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Flashcards in MS - Endocrine System Deck (62):
1

A patient suspected of having acromegaly has an elevated plasma growth hormone (GH) level. In acromegaly, what would the nurse also expect the patient's diagnostic results to indicate?

a. Hyperinsulinemia
b. Plasma glucose of

d. Elevated levels of plasma insulin-like growth factor-1 (IGF-1)

A normal response to growth hormone secretion is stimulation of the liver to produce somatomedin C or insulin-like growth factor-1, which stimulates growth of bones and soft tissues.

2

During assessment of the patient with acromegaly, what should the nurse expect the patient to report?

a. Infertility
b. Dry, irritated skin
c. Undesirable changes in appearance
d. An increase in height of 2 to 3 inches a year

c. Undesirable changes in appearance

The increased production of GH in acromegaly causes an increase in thickness and width of bones and enlargement of soft tissues, resulting in marked changes in facial features, oily and coarse skin, and speech difficulties.

3

A patient with acromegaly is treated with a transsphenoidal hypophysectomy. What should the nurse do postoperatively?

a. Ensure that any clear nasal drainage is tested for glucose
b. Maintain the patient flat in bed to prevent cerebrospinal fluid (CSF) leakage.
c. Assist the patient with toothbrushing every 4 hours to keep the surgical area clean
d. Encourage deep breathing, coughing, and turning to prevent respiratory complications

a. Ensure that any clear nasal drainage is tested for glucose

A transsphenoidal hypophysectomy involves entry into the sella turcica through an incision in the upper lip ans gingiva into the floor of the nose and the sphenoid sinuses. Postoperative clear nasal drainage with glucose content indicates CSF leakage from an open connection to the brain, putting the patient at risk for meningitis. After surgery, the patient is positioned with the head elevated to avoid pressure on the sella turcica. Coughing and straining are avoided to prevent increased ICP and CSF leakage. Although mouth care is required every 4 hours, toothbrushing should not be performed because injury to the suture line may occur.

4

What findings are commonly found in a patient with a prolactinoma?

a. Gynecomastia in men
b. Profuse menstruation in women
c. Excess follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
d. Signs of increased intracranial pressure, including headache, nausea, and vomiting

d. Signs of increased intracranial pressure, including headache, nausea, and vomiting

Compression of the optic chiasm can cause visual problems as well as signs of increased ICP, including headache, nausea, and vomiting. About 30% of prolactinomas will have excess prolactin secretion with manifestations of impotence in men galactorrhea or amenorrhea in women without relationship to pregnancy, and decreased libido in both men and women. There is decreased FSH and LH

5

An African American woman with a history of breast cancer has panhypopituitarism from radiation therapy for primary pituitary tumors. Which medications should the nurse teach her about needing for the resto of her life? Select all that apply

a. Cortisol
b. Vasopressin
c. Sex hormones
d. Levothyroxine (Synthroid)
e. Growth hormone (somatropin [Omnitropel])
f. Dopamine agonists (bromocriptine [Parlodel])

a. Cortisol
b. Vasopressin
d. Levothyroxine (Synthroid)
e. Growth hormone (somatropin [Omnitropel])

With panyhypopituitarism, lifetime hormone replacement is needed for cortisol, vasopressin, thyroid, and GH. Sex hormones will not be replaced because of the patient's histroy of breast cancer. Dopamine agonists will not be used because they reduce secretion of GH, which has already been achieved with the radiation.

6

The patient is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What manifestation should the nurse expect to find?

a. Decreased body weight
b. Decreased urinary output
c. Increased plasma osmolality
d. Increased serum sodium levels

b. Decreased urinary output

With increased antidiuretic hormone (ADH), the permeability of the renal distal tubules is increased, so water is reabsorbed into circulation. Decreased output of concentrated urine with increased urine osmolality and specific gravity occur. In addition, fluid retention with weight gain, serum hypoosmolality, dilutional hyponatremia, and hypochloremia occur.

7

During the care of the patient with SIADH, what should the nurse do?

a. Monitor neurologic status at least every 2 hours
b. Teach the patient receiving tratment with diuretics to restrict sodium intake
c. Keep the head of the bed elevated to prevent antidiuretic hormone (ADH) release
d. Notify the health care provider if the patient's blood pressure decreases more than 20 mm Hg from baseline

a. Monitor neurologic status at least every 2 hours

The patient with SIADH has marked dilutional hyponatremia nd should be monitored for decreased neurologic function and seizures every 2 hours. Sodium intake is supplemented because of the hyponatremia and sodium loss caused by diuretics. ADH release is reduced by keeping the head of the bed flat to increase left atrial filling pressure A reduction in blood pressure indicates a reduction in total fluid volume and is an expected outcome of treatment.

8

A patient with SIADH is treated with water restriction. What does the patient experience when the nurse determines that treatment has been effective?

a. Increased urine output, decreased serum sodium, and increased urine specific gravity
b. Increased urine output, increased serum sodium, and decreased urine specific gravity
c. Decreased urine output, increased serum sodium, and decreased urine specific gravity
d. Decreased urine output, decreased serum sodium and increased urine specific gravity

b. Increased urine output, increased serum sodium, and decreased urine specific gravity

The patient with SIADH has water retention with hyponatremia, decreased urine output, and concentrated urine with high specific gravity. Improvement in the patient's condition is reflected by increased urine output, normalization of serum sodium, and more water in the urine, thus decreasing the specific gravity.

