Galen NUR 257 | Chronic Health Alterations Exam 4 | 2026/2027
GALEN COLLEGE OF NURSING
NUR 257 - Chronic Health Alterations
Exam 4 | 2026/2027
75 Exam-Style Questions with Detailed Rationales
Complete Exam Review | Evidence-Based Practice | NGN-Aligned
Core Domains: Endocrine Disorders, Neurological Conditions, Complex Chronic Care,
Pharmacologic Management, Patient Education, Emergency Interventions,
Psychosocial Support, Legal/Ethical Practice, Interprofessional Collaboration
Exam Format: 75 Multiple-Choice Questions (Single Best Answer & SATA)
Testing Time: 90-120 Minutes | Passing Score: 75-78%
Aligned with Next Generation NCLEX (NGN) Standards and QSEN Competencies
Page 1
, Galen NUR 257 | Chronic Health Alterations Exam 4 | 2026/2027
SECTION I: Endocrine Disorders (Diabetes Mellitus, DKA/HHS, Thyroid, Adrenal, Pituitary)
1. A nurse is providing discharge teaching to a client newly diagnosed with Type 1 diabetes
mellitus. Which statement by the client indicates an understanding of the teaching?
[Single Best Answer]
A. I will stop taking insulin when I feel well.
B. I should monitor my blood glucose before meals and at bedtime.
C. I can eat whatever I want as long as I take my insulin.
D. I only need to check my blood sugar once a week.
Correct Answer: B
Rationale: In Type 1 diabetes mellitus, the pancreas produces no insulin due to autoimmune destruction of
beta cells, requiring lifelong exogenous insulin replacement. Clients must perform self-monitoring of blood
glucose (SMBG) multiple times daily—typically before meals and at bedtime—to assess glycemic control,
adjust insulin doses, and detect hypo- or hyperglycemia early. Insulin must never be discontinued, even
during periods of wellness, because the absence of endogenous insulin will rapidly lead to diabetic
ketoacidosis (DKA). Dietary management remains essential, as carbohydrate intake directly impacts blood
glucose levels. Weekly monitoring is grossly insufficient for safe management of Type 1 diabetes.
2. A client with Type 2 diabetes mellitus is prescribed metformin (Glucophage). The nurse
should instruct the client to avoid which of the following?
[Single Best Answer]
A. Aerobic exercise
B. Alcohol consumption
C. High-fiber foods
D. Taking the medication with meals
Correct Answer: B
Rationale: Metformin, a biguanide, is a first-line oral antidiabetic agent for Type 2 diabetes that
decreases hepatic glucose production and improves peripheral insulin sensitivity. A rare but serious
adverse effect is lactic acidosis, and the risk is significantly increased by alcohol consumption because
alcohol impairs hepatic function and can potentiate the accumulation of metformin-induced lactate. Clients
should be counseled to limit or avoid alcohol while taking metformin. Aerobic exercise is actually
encouraged as part of diabetes management because it improves insulin sensitivity. High-fiber foods help
stabilize blood glucose levels and are recommended. Metformin should be taken with meals to minimize
gastrointestinal side effects such as nausea and diarrhea.
3. A nurse is assessing a client admitted with diabetic ketoacidosis (DKA). Which of the
following findings would the nurse expect? Select all that apply.
[Select All That Apply]
A. Blood glucose level of 320 mg/dL
B. Kussmaul respirations
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, Galen NUR 257 | Chronic Health Alterations Exam 4 | 2026/2027
C. Decreased serum ketones
D. Fruity breath odor
E. Bradycardia
Correct Answer: A, B, D
Rationale: Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus
characterized by insulin deficiency and elevated counter-regulatory hormones (glucagon, catecholamines,
cortisol, growth hormone), leading to hyperglycemia (typically >250 mg/dL), dehydration, and metabolic
acidosis from the accumulation of ketone bodies (beta-hydroxybutyrate and acetoacetate). Kussmaul
respirations (deep, rapid breathing) represent the body’s compensatory mechanism to excrete carbon
dioxide and correct metabolic acidosis. Fruity (acetone) breath odor results from the pulmonary excretion
of ketones. Serum ketones are elevated, not decreased. Tachycardia, not bradycardia, is expected due to
volume depletion from osmotic diuresis.
4. A client with hyperosmolar hyperglycemic state (HHS) has a blood glucose of 684 mg/dL
and a serum osmolality of 330 mOsm/kg. Which intervention is the priority?
