as other malignancies. This is an example of ectopic ADH because the tumor secretes a substance that acts like ADH. Demeclocycline blocks the action of ADH or this ADH-like substance on the renal tubes, allowing diuresis to occur. Test-Taking Strategy: None A patient has had a dramatic decrease in his urine output and the specific gravity of the urine is 1.04. Which of the following findings would support the suspicion that this patient has developed SIADH? a. Hyperkalemia b. Hyponatremia c. Hyperglycemia d. Hyperosmolality - correct answer>>Correct answer: b Rationale: SIADH is an increase in ADH and water intoxication. The increase in antidiuretic (antidiuresis) hormone causes the retention of water, dilution of sodium, and serum hypoosmolality. Test-Taking Strategy: Remember that ADH causes the retention of water rather than sodium and water such as aldosterone. The retention of water without the retention of sodium causes a dilutional hyponatremia.
c. Heart failure d. Lactic acidosis - correct answer>>Correct answer: d Rationale: These are symptoms that may indicate the serious adverse effect of metformin of lactic acidosis and rhabdomyolysis. Test-Taking Strategy: Hypoglycemia can cause weakness. Abdominal pain is associated with metabolic acidosis which can occur with hyperglycemia (DKA) and severe heart failure. Weakness and fatigue do occur with heart failure. The symptom that is inconsistent with both hyperglycemia and heart failure is muscle pain. This would lead you to rhabdomyolysis and the resultant lactic acidosis. A 30-year-old woman with type 1 diabetes mellitus is admitted with complaints of nausea, vomiting, and diarrhea. She has not been eating and she has not taken her insulin for 2 days. She has been taking glargine (Lantus) 45 units daily and aspart (NovoLog) with meals (5 units with breakfast, 8 units with lunch, and 10 units with dinner). Her blood pressure is 92/54 mm Hg, heart rate is 112/min, respiratory rate is 40/min and deep, temperature is 99.2º F. Laboratory results include serum glucose 420 mg/dL, pH 7.1, potassium 4.5 mEq/L, and serum osmolality 320 mOsm/kg. She is not responding to voice but she does respond to pain. Her mucous membranes are dry and urine output is scant and concentrated. What is the priority of care for this patient at this time? a. Reduction of serum glucose b. Replacement of fluid and electrolytes c. Ventilatory support d. Prevention of seizures - correct answer>>Correct answer: b Rationale: The hypotension, tachycardia, dry mucous membranes, and oliguria are all indications that she is severely dehydrated. Also, considering her degree of acidosis, her potassium will fall to approximately 3 mg/dL. The other electrolyte likely to need replacement is phosphorus. This is why KCl and KPO4 are frequently used for potassium replacement.
Test-Taking Strategy: Remember that people do not die from hyperglycemia, but they do die from hypovolemia, and this patient is presenting with indications of significant dehydration. A 30-year-old woman with type 1 diabetes mellitus is admitted with complaints of nausea, vomiting, and diarrhea. She has not been eating and she has not taken her insulin for 2 days. She has been taking glargine (Lantus) 45 units daily and aspart (NovoLog) with meals (5 units with breakfast, 8 units with lunch, and 10 units with dinner). Her blood pressure is 92/54 mm Hg, heart rate is 112/min, respiratory rate is 40/min and deep, temperature is 99.2º F. Laboratory results include serum glucose 420 mg/dL, pH 7.1, potassium 4.5 mEq/L, and serum osmolality 320 mOsm/kg. She is not responding to voice but she does respond to pain. Her mucous membranes are dry and urine output is scant and concentrated. A gradual reduction in serum glucose is planned to prevent what serious complication? a. Pulmonary edema b. Cerebral edema c. Acute kidney injury d. Acute pancreatitis - correct answer>>Correct answer: b Rationale: The goal is to reduce the serum glucose by 50-100 mg/dL/hr to prevent cerebral edema. When the serum glucose is rapidly reduced, it reduces the intravascular osmolality so that fluid moves into the more hypertonic brain cells. Test-Taking Strategy: Consider the effects of high or low serum glucose and note that the brain is much more likely to be affected than the lung, kidney, or pancreas, so choose option b. A 30-year-old woman with type 1 diabetes mellitus is admitted with complaints of nausea, vomiting, and diarrhea. She has not been eating and she has not taken her insulin for 2 days. She has been taking glargine (Lantus) 45 units daily and aspart (NovoLog) with meals (5 units with breakfast, 8 units with lunch, and 10 units with dinner). Her blood pressure
insulin administration. Test-Taking Strategy: Notice from the case study that this insulin is given with meals, so choose the option that is a very short time span, option a. Which laboratory values would differentiate diabetic ketoacidosis (DKA) from a hyperosmolar hyperglycemic state (HHS)? a. Serum glucose of 600 mg/dL b. Serum potassium of 4 mEq/L c. Positive serum ketones d. Serum osmolality of 320 mOsm/L - correct answer>>Correct answer: c Rationale: In DKA there is an absolute insulin deficiency that causes glycogenolysis and gluconeogenesis. The gluconeogenesis causes the incomplete breakdown of free fatty acids, which results in ketones in the blood and urine. In HHS, there is a relative insulin deficiency that causes glycogenolysis but does not cause gluconeogenesis. Therefore tests for ketones are positive in DKA but typically negative in HHS. Test-Taking Strategy: A serum glucose of 600 mg/dL is abnormal but could be due to DKA or HHS. A serum potassium of 4 mEq/L could be seen in DKA or HHS. Elevated serum osmolality of 320 mOsm/L could be seen in DKA or HHS and is due to dehydration. Only the serum ketones distinguish between the two hyperglycemic crises. A patient with type 1 diabetes mellitus is discharged after myocardial infarction. When teaching the patient about his medications, it is important to inform him that which of the following medications would prevent the early symptoms of hypoglycemia? a. Verapamil (Calan) b. Diazepam (Valium) c. Metoprolol (Lopressor) d. Humulin insulin - correct answer>>Correct answer: c Rationale: The early symptoms of hypoglycemia are mediated by the sympathetic nervous system. Sympathetic blocking agents would block