9

The patient with diabetes insipidus is brought to the emergency department with confusion and dehydration after excretion of a large volume of urine today even thought several liters of fluid were drunk. What is a diagnostic test that the nurse should expect to be done to help make a diagnosis?

a. Blood glucose
b. Serum sodium level
c. Urine specific gravity
d. Computed tomography (CT) of the head

c. Urine specific gravity

Patients with diabetes insipidus excrete large amounts of urine with a specific gravity of less than 1.005. Blood glucose would be tested to diagnose diabetes mellitus. The serum sodium level is expected to be low with DI but it is not a diagnostic. To diagnose central DI a water deprivation test is required. Then a CT of the head may be done to determine the cause. Nephrogenic DI is differentiated from central DI with determination of the level of ADH after an analog of ADH is given.

10

In a patient with central diabetes insipidus, what will the administration of ADH during a water deprivation test result in?

a. Decrease in body weight
b. Increase in urinary output
c. Decrease in blood pressure
d. Increase in urine osmolality

d. Increase in urine osmolality

A patient with central diabetes insipidus has a deficiency of ADH with excessive loss of water from the kidney, hypovolemia, hypernatremia nd dilute urine with a low specific gravity. When vasopressin is administered, the symptoms are reversed, with water retention, decreased urinary output that increases urine osmolality and an increase in BP

11

A patient with diabetes insipidus is treated with nasal desmopressin acetate (DDAVP). The nurse determines that the drug is not having an adequate therapeutic effect when the patient experiences.

a. headache and weight gain
b. nasal irritation and nausea
c. a urine specific gravity of 1.002
d. an oral intake greater than urinary output

c. a urine specific gravity of 1.002

Normal urine specific gravity is 1.005 to 1.025 and urine with a specific gravity of 1.002 is very dilute, indicating that there continues to be excessive loss of water and that treatment of diabetes insipidus is inadequate. Headache, weight gain and oral intake greater than urinary output are signs of volume excess that occur with overmedication. Nasal irritation and nausea may also indicate overdosage.

12

When caring for a patient with nephrogenic diabetes insipidus, what should the nurse expect the treatment to include?

a. fluid restriction
b. thiazide diuretics
c. a high-sodium diet
d. chlorpropamide (Diabinese)

b. thiazide diuretics

In nephrogenic diabetes insipidus, the kidney is unable to respond the ADH, so vasopressin or hormone analogs are not effective. Thiazide diuretics slow the glomerular filtration rate in the kidney and produce a decrease in urine output. Low sodium diets are also thought to decrease urine output. Fluids are not restricted because the patient could easily become dehydrated.

13

What characteristic is related to Hashimoto's thyroiditis?

a. Enlarged thyroid gland
b. Viral-induced hyperthyroidism
c. Bacterial or fungal infection of thyroid gland
d. Chronic autoimmune thyroiditis with antibody destruction of thyroid tissue

d. Chronic autoimmune thyroiditis with antibody destruction of thyroid tissue

In Hashimoto's thyroiditis, thyroid tissue is destroyed by autoimmune antibodies. An enlarged thyroid gland is a goiter. Viral-induced hyperthyroidism is subacute granulomatous thyroiditis. Acute thyroiditis is caused by bacterial or fungal infection

14

Which statement accurately describes Graves' disease?

a. Exopthalmos occurs in Graves disease
b. It is an uncommon form of hyperthyroidism
c. Manifestations of hyperthyroidism occur from tissue desensitization to the sympathetic nervous system
d. Diagnostic testing in the patient with Graves' disease will reveal an increased thyroid-stimulating hormone (TSH) level.

a. Exopthalmos occurs in Graves disease

Exopthalmos or protrusion of the eyeballs may occur in Graves' disease from increased fat deposits and fluid in the orbital tissues and ocular muscles, forcing the eyeballs outward. Graves' disease is the most common form of hyperthyroidism. Increased metabolic rate and sensitivity of the sympathetic nervous system lead to the clinical manifestations. TSH level is decreased in Graves' disease

15

A patient with Graves' disease asks the nurse what caused the disorder. What is the best response by the nurse?

a. "The cause of Graves' disease is not known, although it is thought to be genetic."
b. "It is usually associated with goiter formation from an iodine deficiency over long period of time."
c. "Antibodies develop against thyroid tissue and destroy it, causing a deficiency of thyroid hormones."
d. "In genetically susceptible persons, antibodies are formed that cause excessive thyroid hormone secretion."

d. "In genetically susceptible persons, antibodies are formed that cause excessive thyroid hormone secretion."

In Graves' disease, antibodies to the TSH receptor are formed, attach to the receptors, and stimulate the thyroid gland to release T3 and T4, or both, creating hyperthyroidism. The disease is not directly genetic but individuals appear to have a genetic susceptiblity to develop autoimmune antibodies. Goiter formation from insufficient iodine intake is usually associated with hypothyroidism.

