Ch 45 Endocrine Disorders

The adrenal cortex manufactures and secretes glucocorticoids, such as cortisol, which affect body metabolism, suppress inflammation, and help the body withstand stress.

A nurse is reviewing the laboratory order for a client suspected of having an endocrine disorder. The lab slip includes obtaining cortisol levels. What is being tested?

puffiness of the face and hands. Hypothyroidism (myxedema) causes facial puffiness, extremity edema, and weight gain. Signs and symptoms of hyperthyroidism (Graves' disease) include an increased appetite, weight loss, nervousness, tremors, and thyroid gland enlargement (goiter).

A nurse should expect a client with hypothyroidism to report:

a corticotropin-secreting pituitary adenoma. A corticotropin-secreting pituitary adenoma is the most common cause of Cushing's syndrome in women ages 20 to 40. Ectopic corticotropin-secreting tumors are more common in older men and are commonly associated with weight loss. Adrenal carcinoma isn't usually accompanied by hirsutism. A female with an inborn error of metabolism wouldn't be menstruating.

A 35-year-old female client who complains of weight gain, facial hair, absent menstruation, frequent bruising, and acne is diagnosed with Cushing's syndrome. Cushing's syndrome is most likely caused by: pg 1479

Stimulate more hormones using the negative feedback system Feedback can be either negative or positive. Most hormones are secreted in response to negative feedback; a decrease in levels stimulates the releasing gland.

A client has a decreased level of thyroid hormone being excreted. What will the feedback loop do to maintain the level of thyroid hormone required to maintain homeostatic stability?

Exophthalmos Exophthalmos is an abnormal bulging or protrusion of the eyes and periorbital swelling. These findings are not consistent with retinal detachment.

A client is being seen in the clinic to receive the results of the lab work to determine thyroid levels. The nurse observes the client's eyes appear to be bulging, and there is swelling around the eyes. What does the nurse know that the correct documentation of this finding is?

The concentration of a substance in plasma Measuring blood hormone levels helps determine the functioning of endocrine glands. A radioimmunoassay determines the concentration of a substance in plasma. The measurement of blood hormone levels will not reveal a client's blood sugar level. Radiographs of the chest or abdomen determine the size of the organ and its location.

A client is scheduled for a diagnostic test to measure blood hormone levels. The nurse expects that this test will determine which of the following?

Magnetic resonance imaging (MRI) A computed tomography (CT) or magnetic resonance imaging (MRI) scan is performed to detect a suspected pituitary tumor or to identify calcifications or tumors of the parathyroid glands. A radioactive iodine uptake test would be useful for a thyroid tumor. Radioimmunoassay determines the concentration of a substance in plasma.

A client is suspected to have a pituitary tumor due to signs of diabetes insipidus. What initial test does the nurse help to prepare the client for?

hyperpituitarism Acromegaly (hyperpituitarism) is a condition in which growth hormone is oversecreted after the epiphyses of the long bones have sealed. A client with acromegaly has coarse features, a huge lower jaw, thick lips, a thickened tongue, a bulging forehead, a bulbous nose, and large hands and feet. When the overgrowth is from a tumor, headaches caused by pressure on the sella turcica are common.

A client presents with a huge lower jaw, bulging forehead, large hands and feet, and frequent headaches. What could be causing this client's symptoms?

sodium and potassium abnormalities. In Addison's disease, a form of adrenocortical hypofunction, aldosterone secretion is reduced. Aldosterone promotes sodium conservation and potassium excretion. Therefore, aldosterone deficiency increases sodium excretion, predisposing the client to hyponatremia, and inhibits potassium excretion, predisposing the client to hyperkalemia. Because aldosterone doesn't regulate calcium, phosphorus, chloride, or magnesium, an aldosterone deficiency doesn't affect levels of these electrolytes directly.

A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of:

Hydrocortisone Emergency treatment for acute adrenal insufficiency (addisonian crisis) is IV infusion of hydrocortisone and saline solution. The client is usually given a dose containing hydrocortisone 100 mg I.V. in normal saline every 6 hours until blood pressure returns to normal. Insulin isn't indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia. Potassium isn't indicated because these clients are usually hyperkalemic. The client needs normal — not hypotonic — saline solution.

A client with a history of Addison's disease and flu-like symptoms accompanied by nausea and vomiting over the past week is brought to the facility. His wife reports that he acted confused and was extremely weak when he awoke that morning. The client's blood pressure is 90/58 mm Hg, his pulse is 116 beats/minute, and his temperature is 101° F (38.3° C). A diagnosis of acute adrenal insufficiency is made. What should the nurse expect to administer by IV infusion?