these symptoms. Metoprolol (Lopressor) is a beta-blocker, which would block the tachycardia, nervousness, and diaphoresis indicative of early hypoglycemia. Test-Taking Strategy: Think "prevent equals block." Option a is a calcium channel blocker, and option c is a beta-blocker. Remember that beta in beta-blocker refers to the receptors of the sympathetic nervous system and that the early indications of hypoglycemia are sympathetic nervous system symptoms. Choose option c A patient received Humulin NPH insulin at 7 AM. He was nauseated and vomiting at lunchtime and did not eat. It is now 3 PM. What are the early signs of hypoglycemia for which the nurse should monitor? a. Decreased skin turgor; abdominal pain; fever b. Tachycardia; tachypnea; diaphoresis c. Thirst; hypotension; fruity odor to breath d. Flushed skin; confusion; rapid, deep breathing - correct answer>>Correct answer: b Rationale: The early signs of hypoglycemia are mediated by the sympathetic nervous system, which acts to mobilize glucose stores. Later signs of hypoglycemia are related to low glucose levels in the brain (neuroglycopenia). Test-Taking Strategy: Remember that sympathetic nervous system innervation occurs in any physiologic stressor. Because the question says "early," choose the option that identifies sympathetic nervous system signs. Choose option b. A patient received Humulin NPH insulin at 7 AM. He was nauseated and vomiting at lunchtime and did not eat. If this patient develops manifestations of hypoglycemia, treatment would include: a. 25 mL of 50% dextrose in water (D50W). b. glucagon intramuscularly.
treated with insulin therapy and rehydration. Sodium bicarbonate generally is reserved for pH of 7 or less. Dextrose should be added to the intravenous solution when the serum glucose is less than 250 mg/dL. The serum potassium is normal on admission only because the patient is acidotic and potassium is shifted out of the cell and into the serum. As soon as the pH is corrected, the potassium will shift back into the cell and the serum potassium will drop and need to be replaced. As the serum glucose comes down, the insulin infusion should be adjusted. Test-Taking Strategy: The pH is very close to normal, and sodium bicarbonate is reserved for severely acidotic states A patient had a craniotomy 2 days ago for removal of a tumor. He is awake and talking to the nurse and demonstrates no neurologic deficit. Blood pressure is 110/80 mm Hg, pulse is 92 beats/min, and respiratory rate is 22 breaths/min. Urine outputs have been approximately 60 mL/hr over the last 2 days, but he has had a recent change. He has had 300 to 400 mL/hr of urine output over the last several hours. The urine has a specific gravity of 1.002. The nurse checks his serum glucose and finds that it is 100 mg/dL. The nurse should suspect: a. diabetic ketoacidosis. b. syndrome of inappropriate antidiuretic hormone (SIADH). c. acute adrenal crisis. d. diabetes insipidus. - correct answer>>Correct answer: d Rationale: The classic sign of diabetes insipidus is diuresis of very dilute urine. The normal serum glucose indicates that this diuresis is not being caused by hyperglycemia. Test-Taking Strategy: Eliminate option a because the serum glucose is normal. Eliminate option b because SIADH causes decreased amounts of urine with high urine specific gravity. Aldosterone is the problem in acute adrenal crisis (option c), and the diuresis that occurs is isotonic. This urine is extremely hypotonic. Remember that the specific gravity of water is 1.000.
This urine is much like water because of the inability of the kidney to concentrate it as a result of a deficiency of antidiuretic hormone. Choose option d A patient had a craniotomy 2 days ago for removal of a tumor. He is awake and talking to the nurse and demonstrates no neurologic deficit. Blood pressure is 110/80 mm Hg, pulse is 92 beats/min, and respiratory rate is 22 breaths/min. Urine outputs have been approximately 60 mL/hr over the last 2 days, but he has had a recent change. He has had 300 to 400 mL/hr of urine output over the last several hours. The urine has a specific gravity of 1.002. The nurse checks his serum glucose and finds that it is 100 mg/dL. The nurse would expect the following osmolality of the urine and serum: a. Both are elevated. b. Both are decreased. c. Urine osmolality is decreased, and serum osmolality is increased. d. Urine osmolality is increased, and serum osmolality is decreased. - correct answer>>Correct answer: c Rationale: The dilute urine has a low osmolality, and as the patient becomes increasingly dehydrated, the serum osmolality will be increased. Test-Taking Strategy: Remember that osmolality is a reflection of solutes in solution. This patient is losing more water than sodium, so the urine osmolality will be low, but the sodium left in the blood will make the serum osmolality high. A patient had a craniotomy 2 days ago for removal of a tumor. He is awake and talking to the nurse and demonstrates no neurologic deficit. Blood pressure is 110/80 mm Hg, pulse is 92 beats/min, and respiratory rate is 22 breaths/min. Urine outputs have been approximately 60 mL/hr over the last 2 days, but he has had a recent change. He has had 300 to 400 mL/hr of urine output over the last several hours. The urine has a specific gravity of 1.002. The nurse checks his serum glucose and finds that it is 100 mg/dL.