16

A patient is admitted to the hospital with thyrotoxicosis. On physical assessment of the patient, what should the nurse expect to find?

a. Hoarseness and laryngeal stridor
b. Bulging eyeballs and dysrhythmias
c. Elevated temperature and signs of heart failure
d. Lethargy progressing suddenly to impairment of consciousness

c. Elevated temperature and signs of heart failure

A hyperthyroid crisis results in marked manifestations of hyperthyroidism, with sever tachycardia, heart failure, shock, hyperthermia, restlessness, irritability, abdominal pain, vomiting, diarrhea, delirium, and coma. Although exopthalamos may be present in the patient with Graves' disease, it is not a significant factor in hyperthyroid crisis. Hoarseness and laryngeal stridor are characteristic of the tetany of hypoparathyroidism and lethargy progressing to coma is characteristic of myxedema coma, a complication of hypothyroidism

17

What medication is used with thyrotoxicosis to block the effects of the sympathetic nervous stimulation of the thyroid hormones?

a. Potassium iodide
b. Atenolol (Tenormin)
c. Propylthiouracil (PTU)
d. Radioactive iodine (RAI)

b. Atenolol (Tenormin)

The B-adrenergic blocker atenolol is used to block the sympathetic nervous system stimulation by thyroid hormones. Potassium iodide is used to prepare the patient for thyroidectomy or for treatment of thyrotoxic crisis to inhibit the synthesis of thyroid hormones. Antithyroid medications inhibit the synthesis of thyroid hormones. RAI destroys thyroid tissue, which limits thyroid hormone secretion

18

Which characteristics describe the use of RAI? (select all that apply)

a. Often causes hypothyroidism over time
b. Decreases release of thyroid hormones
c. Blocks peripheral conversion of T4 to T3
d. Treatment of choice in nonpregnant adults
e. Decreases thyroid secretion by damaging thyroid gland
f. Often used with iodine to produce euthyroid before surgery

a. Often causes hypothyroidism over time
d. Treatment of choice in nonpregnant adults
e. Decreases thyroid secretion by damaging thyroid gland

RAI causes hypothyroidism over time by damaging thyroid tissue and is the treatment of choice for nonpregnant adults. Potassium iodide decreases the release of thyroid hormones and decreases the size of the thyroid gland preoperatively. Propylthiouracil (PTU) blocks peripheral conversion of T4 to T3 and may be used with iodine to produce a euthyroid state before surgery.

19

What preoperative instruction should the nurse give to the patient scheduled for a subtotal thyroidectomy?

a. How to support the head with the hands when turning in bed
b. Coughing should be avoided to prevent pressure on the the incision
c. Head and neck will need to remain immobile until the incision heals
d. Any tingling around the lips or in the fingers after surgery is expected and temporary

a. How to support the head with the hands when turning in bed

To prevent strain on the suture line postoperatively, the patient's head must be manually supported while turning and moving in bed but range-of-motion exercises for the head and neck are also taught preoperatively to be gradually implemented after surgery. There is no contraindication for coughing and deep breathing and these should be carried out postoperatively. Tingling around the lips or fingers is a sign of hypocalcemia, which may occur if the parathyroid glands are inadvertently removed during surgery. This sign should be reported immediately.

20

After a hypophysectomy for acromegaly, postoperative nursing care should focus on

a) frequently monitoring of serum and urine osmolarity
b) parenteral administration of a GH-receptor antagonist
c) keeping the patient in a recumbant position at all times
d) patient teaching regarding the need for lifelong hormone therapy

a) frequently monitoring of serum and urine osmolarity

A possible postoperative complication after a hypophysectomy is transient diabetes insipidus (DI). It may occur because of the loss of antidiuretic hormone (ADH), which is stored in the posterior lobe of the pituitary gland, or because of cerebral edema related to manipulation of the pituitary gland during surgery. To assess for DI, urine output and serum and urine osmolarity should be monitored closely.

21

A patient with a head injury develops SIADH. Manifestations the nurse would expect to find would include.

a) hypernatremia and edema
b) muscle spasticity and hypertension
c) low urine output and hyponatremia
d) weight gain and decreased glomerular filtration rate

c) low urine output and hyponatremia

Excess ADH increases the permeability of the renal distal tubule and collecting ducts, which leads to the reabsorption of water into the circulation. Consequently, extracellular fluid volume expands, plasma osmolality declines, the glomerular filtration rate increases, and sodium levels decline (i.e., dilutional hyponatremia). Hyponatremia causes muscle cramping, pain, and weakness. Initially, the patient displays thirst, dyspnea on exertion, and fatigue. Patients with the syndrome of inappropriate antidiuretic hormone secretion (SIADH) experience low urinary output and increased body weight. As the serum sodium level falls (usually to less than 120 mEq/L), manifestations become more severe and include vomiting, abdominal cramps, muscle twitching, and seizures. As plasma osmolality and serum sodium levels continue to decline, cerebral edema may occur, leading to lethargy, anorexia, confusion, headache, seizures, and coma.

22

The health care provider prescribe levothyroxine (Synthroid) for a patient with hypothyroidism . After teaching regarding this drug, the nurse determines that further instruction is needed when the patient says

a) "I can expect the medication dose may need to be adjusted"
b) "I only need to take this drug until my symptoms are improved"
c) "I can expect to return to normla function with the use of this drug"
d) "I will report any chest pain or difficulty breathing tot he Dr. right away"

b) "I only need to take this drug until my symptoms are improved"

Levothyroxine (Synthroid) is the drug of choice to treat hypothyroidism. The need for thyroid replacement therapy is usually lifelong

23

After thyroid surgery, the nurse suspects damage or removal of the parathyroid glands when the patient develops

a) muscle weakness and weight loss
b) hyperthermia and sever tachycardia
c) hypertension and difficulty swallowing
d) laryngospasms and tingling in hands and feet

d) laryngospasms and tingling in hands and feet

Painful tonic spasms of smooth and skeletal muscles can cause laryngospasms that may compromise breathing. These spasms may be related to tetany, which occurs if the parathyroid glands are removed or damaged during surgery, which leads to hypocalcemia.