[Single Best Answer]
A. Administering intravenous regular insulin bolus
B. Initiating intravenous fluid resuscitation with 0.9% NaCl
C. Administering oral hypoglycemic agents
D. Performing a chest X-ray
Correct Answer: B
Rationale: In hyperosmolar hyperglycemic state (HHS), the priority nursing intervention is fluid
resuscitation. HHS is characterized by profound dehydration resulting from sustained osmotic diuresis in
the setting of extreme hyperglycemia (typically >600 mg/dL) without significant ketoacidosis. The mean
fluid deficit is approximately 8-12 liters. Intravenous 0.9% sodium chloride (normal saline) is the initial
fluid of choice to restore intravascular volume, improve tissue perfusion, and reduce serum osmolality.
Insulin therapy is initiated after fluid resuscitation has begun and serum potassium levels are confirmed to
be adequate, because insulin without adequate fluids can worsen hypovolemia and shift potassium
intracellularly, causing dangerous hypokalemia. Oral hypoglycemic agents are contraindicated in this
acute emergency.
5. A nurse is teaching a client with diabetes mellitus about hypoglycemia. Which
manifestations should the nurse include as early signs of hypoglycemia?
[Single Best Answer]
A. Tremors, diaphoresis, and tachycardia
B. Confusion, seizures, and loss of consciousness
C. Bradycardia, hypotension, and cool skin
D. Polyuria, polydipsia, and polyphagia
Correct Answer: A
Rationale: Hypoglycemia is defined as a blood glucose level below 70 mg/dL and can occur in clients with
diabetes due to excessive insulin, inadequate food intake, or increased physical activity. Early
manifestations of hypoglycemia are primarily adrenergic (sympathetic nervous system) in nature and
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, Galen NUR 257 | Chronic Health Alterations Exam 4 | 2026/2027
include tremors, diaphoresis, tachycardia, palpitations, anxiety, and hunger. These symptoms result from
the release of catecholamines in response to low blood glucose. Late manifestations are neuroglycopenic
and occur when the brain is deprived of glucose; these include confusion, seizures, loss of consciousness, and
even death. Polyuria, polydipsia, and polyphagia are the classic triad of hyperglycemia, not hypoglycemia.
Bradycardia and hypotension are not typical of hypoglycemic episodes.
6. A client with Type 1 diabetes mellitus reports blurred vision, fatigue, and frequent urination
over the past two weeks. The nurse understands that these findings are most likely related to
which pathophysiological mechanism?
[Single Best Answer]
A. Insulin resistance at the cellular level
B. Autoimmune destruction of pancreatic alpha cells
C. Sustained hyperglycemia and osmotic diuresis
D. Overproduction of cortisol by the adrenal glands
Correct Answer: C
Rationale: The client’s symptoms of blurred vision, fatigue, and frequent urination (polyuria) are classic
manifestations of sustained hyperglycemia in diabetes mellitus. When blood glucose exceeds the renal
threshold (approximately 180 mg/dL), the kidneys can no longer reabsorb all glucose, leading to osmotic
diuresis—excess glucose in the urine draws water with it, resulting in polyuria. This fluid loss leads to
dehydration and fatigue. Blurred vision occurs because hyperglycemia causes osmotic swelling of the lens
due to sorbitol accumulation. These findings indicate inadequate glycemic control and may signal the need
for insulin adjustment. Insulin resistance is primarily associated with Type 2 diabetes. Autoimmune
destruction targets beta cells (which produce insulin), not alpha cells (which produce glucagon). Cortisol
overproduction is associated with Cushing’s syndrome.
7. A nurse is caring for a client with Graves’ disease. Which assessment finding is most specific
to this condition?
[Single Best Answer]
A. Weight gain and cold intolerance
B. Exophthalmos (protrusion of the eyeballs)
C. Dry skin and bradycardia
D. Constipation and lethargy
Correct Answer: B
Rationale: Graves’ disease is the most common cause of hyperthyroidism and is an autoimmune disorder
in which thyroid-stimulating immunoglobulins (TSI) stimulate the thyroid gland to produce excessive
amounts of thyroid hormones (T3 and T4). The hallmark clinical finding specific to Graves’ disease is
exophthalmos—protrusion of the eyeballs due to inflammation and accumulation of glycosaminoglycans in
the retro-orbital tissues. While other symptoms of hyperthyroidism (weight loss, heat intolerance,
tachycardia, tremors, anxiety) can occur with any cause of thyrotoxicosis, exophthalmos is unique to
Graves’ disease. Weight gain, cold intolerance, dry skin, bradycardia, constipation, and lethargy are all
manifestations of hypothyroidism, which is the opposite end of the thyroid disorder spectrum.