Sodium level of 150 mEq/L Diabetes insipidus (DI) is a rare disorder that occurs due to injury to the hypothalamus or pituitary gland with a deficiency of ADH (vasopressin) that results in excretion of large volumes of dilute urine and extreme thirst. Without the action of ADH on the distal nephron of the kidney, an enormous daily output (greater than 250 mL per hour) of very dilute urine with a specific gravity of 1.001 to 1.005 occurs. The urine contains no abnormal substances such as glucose or albumin. Due to the intense thirst, the client tends to drink 2 to 20 L of fluid daily and craves cold water. In adults, the onset of DI may be insidious or abrupt. The disease cannot be controlled by limiting fluid intake because the high-volume loss of urine continues even without fluid replacement. Attempts to restrict fluids cause the client to experience an insatiable craving for fluid and to develop hypernatremia and severe dehydration. DI does not affect the glucose, potassium, or phosphate levels.

A client with a history of diabetes insipidus seeks medical attention for an exacerbation of symptoms. Which laboratory finding indicates to the nurse that the client has been restricting fluids in an attempt to control the symptoms?

Pressure on the optic nerve Partial blindness may result from pressure on the optic nerve. Glaucoma does not occur suddenly, and the client did not report injury to suspect corneal abrasions or retinal detachment.

A client with acromegaly is admitted to the hospital with complaints of partial blindness that began suddenly. What does the nurse suspect is occurring with this client?

Reassure the client that their emotional reactions are a result of the disorder and symptoms can be controlled with effective treatment. The client with hyperthyroidism needs reassurance that the emotional reactions being experienced are a result of the disorder and that with effective treatment those symptoms can be controlled. It is important to use a calm, unhurried approach with the client. Stressful experiences should be minimized, and a quiet uncluttered environment should be maintained. The nurse encourages relaxing activities that will not overstimulate the client. It is important to balance periods of activity with rest.

A client with hyperthyroidism is concerned about changes in appearance. How can the nurse convey an understanding of the client's concern and promote effective coping strategies?

Acromegaly Acromegaly, which is caused by a pituitary tumor that releases excessive growth hormone, is associated with hyperglycemia, hypertension, diaphoresis, peripheral neuropathy, and joint pain. Enlarged hands and feet are related to lateral bone growth, which is seen in adults with this disorder. The accompanying soft tissue swelling causes hoarseness and, commonly, sleep apnea. Type 1 diabetes is usually seen in children, and newly diagnosed persons are usually very ill and thin. Hypothyroidism and growth hormone deficiency aren't associated with hyperglycemia.

A female client with hyperglycemia who weighs 210 lb (95 kg) tells the nurse that her husband sleeps in another room because her snoring keeps him awake. The nurse notices that the client has large hands and a hoarse voice. Which disorder would the nurse suspect as a possible cause of the client's hyperglycemia?

An irregular apical pulse Because Cushing's syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician. Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. Dry mucous membranes and frequent urination signal dehydration, which isn't associated with Cushing's syndrome.

A nurse is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately?

A 24-year-old client with unstable hyperthyroidism with sinus tachycardia The client with hyperthyroidism is probably irritable and anxious and needs uninterrupted rest. The nurse should assign him to a quiet room away from the noise at the nurses' station. The client who had a CABG is most likely to develop an arrhythmia on his third postoperative day. The unstable client with diabetes mellitus could experience hypoglycemia or hyperglycemia and requires frequent monitoring of blood glucose levels. The elderly male is confused and agitated. The nurse should assign these three clients to beds as close to the nurses' station as possible.

A nurse is assigning beds to four new clients being admitted to the cardiac telemetry floor. Which client should she assign to the bed at the end of the hall, away from the nurses' station?

Potassium chloride The nurse should question an order for potassium chloride because addisonian crisis results in hyperkalemia. Administering potassium chloride is contraindicated. Because the client is hyponatremic, an order for normal saline solution is appropriate. Hydrocortisone and fludrocortisone are used to replace deficient adrenal cortex hormones.

A nurse is caring for a client in addisonian crisis. Which medication order should the nurse question?

"I will increase my fluid and calcium intake." The client requires additional teaching if he states that he will increase his calcium intake. Hyperparathyroidism causes extreme increases in serum calcium levels. The client should increase his fluid intake, but he should limit his calcium and vitamin D intake. The client should continue to take pain mediations as scheduled and have regular follow-up visits with his physician. Tingling around the lips is a sign of hypercalcemia and should be reported to the physician immediately.

A nurse is caring for a client who was recently diagnosed with hyperparathyroidism. Which statement by the client indicates the need for additional discharge teaching?

"Has your shoe size increased recently?" Excessive skeletal growth occurs only in the feet, the hands, the superciliary ridge, the molar eminences, the nose, and the chin, giving rise to the clinical condition of acromegaly.