24

Important nursing interventions when caring for a patient with Cushing syndrome include

a) restricting protein intake
b) monitoring blood glucose levels
c) observing for signs of hypotension
d) administering medication in equal doses
e) protecting patient from exposure to infection

b) monitoring blood glucose levels
e) protecting patient from exposure to infection

Hyperglycemia occurs with Cushing disease because of glucose intolerance (associated with cortisol-induced insulin resistance) and increased gluconeogenesis by the liver. High levels of corticosteroids increase susceptibility to infection and delay wound healing.

25

An important preoperative nursing intervention before an adrenalectomy for hyperaldosteronism is to

a) monitor blood glucose levels
b) restrict fluid and sodium intake
c) administer potassium sparing diuretics
d) advise the patient to make postural changes slowly

c) administer K sparing diuretics

Before surgery, patients should be treated with potassium-sparing diuretics (spironolactone [Aldactone], eplerenone [Inspra]) to normalize serum potassium levels. Spironolactone and eplerenone block the binding of aldosterone to the mineralocorticoid receptor in the terminal distal tubules and collecting ducts of the kidney, thus increasing sodium excretion, water excretion, and potassium retention. Oral potassium supplements may also be necessary.

26

To control the side effects of corticosteroid therapy, the nurse teaches the patient who is taking corticosteroids to

a) increase calcium intake to 1500 mg/day
b) perform glucose monitoring for hypoglycemia
c) obtain immunizations due to high risk of infections
d) avoid abrupt position changes because of orthostatic hypotension

a) increase calcium intake to 1500 mg/day

Because patients often receive corticosteroid treatment for prolonged periods (more than 3 months), corticosteroid-induced osteoporosis is an important concern. Therapies to reduce the resorption of bone may include increased calcium intake, vitamin D supplementation, bisphosphonates (e.g., alendronate [Fosamax]), and institution of a low-impact exercise program.

27

The nurse teaches the patient that the best time to take corticosteroids for replacement purposes is

a) once a day at bedtime
b) every other day on awakening
c) on arising and in the late afternoon
d) at consistent intervals every 6-8 hours

c) on arising and in the late afternoon

As replacement therapy, glucocorticoids are usually administered in divided doses: two thirds in the morning and one third in the afternoon. This dosage schedule reflects normal circadian rhythm in endogenous hormone secretion and decreases the side effects associated with corticosteroid replacement therapy.

28

The nurse instructs a 28-year-old man with acromegaly resulting from an unresectable benign pituitary tumor about octreotide (Sandostatin). The nurse should intervene if the patient makes which statement?

a) “I will come in to receive this medication IV every 2 to 4 weeks.”
b)“I will inject the medication in the subcutaneous layer of the skin.”
c) “The medication will decrease the growth hormone production to normal.”
d) “If radiation treatment is not effective, I may need to take the medication.”


a) “I will come in to receive this medication IV every 2 to 4 weeks.”

Drugs are most commonly used in patients who have had an inadequate response to or cannot be treated with surgery and/or radiation therapy. The most common drug used for acromegaly is octreotide (Sandostatin), a somatostatin analog that reduces growth hormone levels to within the normal range in many patients. Octreotide is given by subcutaneous injection three times a week. Two long-acting analogs, octreotide (Sandostatin LAR) and lanreotide SR (Somatuline Depot), are available as intramuscular (IM) injections given every 2 to 4 weeks.

29

The nurse receives a phone call from a 36-year-old woman taking cyclophosphamide (Cytoxan) for treatment of non-Hodgkin’s lymphoma. The patient tells the nurse that she has muscle cramps and weakness and very little urine output. Which response by the nurse is best?

a) “Start taking supplemental potassium, calcium, and magnesium.”
b) “Stop taking the medication now and call your health care provider.”
c) “These symptoms will decrease with continued use of the medication.”
d) “Increase fluids to 3000 mL per 24 hours to improve your urine output.”

b) “Stop taking the medication now and call your health care provider."

Cyclophosphamide may cause syndrome of inappropriate antidiuretic hormone (SIADH). Medications that stimulate the release of ADH should be avoided or discontinued. Treatment may include restriction of fluids to 800 to 1000 mL per day. If a loop diuretic such as furosemide (Lasix) is used to promote diuresis, supplements of potassium, calcium, and magnesium may be needed.

30

The nurse is caring for a 40-year-old man who has begun taking levothyroxine (Synthroid) for recently diagnosed hypothyroidism. What information reported by the patient is most important for the nurse to further assess?

a) Weight gain or weight loss
b) Chest pain and palpitations
c) Muscle weakness and fatigue
d) Decreased appetite and constipation

b) Chest pain and palpitations

Levothyroxine (Synthroid) is used to treat hypothyroidism. Any chest pain or heart palpitations or heart rate greater than 100 beats/minute experienced by a patient starting thyroid replacement should be reported immediately, and an electrocardiogram (ECG) and serum cardiac enzyme tests should be performed.

31

The nurse is caring for a 68-year-old woman after a parathyroidectomy related to hyperparathyroidism. The nurse should administer IV calcium gluconate if the patient exhibits which clinical manifestations?

a) Facial muscle spasms or laryngospasms
b) Decreased muscle tone or muscle weakness
c) Tingling in the hands and around the mouth
d) Shortened QT interval on the electrocardiogram

a) Facial muscle spasms or laryngospasms

Nursing care for the patient following a parathyroidectomy includes monitoring for a sudden decrease in serum calcium levels causing tetany, a condition of neuromuscular hyperexcitability. If tetany is severe (e.g., muscular spasms or laryngospasms develop), IV calcium gluconate should be administered. Mild tetany, characterized by unpleasant tingling of the hands and around the mouth, may be present but should decrease over time without treatment. Decreased muscle tone, muscle weakness, and shortened QT interval are clinical manifestations of hyperparathyroidism.