Page 4
GALEN COLLEGE OF NURSING
NUR 257 - Chronic Health Alterations
Exam 4 | 2026/2027
75 Exam-Style Questions with Detailed Rationales
Complete Exam Review | Evidence-Based Practice | NGN-Aligned
Core Domains: Endocrine Disorders, Neurological Conditions, Complex Chronic Care,
Pharmacologic Management, Patient Education, Emergency Interventions,
Psychosocial Support, Legal/Ethical Practice, Interprofessional Collaboration
Exam Format: 75 Multiple-Choice Questions (Single Best Answer & SATA)
Testing Time: 90-120 Minutes | Passing Score: 75-78%
Aligned with Next Generation NCLEX (NGN) Standards and QSEN Competencies
Page 1
, Galen NUR 257 | Chronic Health Alterations Exam 4 | 2026/2027
SECTION I: Endocrine Disorders (Diabetes Mellitus, DKA/HHS, Thyroid, Adrenal, Pituitary)
1. A nurse is providing discharge teaching to a client newly diagnosed with Type 1 diabetes
mellitus. Which statement by the client indicates an understanding of the teaching?
[Single Best Answer]
A. I will stop taking insulin when I feel well.
B. I should monitor my blood glucose before meals and at bedtime.
C. I can eat whatever I want as long as I take my insulin.
D. I only need to check my blood sugar once a week.
Correct Answer: B
Rationale: In Type 1 diabetes mellitus, the pancreas produces no insulin due to autoimmune destruction of
beta cells, requiring lifelong exogenous insulin replacement. Clients must perform self-monitoring of blood
glucose (SMBG) multiple times daily—typically before meals and at bedtime—to assess glycemic control,
adjust insulin doses, and detect hypo- or hyperglycemia early. Insulin must never be discontinued, even
during periods of wellness, because the absence of endogenous insulin will rapidly lead to diabetic
ketoacidosis (DKA). Dietary management remains essential, as carbohydrate intake directly impacts blood
glucose levels. Weekly monitoring is grossly insufficient for safe management of Type 1 diabetes.
2. A client with Type 2 diabetes mellitus is prescribed metformin (Glucophage). The nurse
should instruct the client to avoid which of the following?
[Single Best Answer]
A. Aerobic exercise
B. Alcohol consumption
C. High-fiber foods
D. Taking the medication with meals
Correct Answer: B
Rationale: Metformin, a biguanide, is a first-line oral antidiabetic agent for Type 2 diabetes that
decreases hepatic glucose production and improves peripheral insulin sensitivity. A rare but serious
adverse effect is lactic acidosis, and the risk is significantly increased by alcohol consumption because
alcohol impairs hepatic function and can potentiate the accumulation of metformin-induced lactate. Clients
should be counseled to limit or avoid alcohol while taking metformin. Aerobic exercise is actually
encouraged as part of diabetes management because it improves insulin sensitivity. High-fiber foods help
stabilize blood glucose levels and are recommended. Metformin should be taken with meals to minimize
gastrointestinal side effects such as nausea and diarrhea.
3. A nurse is assessing a client admitted with diabetic ketoacidosis (DKA). Which of the
following findings would the nurse expect? Select all that apply.
[Select All That Apply]
A. Blood glucose level of 320 mg/dL
B. Kussmaul respirations
Page 2
, Galen NUR 257 | Chronic Health Alterations Exam 4 | 2026/2027
C. Decreased serum ketones
D. Fruity breath odor
E. Bradycardia
Correct Answer: A, B, D
Rationale: Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus
characterized by insulin deficiency and elevated counter-regulatory hormones (glucagon, catecholamines,
cortisol, growth hormone), leading to hyperglycemia (typically >250 mg/dL), dehydration, and metabolic
acidosis from the accumulation of ketone bodies (beta-hydroxybutyrate and acetoacetate). Kussmaul
respirations (deep, rapid breathing) represent the body’s compensatory mechanism to excrete carbon
dioxide and correct metabolic acidosis. Fruity (acetone) breath odor results from the pulmonary excretion
of ketones. Serum ketones are elevated, not decreased. Tachycardia, not bradycardia, is expected due to
volume depletion from osmotic diuresis.
4. A client with hyperosmolar hyperglycemic state (HHS) has a blood glucose of 684 mg/dL
and a serum osmolality of 330 mOsm/kg. Which intervention is the priority?
