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TEST-TAKING HINT:White girls sometimes enter puberty as early as 7 years of age. This is rare, however, and the extent of her pubertal development should prompt concern.

4. 1. Although monitoring fluid intake is neces- sary, the child is on fluid restriction, and the amount of intake will be prescribed.

2. It is crucial to monitor and record urine output. The infant with DI has hypose- cretion of ADH, and fluid restriction has little effect on urine formation. This in- fant is at risk for dehydration and for fluid and electrolyte imbalances.

3. It is a basic part of assessing the infant with fluid restriction to monitor skin turgor and the appearance of the mucous membranes, but they are not an absolute determination of overall well-being.

4. It is a basic part of assessing the infant to check pulse and temperature (the infant can become very hyperthermic), but neither would be an absolute indicator of well-being. TEST-TAKING HINT:DI results from pituitary dysfunction. The posterior pituitary targets the renal tubules and acts on the distal and collecting tubules to make them permeable to water, thus increasing resorption and decreasing excretion of urine.

5. 1. Children with Graves disease have voracious appetites and lose weight. 2. Encouraging school and continuation of

typical activities is better in terms of long- term management. Gym class and after- school sports should be restricted until the child is euthyroid.

3. Graves disease may go into remission after 2 or 3 years; there are some children, however, for whom it does not.

4. Because the child is 12 years old, en- couraging responsibility for health care is important. The child still needs family involvement and ongoing supervision but should not be completely dependent on family for care.

TEST-TAKING HINT:The age of the patient is the key to answering the question.

6. 1. Hashimoto thyroiditis is a term that refers to hypothyroid disease. Laboratory tests would reveal a high TSH level.

2. Graves disease is hyperthyroidism and presents with low TSH levels, weight loss, and excessive nervousness. 1. 1. One would not be able to determine if

measuring was incorrect at a previous visit. 2. Expected adult height can be determined

using a formula that takes into account the parents’ height and can be calculated at any visit.

3. Height velocity is the most important aspect of a growth evaluation and can demonstrate deceleration in growth if it is present.

4. The dose of growth hormone replacement medication is based on weight.

TEST-TAKING HINT:The key point is the third visit. The HCP is interested in height velocity over time. The need for multiple measurements ensures that there is a measurable growth delay.

2. 1. Growth hormone levels elevate during sleep but cannot be used to determine a definitive diagnosis.

2. Exercise increases growth hormone secre- tion but cannot be used for definitive diagnosis.

3. Screening tests assist in determining in which direction further studies should be done.

4. The need for additional testing requires explanation. The abnormal IGF-1 and insulin-like growth factor binding pro- tein require a definitive diagnosis when the levels are either abnormally high or low. Very young children do not secrete adequate levels of growth hormone to measure accurately and thus require challenge/stimulation testing.

TEST-TAKING HINT:The test taker should know that definitive diagnosis requires that more specific testing be done.

3. 1. Although girls in the United States mature earlier than in previous decades, the lowest age at which puberty is considered normal is 7 years for white girls and 6 years for African American girls.

2. Dressing and acting appropriately for her chronological age should be encour- aged for the well-being of the child.

3. Although she is fertile if she is pubescent, it is not developmentally necessary to con- sider the use of birth control at this time. 4. The estrogen that is produced during

puberty does assist in the closure of the epiphyseal plates. With proper medication management, however, the estrogen will be suppressed, and she will continue to grow.

2. Children should wear MedicAlert tags as soon as they are diagnosed.

3. Explaining that DI is different from DM is crucial to the parents’ under- standing of the management of the dis- ease. DI is a rare condition that affects the posterior pituitary gland, whereas DM is a more common condition that affects the pancreas.

4. Children with DI do not grow out of their condition and will require close medical management and medications for the rest of their lives.

TEST-TAKING HINT:The term “diabetes” is associated with DM. As DI is an uncom- mon condition that is treated differently, families may easily confuse it with the more common condition DM.

10. 1. Bone age is a method of assessing skeletal maturity and does not give a diagnosis. 2. The child with a delayed bone age may

continue to grow. In many children with a delayed bone age, medication is required to help them continue to grow.

3. The bone age is a method of evaluating the epiphyseal growth centers of the bone using standardized, age- appropriate tables.

4. A bone age that is not delayed in a child of short stature is more concerning than if the growth were delayed. This means that further testing and evaluation are needed if the growth delay is to be reversed. TEST-TAKING HINT:Explaining a bone age

film clarifies for the family why the test is needed.

11. 1. Oily skin is not associated with a low serum thyroxine level. It is more consistent with hyperthyroidism. 2. Pale, thickened patches of skin are not

associated with hypothyroidism.

3. Sunken eyes and thickened hair are not associated with hypothyroidism, in which the hair is more often thin.

4. Myxedema, associated with low serum thyroxine and raised thyrotropin levels, is characteristic of hypothyroid dys- function and presents with swelling or puffiness of the limbs and face, sparse hair, and very dry skin. These signs may be accompanied by slowness of movements and mental dullness.

TEST-TAKING HINT:Describing various assessments is integral to charting accurately. Myxedema is a term used to describe hypothyroid skin.

3. Hypothyroidism is accompanied by a high TSH level.

4. Juvenile autoimmune thyroiditis is a term referring to hypothyroid disease. Labora- tory tests would reveal a high TSH level. TEST-TAKING HINT:The clues to the answer are the low TSH level and the child’s symptoms.