32

The nurse is caring for a 56-year-old man receiving high-dose oral corticosteroid therapy to prevent organ rejection after a kidney transplant. What is most important for the nurse to observe related to this medication?

a) Signs of infection
b) Low blood pressure
c) Increased urine output
d) Decreased blood glucose

a) Signs of infection

Side effects of corticosteroid therapy include increased susceptibility to infection, edema related to sodium and water retention (decreased urine output), hypertension, and hyperglycemia. Other side effects are listed in Table 50-19.

33

The nurse is caring for a patient admitted with suspected hyperparathyroidism. Because of the potential effects of this disease on electrolyte balance, the nurse should assess this patient for what manifestation?

a) Neurologic irritability
b) Declining urine output
c) Lethargy and weakness
d) Hyperactive bowel sounds

c) Lethargy and weakness

Hyperparathyroidism can cause hypercalcemia. Signs of hypercalcemia include muscle weakness, polyuria, constipation, nausea and vomiting, lethargy, and memory impairment. Neurologic irritability, declining urine output, and hyperactive bowel sounds do not occur with hypercalcemia.

34

The nurse should monitor for increases in which laboratory value for the patient as a result of being treated with dexamethasone (Decadron)?

a) Sodium
b) Calcium
c) Potassium
d) Blood glucose


d) Blood glucose

Hyperglycemia or increased blood glucose level is an adverse effect of corticosteroid therapy. Sodium, calcium, and potassium levels are not directly affected by dexamethasone.

35

The nurse is providing discharge instructions to a patient with diabetes insipidus. Which instructions regarding desmopressin acetate (DDAVP) would be most appropriate?

a) The patient can expect to experience weight loss resulting from increased diuresis.
b) The patient should alternate nostrils during administration to prevent nasal irritation.
c) The patient should monitor for symptoms of hypernatremia as a side effect of this drug.
d) The patient should report any decrease in urinary elimination to the health care provider.

b) The patient should alternate nostrils during administration to prevent nasal irritation.

DDAVP is used to treat diabetes insipidus by replacing the antidiuretic hormone that the patient is lacking. Inhaled DDAVP can cause nasal irritation, headache, nausea, and other signs of hyponatremia. Diuresis will be decreased and is expected, and hypernatremia should not occur.

36

What is a nursing priority in the care of a patient with a diagnosis of hypothyroidism?

a) Providing a dark, low-stimulation environment
b) Closely monitoring the patient's intake and output
c) Patient teaching related to levothyroxine (Synthroid)
d) Patient teaching related to radioactive iodine therapy


c) Patient teaching related to levothyroxine (Synthroid)

A euthyroid state is most often achieved in patients with hypothyroidism by the administration of levothyroxine (Synthroid). It is not necessary to carefully monitor intake and output, and low stimulation and radioactive iodine therapy are indicated in the treatment of hyperthyroidism.

37

A patient has been taking oral prednisone for the past several weeks after having a severe reaction to poison ivy. The nurse has explained the procedure for gradual reduction rather than sudden cessation of the drug. What is the rationale for this approach to drug administration?

a) Prevention of hypothyroidism
b) Prevention of diabetes insipidus
c) Prevention of adrenal insufficiency
d) Prevention of cardiovascular complications

c) Prevention of adrenal insufficiency

Sudden cessation of corticosteroid therapy can precipitate life-threatening adrenal insufficiency. Diabetes insipidus, hypothyroidism, and cardiovascular complications are not common consequences of suddenly stopping corticosteroid therapy.

38

The surgeon was unable to spare a patient's parathyroid gland during a thyroidectomy. Which assessments should the nurse prioritize when providing postoperative care for this patient?

a) Assessing the patient's white blood cell levels and assessing for infection
b) Monitoring the patient's hemoglobin, hematocrit, and red blood cell levels
c) Monitoring the patient's serum calcium levels and assessing for signs of hypocalcemia
d) Monitoring the patient's level of consciousness and assessing for acute delirium or agitation

c) Monitoring the patient's serum calcium levels and assessing for signs of hypocalcemia

Loss of the parathyroid gland is associated with hypocalcemia. Infection and anemia are not associated with loss of the parathyroid gland, whereas cognitive changes are less pronounced than the signs and symptoms of hypocalcemia.

39

The patient with systemic lupus erythematosus had been diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What should the nurse expect to include in this patient's plan of care (select all that apply)?

a) Obtain weekly weights.
b) Limit fluids to 1000 mL per day.
c) Monitor for signs of hypernatremia.
d) Minimize turning and range of motion.
e) Keep the head of the bed at 10 degrees or less elevation.

b) Limit fluids to 1000 mL per day
e) Keep the head of the bed at 10 degrees or less elevation.

The care for the patient with SIADH will include limiting fluids to 1000 mL per day or less to decrease weight, increase osmolality, and improve symptoms; and keeping the head of the bed elevated at 10 degrees or less to enhance venous return to the heart and increase left atrial filling pressure, thereby reducing the release of ADH. The weights should be done daily along with intake and output. Signs of hyponatremia should be monitored, and frequent turning, positioning, and range-of-motion exercises are important to maintain skin integrity and joint mobility.