[Single Best Answer]
A. Administering intravenous regular insulin bolus
B. Initiating intravenous fluid resuscitation with 0.9% NaCl
C. Administering oral hypoglycemic agents
D. Performing a chest X-ray
Correct Answer: B
Rationale: In hyperosmolar hyperglycemic state (HHS), the priority nursing intervention is fluid
resuscitation. HHS is characterized by profound dehydration resulting from sustained osmotic diuresis in
the setting of extreme hyperglycemia (typically >600 mg/dL) without significant ketoacidosis. The mean
fluid deficit is approximately 8-12 liters. Intravenous 0.9% sodium chloride (normal saline) is the initial
fluid of choice to restore intravascular volume, improve tissue perfusion, and reduce serum osmolality.
Insulin therapy is initiated after fluid resuscitation has begun and serum potassium levels are confirmed to
be adequate, because insulin without adequate fluids can worsen hypovolemia and shift potassium
intracellularly, causing dangerous hypokalemia. Oral hypoglycemic agents are contraindicated in this
acute emergency.
5. A nurse is teaching a client with diabetes mellitus about hypoglycemia. Which
manifestations should the nurse include as early signs of hypoglycemia?
[Single Best Answer]
A. Tremors, diaphoresis, and tachycardia
B. Confusion, seizures, and loss of consciousness
C. Bradycardia, hypotension, and cool skin
D. Polyuria, polydipsia, and polyphagia
Correct Answer: A
Rationale: Hypoglycemia is defined as a blood glucose level below 70 mg/dL and can occur in clients with
diabetes due to excessive insulin, inadequate food intake, or increased physical activity. Early
manifestations of hypoglycemia are primarily adrenergic (sympathetic nervous system) in nature and
Page 3
, Galen NUR 257 | Chronic Health Alterations Exam 4 | 2026/2027
include tremors, diaphoresis, tachycardia, palpitations, anxiety, and hunger. These symptoms result from
the release of catecholamines in response to low blood glucose. Late manifestations are neuroglycopenic
and occur when the brain is deprived of glucose; these include confusion, seizures, loss of consciousness, and
even death. Polyuria, polydipsia, and polyphagia are the classic triad of hyperglycemia, not hypoglycemia.
Bradycardia and hypotension are not typical of hypoglycemic episodes.
6. A client with Type 1 diabetes mellitus reports blurred vision, fatigue, and frequent urination
over the past two weeks. The nurse understands that these findings are most likely related to
which pathophysiological mechanism?
[Single Best Answer]
A. Insulin resistance at the cellular level
B. Autoimmune destruction of pancreatic alpha cells
C. Sustained hyperglycemia and osmotic diuresis
D. Overproduction of cortisol by the adrenal glands
Correct Answer: C
Rationale: The client’s symptoms of blurred vision, fatigue, and frequent urination (polyuria) are classic
manifestations of sustained hyperglycemia in diabetes mellitus. When blood glucose exceeds the renal
threshold (approximately 180 mg/dL), the kidneys can no longer reabsorb all glucose, leading to osmotic
diuresis—excess glucose in the urine draws water with it, resulting in polyuria. This fluid loss leads to
dehydration and fatigue. Blurred vision occurs because hyperglycemia causes osmotic swelling of the lens
due to sorbitol accumulation. These findings indicate inadequate glycemic control and may signal the need
for insulin adjustment. Insulin resistance is primarily associated with Type 2 diabetes. Autoimmune
destruction targets beta cells (which produce insulin), not alpha cells (which produce glucagon). Cortisol
overproduction is associated with Cushing’s syndrome.
7. A nurse is caring for a client with Graves’ disease. Which assessment finding is most specific
to this condition?
[Single Best Answer]
A. Weight gain and cold intolerance
B. Exophthalmos (protrusion of the eyeballs)
C. Dry skin and bradycardia
D. Constipation and lethargy
Correct Answer: B
Rationale: Graves’ disease is the most common cause of hyperthyroidism and is an autoimmune disorder
in which thyroid-stimulating immunoglobulins (TSI) stimulate the thyroid gland to produce excessive
amounts of thyroid hormones (T3 and T4). The hallmark clinical finding specific to Graves’ disease is
exophthalmos—protrusion of the eyeballs due to inflammation and accumulation of glycosaminoglycans in
the retro-orbital tissues. While other symptoms of hyperthyroidism (weight loss, heat intolerance,
tachycardia, tremors, anxiety) can occur with any cause of thyrotoxicosis, exophthalmos is unique to
Graves’ disease. Weight gain, cold intolerance, dry skin, bradycardia, constipation, and lethargy are all
manifestations of hypothyroidism, which is the opposite end of the thyroid disorder spectrum.
Page 4