7. 1. The baby has hypocalcemia and is being treated for this condition by the team. This should be reviewed with the family.

2. Vitamin D toxicity is a serious conse- quence of therapy and should be the top priority in teaching.

3. Reminding the family to give the medica- tion as prescribed is helpful and should be a basic part of discharge care, but it is not the most important information.

4. Giving the family the phone number for calling the clinic is part of basic care for discharge to home, but it is not the most important information.

TEST-TAKING HINT:Going over the side

effects and risks of vitamin D treatment educates the family about what to watch for when giving the new medications.

8. 1. The most common causes of secondary hyperparathyroidism are chronic renal disease and anomalies of the urinary tract. Blood studies indicate very high levels of calcium because the kidney is unable to process it.

2. Renal impairment causes phosphorus levels to become very high, and patients in renal failure are often put on low-phosphorus diets to control the levels.

3. Massive doses of vitamin D are utilized to help improve the calcium levels in the bloodstream. Vitamin D toxicity has symp- toms of weakness, vomiting, and diarrhea. 4. Aluminum hydroxide keeps phosphorus

mobilized so it can be excreted.

TEST-TAKING HINT:CRF is caused by the kidney’s inability to process waste and ex- cess minerals. Review which substances in excess cause which symptoms.

9. 1. Training two caretakers in the administra- tion of the vasopressin reinforces the im- portance of the need to give the medication and ensures that medication can be given when the primary caretaker is unable to administer it. For someone on long-term injectable medication, two people need to know how to administer it for the above reason.

12. 1. Initially, in the ED, the child will be given an IV line, vital signs will be taken frequently, and seizure precau- tions will be taken.

2. The child will be sent to the intensive care unit after being stabilized.

3. When children start to recover from an adrenocortical crisis, their progress is often very rapid, within 24 hours. 4. The child will present with headache,

nausea and vomiting, high fever, high blood pressure, weakness, and abdominal pain. With prompt diagnosis and the institution of cortisol and fluids, a good recovery is likely.

TEST-TAKING HINT:The question is asking for a procedure that needs explaining while in the ED.

13. 1. Keeping an extra month’s supply of all medications, along with a prefilled sy- ringe of hydrocortisone, will enable the family to treat an impending adrenal crisis before it gets severe.

2. Wearing a MedicAlert bracelet is advanta- geous and can be periodically mentioned to the family.

3. Patients will know the medication has a bit- ter taste if they are taking the medication. 4. Weight gain will occur over time, but with

good diet and adequate exercise this can be controlled.

TEST-TAKING HINT:Steroids are essential

to life, so it is important to remind the family to have extra medication on hand at all times.

14. 1. Weight gain can and should be control- lable with appropriate eating habits and adequate exercise.

2. The patient will quickly figure out that the medication tastes bitter and that the taste needs to be masked.

3. Anorexia and depression can result from taking steroids.

4. Cortisone should be taken with food to decrease gastric irritation.

TEST-TAKING HINT:Administration of cor- tisone can cause serious gastric irritation. The nurse should teach the family to an- ticipate this problem and ensure that the medicine is taken with food.

15. 1. The baby should not be discharged from the hospital without a name, and never call the infant “it.”

2. The fact that the baby is a girl may be difficult for the family to accept, but the

gender should be determined before discharge.

3. Selecting a gender-neutral name en- ables the family and child to gradually accept and adjust to the baby’s medical condition and sex.

4. Calling the infant “baby” is akin to using the word “it.”

TEST-TAKING HINT:The family needs to be given some positive way to cope with the fact that the infant’s gender is in question.

16. 1. Cortisone increases the mobilization and utilization of fatty acids for energy, but it does not influence the hypertension.

2. Cortisone suppresses the ACTH being secreted by the pituitary. Because very little, if any, cortisol is produced by the adrenal glands, the ACTH acts to in- crease cardiac activity and constrict the blood vessels, leading to hypertension.

3. The adrenal glands synthesize and secrete cortisol.

4. Cortisone suppresses lymphocytes,

eosinophils, and basophils, resulting in a de- creased inflammatory and allergic response. TEST-TAKING HINT:Regulation of hor-

monal secretions is based on negative feedback. The 21-hydroxylase deficiency is causing the adrenal gland to secrete too little cortisol. The pituitary is producing excess ACTH, trying to increase the adre- nal secretion of cortisol, and causing the hypertension.

17. 1. A pheochromocytoma is a rare tumor of the adrenal glands that secretes ex- cess catecholamines, which are a group of amines secreted in the body that act as neurotransmitters. Examples include epinephrine, norepinephrine, and dopamine. Hypertension, headache, and decreased gastric motility are common with pheochromocytoma.

2. A pheochromocytoma is a rare tumor of the adrenal glands that secretes excess cat- echolamines such as epinephrine, norepi- nephrine, and dopamine. Hypoglycemia and lethargy are not typical of pheochro- mocytoma. The excess catecholamines cause increased, not decreased, gastric motility.

3. A pheochromocytoma is a rare tumor of the adrenal glands that secretes excess cat- echolamines such as epinephrine, norepi- nephrine, and dopamine. Bradycardia, diarrhea, and weight gain are not typical of pheochromocytoma.