40

A 50-year-old female patient smokes, is getting a divorce, and is reporting eye problems. On assessment of this patient, the nurse notes exophthalmos. What other abnormal assessments should the nurse expect to find in this patient?

a) Puffy face, decreased sweating, and dry hair
b) Muscle aches and pains and slow movements
c) Decreased appetite, increased thirst, and pallor
d) Systolic hypertension and increased heart rate

d) Systolic hypertension and increased heart rate

The patient's manifestations point to Graves' disease or hyperthyroidism, which would also include systolic hypertension and increased heart rate and increased thirst. Puffy face, decreased sweating; dry, coarse hair; muscle aches and pains and slow movements; decreased appetite and pallor are all manifestations of hypothyroidism.

41

A patient with a severe pounding headache has been diagnosed with hypertension. However, the hypertension is not responding to traditional treatment. What should the nurse expect as the next step in management of this patient?

a) Administration of β-blocker medications
b) Abdominal palpation to search for a tumor
c) Administration of potassium-sparing diuretics
d) A 24-hour urine collection for fractionated metanephrines

d) A 24-hour urine collection for fractionated metanephrines

Pheochromocytoma should be suspected when hypertension does not respond to traditional treatment. The 24-hour urine collection for fractionated metanephrines is simple and reliable with elevated values in 95% of people with pheochromocytoma. In a patient with pheochromocytoma preoperatively an α-adrenergic receptor blocker is used to reduce BP. Abdominal palpation is avoided to avoid a sudden release of catecholamines and severe hypertension. Potassium-sparing diuretics are not needed. Most likely they would be used for hyperaldosteronism, which is another cause of hypertension.

42

The patient with an adrenal hyperplasia is returning from surgery for an adrenalectomy. For what immediate postoperative risk should the nurse plan to monitor the patient?

a) Vomiting
b) Infection
c) Thomboembolism
d) Rapid BP changes

d) Rapid BP changes

The risk of hemorrhage is increased with surgery on the adrenal glands as well as large amounts of hormones being released in the circulation, which may produce hypertension and cause fluid and electrolyte imbalances to occur for the first 24 to 48 hours after surgery. Vomiting, infection, and thromboembolism may occur postoperatively with any surgery.

43

The patient is brought to the ED following a car accident and is wearing medical identification that says she has Addison's disease. What should the nurse expect to be included in the collaborative care of this patient?

a) Low sodium diet
b) Increased glucocorticoid replacement
c) Suppression of pituitary ACTH synthesis
d) Elimination of mineralocorticoid replacement


b) Increased glucocorticoid replacement

The patient with Addison's disease needs lifelong glucocorticoid and mineralocorticoid replacement and has an increased need with illness, injury, or stress, as this patient is experiencing. The patient with Addison's may also need a high sodium diet. Suppression of pituitary ACTH synthesis is done for Cushing syndrome. Elimination of mineralocorticoid replacement cannot be done for Addison's disease.

44

As a precaution for vocal cord paralysis from damage to the recurrent laryngeal nerve during thyroidectomy surgery, what equipment should be in the room in case it is needed for this emergency situation.

a. Tracheostomy tray
b. Oxygen equipment
c. IV calcium gluconate
d. Paper and pencil for communication

a. Tracheostomy tray

A tracheosotmy tray is in the room to use if vocal cord paralysis occurs from recurrent laryngeal nerve damage or for laryngeal stridor from tetany. The oxygen equipment may be useful but will not improve oxygenation with vocal cord paralysis without a tracheostomy. IV calcium salts will be used if hypocalcemia occurs from parathyroid damage.

45

When providing discharge instructions to a patient who had a subtotal thyroidectomy for hyperthyroidism, what should the nurse teach the patient?

a. Never miss a daily dose of thyroid replacement therapy
b. Avoid regular exercise until thyroid function is normalized
c. Use warm saltwater gargles several times a day to relieve throat pain
d. Substantially reduce caloric intake compared to what was eaten before surgery.

d. Substantially reduce caloric intake compared to what was eaten before surgery.

With the decrease in thyroid hormone postoperatively, calories need to be reduced substantially to prevent weight gain. When a patient has had a subtotal thyroidectomy, thyroid replacement therapy is not given because exogenous hormone inhibits pituitary production of TSH and delays or prevents the restoration of thyroid tissue regeneration. Regular exercise stimulates the thyroid gland and is encouraged. Saltwater gargles are used for dryness and irritation of the mouth and throat following RAI

46

What is a cause of primary hypothyroidism in adults?

a. Malignant or benign thyroid nodules
b. Surgical removal or failure of the pituitary gland
c. Surgical removal or radiation of the thyroid
d. Autoimmune-induced atrophy of the thyroid gland

d. Autoimmune-induced atrophy of the thyroid gland

Both Graves' disease and Hashimoto's thyroiditis are autoimmune disorders that eventually destroy the thyroid gland, leading to primary hypothyroidism. Thyroid tumors most often result in hyperthyroidism. Secondary hypothyroidism occurs as a result of pituitary failure and iatrogenic hypothyroidism results from thyroidectomy or radiation of the thyroid gland

47

The nurse has identified the nursing diagnosis of fatigue for a patient who is hypothyroid. What should the nurse do while caring for this patient?

a. Monitor for changes in orientation, cognition, and behavior
b. Monitor for vital signs and cardiac rhythm response to activity
c. Monitor bowel movement frequency, consistency, shape, volume and color
d. Assist in developing well-balanced meal plans consistent with level of energy expenditure

b. Monitor for vital signs and cardiac rhythm response to activity

Cardiorespiratory response to activity is important to monitor in this patient to determine the effect of activities and plan activity increases. Monitoring changes in orientation, cognition, and behavior are interventions for impaired memory. Monitoring bowels is needed to plan care for the patient with constipation. Assisting with meal planning will help the patient with imbalanced nutrition: more than body requirements to lose weight if needed.

48

When replacement therapy is started for a patient with long-standing hypothryroidism, what is most important for the nurse to monitor the patient for?

a. Insomnia
b. Weight loss
c. Nervousness
d. Dysrhythmias

d. Dysrhythmias

All these manifestations may occur with treatment of hypothyroidism. However, as a result of the effects of hypothyroidism on the cardiovascular system, when thyroid replacement therapy is started myocardial oxygen consumption is increased and the resultant oxygen demand may cause angina, cardiac dysrhythmias, and heart failure, so monitoring for dysrhythmias is most important

49

A patient with hypothyroidism is treated with levothyroxine (Synthroid). What should the nurse include when teaching the patient about this therapy?

a. Explain that alternate-day dosage may be used if side effects occur
b. Provide written instruction for all information related to the drug therapy
c. Assure the patient that a return to normal function will occur with replacement therapy
d. Inform the patient that the drug must be taken until the hormone balance is reestablished

b. Provide written instruction for all information related to the drug therapy

Because of the mental sluggishness, inattentiveness, and memory loss that occur with hypothyroidism, it is important to provide written instructions and repeat information when teaching the patient. Replacement therapy must be taken for life and alternate-day dosing is not therapeutic. Although most patients return to a normal state with treatment, cardiovascular conditions and psychoses may persist.

50

A patient who recently had a calcium oxalate renal stone had a bone density study, which showed a decrease in her bone density. What endocrine problem could this patient have?

a. SIADH
b. Hypothyroidism
c. Cushing syndrome
d. Hyperparathyroidism

d. Hyperparathyroidism

The patient with hyperparathyroidism may have calcium nephrolithiasis, skeletal pain, decreased bone density, psychomotor retardation, or cardiac dysrhythmias. The other endocrine problems would not be related to calcium kidney stones or decreased bone density.

51

What is an appropriate nursing intervention for the patient with hyperparathyroidism?

a. Pad side rails as a seizure precaution
b. Increase fluid intake to 3000 to 4000 mL daily
c. Maintain bed rest to prevent pathologic fractures
d. Monitor the patient for Trousseau's and Chvostek's signs

b. Increase fluid intake to 3000 to 4000 mL daily

A high fluid intake is indicated in hyperparathyroidism to dilute the hypercalcemia and flush the kidneys so that calcium stone formation is reduced. Seizures are not associated with hyperparathyroidism. Impending tetany of hypoparathyroidism after parathyroidectomy can be noted with Trousseau's and Chvostek's signs. The patient with hyperparathyroidism is at risk for pathologic fractures resulting from decreased bone density but mobility is encouraged to promote bone calcification.

52

A patient has been diagnosed with hypoparathyroidism. What manifestations should the nurse expect to observe? Select all that apply

a. Skeletal pain
b. Dry, scaly skin
c. Personality changes
d. Abdominal cramping
e. Cardiac dysrhythmias
f. Muscle spasms and stiffness

b. Dry, scaly skin
c. Personality changes
d. Abdominal cramping
e. Cardiac dysrhythmias
f. Muscle spasms and stiffness

In hypoparathyroidism the patient has inadequate circulating parathyroid hormone (PTH) that leads to hypocalcemia from the inability to maintain serum calcium levels. With hypocalcemia there is muscle stiffness and spasms, which can lead to cardiac dysrhythmias and abdominal cramps. There can also be personality and visual changes and dry, scaly skin

53

When the patient with parathyroid disease experiences symptoms of hypocalcemia, what is a measure that can be used to temporarily raise serum calcium levels?

a. Administer IV normal saline
b. Have patient rebreathe in a paper bag
c. Administer furosemide (Lasix) as ordered
d. Administer oral phosphorus supplements

b. Have patient rebreathe in a paper bag

Rebreathing in a paper bag promotes carbon dioxide retention in the blood which lowers pH and creates an acidosis. An acidemia enhances the solubility and ionization of calcium, increasing the proportion of total body calcium available in physiologically active form and relieving the symptoms of hypocalcemia. Saline promotes calcium excretion, as does furosemide. Phosphate levels in the blood are reciprocal to calcium and an increase in phosphate promotes calcium excretion.

54

A patient with hypoparathyroidism resulting from surgical treatment of hyperparathyroidism is preparing for discharge. What should the nurse teach the patient?

a. Milk and milk products should be increased in the diet
b. Parenteral replacement of parathyroid hormone will be required for life
c. Calcium supplements with vitamin D can effectively maintain calcium balance
d. Bran and whole-grain foods should be used to prevent GI effects of replacement therapy.

c. Calcium supplements with vitamin D can effectively maintain calcium balance

The hypocalcemia that results from PTH deficiency is controlled with calcium and vitamin D supplementation and possible oral phosphate binders. Replacement with PTH is not used because of antibody formation to PTH, the need for parenteral administration, and cost. Milk products, although good sources of calcium, also have high levels of phosphate, which reduce calcium absorption. Whole grains and foods containing oxalic acid also impair calcium absorption.

55

A patient is admitted to the hospital with a diagnosis of Cushing syndrome. On the physical assessment of the patient, what should the nurse expect to fine?

a. Hypertension, peripheral edema, and petechiae
b. Weight loss, buffalo hump, and moon face with acne
c. Abdominal and buttock striae, truncal obesity and hypotension
d. Anorexia, signs of dehydration, and hyperpigmentation of the skin

a. Hypertension, peripheral edema, and petechiae

The effects of adrenocortical hormone excess, especially glucocorticoid excess, include weight gain from accumulation and redistribution of adipose tissue, sodium and water retention glucose intolerance, protein wasting, loss of bone structure, loss of collagen, and capillary fragility leading to petechiae. Clinical manifestations of adrenocortical hormone deficiency include hypotension, dehydration, weight loss, and hyperpigmentation of the skin.

56

A patient is scheduled for a bilateral adrenalectomy. During the postoperative period, what should the nurse expect related to the administration of corticosteroids?

a. Reduced to promote wound healing
b. Withheld until symptoms of hypocortisolism appear
c. Increased to promote an adequate response to the stress of surgery
d. Reduced because excessive hormones are released during surgical manipulation of adrenal glands

c. Increased to promote an adequate response to the stress of surgery

Although the patient with Cushing syndrome has excess corticosteroids, removal of the glands and the stress of surgery require that high doses of corticosteroids (cortisone) be administered postoperatively for several days before weaning the dose. The nurse should monitor the patient's vital signs postoperatively to detect whether large amounts of hormones were released during surgical manipulation, obtain morning urine specimens for cortisol measurement to evaluate the effectiveness of the surgery, and provide dressing changes with aseptic technique to avoid infection as usual inflammatory responses are suppressed.

57

A patient with Addison's disease comes to the emergency department with complaints of nausea, vomiting, diarrhea, and fever. What collaborative care should the nurse expect?

a. IV administration of vasopressors
b. IV administration of hydrocortisone
c. IV administration of D5W with 20 mEq KCl
d. Parenteral injections of adrenocorticotropic hormone (ACTH)

b. IV administration of hydrocortisone

Vomiting and diarrhea are early indicators of Addisonian crisis and fever indicates an infection, which is causing additional stress for the patient. Treatment of a crisis requires immediate glucocorticoid replacement and IV hydrocortisone, fluids, sodium, and glucose are necessary for 24 hours. Addison's disease is a primary insufficiency of the adrenal gland and adrenocorticotropic hormone (ACTH) is not effective, nor would vasopressors be effective with the fluid deficiency of Addison's disease. Potassium levels are increased in Addison's disease and KCl would be contraindicated.

58

During discharge teaching for the patient with Addison's disease, which statement by the patient indicates that the nurse needs to do additional teaching?

a. "I should always call the doctor if I develop vomiting or diarrhea."
b. If my weight goes down, my dosage of steroid is probably too high."
c. "I should double or triple my steroid used if I undergo rigorous physical exercise."
d. "I need to carry an emergency kit with injectable hydrocortisone in case I can't take my medication by mouth."

b. If my weight goes down, my dosage of steroid is probably too high."

A weight reduction in the patient with Addison's disease may indicate a fluid loss and a dose of replacement therapy that is too low rather than too high. Because vomiting and diarrhea are early signs of crisis and because fluid and electrolytes must be replaced, patients should notify their healthcare provider if these symptoms occur. Patients with Addison's disease are taught to take 2 or 3 times their usual dose of steroids if they become ill, have teeth extracted, or engage in rigorous physical activity and should always have injectable hydrocortisone available if oral doses cannot be taken.

59

A patient who is on corticosteroid therapy treatment for an autoimmune disorder has the following additional drugs ordered. Which one is used to prevent corticosteroid-induced osteoporosis?

a. Potassium
b. Furosemide (Lasix)
c. Alendronate (Fosamax)
d. Pantoprazole (Protonix)

c. Alendronate (Fosamax)

Alendronate (Fosamax) is used to prevent corticosteroid-induced osteoporosis. Potassium is used to prevent the minaralcorticoid effect of hypokalemia. Furosemide (Lasix) is used to decrease sodium and fluid retention from the mineralcorticoid effect. Pantoprazole (Protonix) is used to prevent GI irritation from an increase in secretion of pepsin and HCl.

60

A patient with mild iatrogenic Cushing syndrome is on an alternate-day regimen of corticosteroid therapy. What does the nurse explain to the patient about this regimen?

a. It maintains normal adrenal hormone balance
b. It prevents ACTH release from the pituitary gland
c. It minimizes hypothalamic-pituitary-adrenal suppression
d. It provides a more effective therapeutic effect of the drug

c. It minimizes hypothalamic-pituitary-adrenal suppression

Taking corticosteroids on an alternate-day schedule for pharmacologic purposes is less likely to suppress ACTH production from the pituitary and prevent adrenal atrophy. Normal adrenal hormone balance is not maintained during glucocorticoid therapy because excessive exogenous hormone is used.

61

When caring for a patient with primary hyperaldosteronism, the nurse would question a health care provider's prescription for which drug?

a. Furosemide (Lasix)
b. Amiloride (Midamor)
c. Spironolactone (Aldactone)
d. Aminoglutethimide (Cytadren)

a. Furosemide (Lasix)

Hyperaldosteronism is an excess of aldosterone, which is manifested by sodium and water retention and potassium excretion. Furosemide is a potassium-wasting diuretic that would increase the potassium deficiency. Aminoglutethimide blocks aldosterone synthesis. Spironolactone and amiloride are potassium-sparing diuretics.

62

What is the priority nursing intervention during the management of the patient with pheochromocytoma?

a. Administering IV fluids
b. Monitoring blood pressure
c. Administering B-adrenergic blockers
d. Monitoring intake and output and daily weights

b. Monitoring blood pressure

Pheochromocytoma is a catecholamine-producing tumor of the adrenal medulla, which may cause severe, episodic hypertension; severe, pounding headache; and profuse sweating. Monitoring for a dangerously high BP before surgery is critical, as is monitoring for BP fluctuations during medical and surgical treatment.