A nurse is completing an assessment of a client with suspected acromegaly. To assist in making the diagnosis, which question should the nurse ask?

Decreased cardiac output An acute addisonian crisis is a life-threatening event, caused by deficiencies of cortisol and aldosterone. Glucocorticoid insufficiency causes a decrease in cardiac output and vascular tone, leading to hypovolemia. The client becomes tachycardic and hypotensive and may develop shock and circulatory collapse. The client with Addison's disease is at risk for infection; however, reducing infection isn't a priority during an addisonian crisis. Impaired physical mobility and Imbalanced nutrition: Less than body requirements are appropriate nursing diagnoses for the client with Addison's disease, but they aren't priorities in a crisis.

A nurse is planning care for a client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority?

Encircle the client's neck with both hands, have the client slightly extend his neck, and ask him to swallow. When palpating the thyroid gland, the nurse should encircle the client's neck with both hands, have the client slightly extend his neck, and ask him to swallow. As the client swallows, the gland is palpated for enlargement as the tissue rises and falls. Having the client flex his neck wouldn't allow for palpation. Massaging the area or checking during inhalation doesn't allow for the movement of tissue that swallowing provides.

A nurse is preparing to palpate a client's thyroid gland. Which action by the nurse is appropriate?

Explain that the client's physical changes are a result of excessive corticosteroids. The nurse should explain to the client that Cushing's syndrome causes physical changes related to excessive corticosteroids. Clients with hyperthyroidism, not Cushing's syndrome, are heat intolerant and must have cool clothing and bedding. Clients with Cushing's syndrome should have a high-protein, not low-protein, diet. Clients with Addison's disease must increase sodium intake and fluid intake in times of stress of prevent hypotension.

A nurse should perform which intervention for a client with Cushing's syndrome?

Epinephrine @ 450 pg/mL A plasma level of epinephrine that is more than 400 pg/mL is diagnostic of a pheochromocytoma. Refer to Table 31-4 in the text.

A patient is being evaluated for a diagnosis of pheochromocytoma. He is scheduled for epinephrine and norepinephrine laboratory tests. Which of the following plasma levels is a positive value that is diagnostic for pheochromocytoma?

Kidneys Although the kidneys secrete renin and erythropoietin, they are typically not considered endocrine glands. Therefore, if the students identify the kidneys as endocrine glands, they need further instruction. The pancreas, adrenal glands, and testes are considered endocrine glands.

An instructor has just finished teaching a class about the endocrine system. The instructor determines that the students need additional instruction when they identify which of the following as an endocrine gland?

Oxytocin The posterior pituitary gland released oxytocin and antidiuretic hormone. Somatotropin, prolactin, and adrenocorticotropic hormone are released by the anterior pituitary gland.

An instructor is preparing a teaching plan for a class on the various pituitary hormones. Which hormone would the instructor include as being released by the posterior pituitary gland?

Sympathetic Beta-adrenergic blocking agents are important in controlling the sympathetic nervous system effects of hyperthyroidism. For example, propranolol is used to control nervousness, tachycardia, tremor, anxiety, and heat intolerance.

Beta-blockers are used in the treatment of hyperthyroidism to counteract which of the following effects?

Pituitary The pituitary gland is located close to the optic nerves and hence causes pressure on these nerves; thus, changes in the vision and the visual fields may occur.

Vision and visual fields are altered in disorders of which of the following endocrine glands?

Assess vital signs. Because the client in addisonian crisis is unstable, vital signs and fluid and electrolyte balance should be assessed every 30 minutes until he's stable. Daily weights are sufficient when assessing the client's condition. The client shouldn't have ketones in his urine, so there is no need to assess the urine for their presence. Oral hydrocortisone isn't administered during the first 24 hours in severe adrenal insufficiency.

During the first 24 hours after a client is diagnosed with addisonian crisis, which intervention should the nurse perform frequently?

Kidney stones. Kidney stones occur in 55% of patients with primary hyperparathyroidism. They are caused by renal damage from the precipitation of calcium phosphate in the renal pelvis and parenchyma.

One of the most frequently occurring complications (55% occurrence) of primary hyperparathyroidism is:

Iodine Oversecretion of thyroid hormones is usually associated with an enlarged thyroid gland known as a goiter. Goiter also commonly occurs with iodine deficiency.

The nurse assesses a patient who has an obvious goiter. What type of deficiency does the nurse recognize is most likely the cause of this?

The patient may have hyperthyroidism. If palpation discloses an enlarged thyroid gland, both lobes are auscultated using the diaphragm of the stethoscope. Auscultation identifies the localized audible vibration of a bruit. This is indicative of increased blood flow through the thyroid gland associated with hyperthyroidism and necessitates referral to a physician.

The nurse auscultates a bruit over the thyroid glands. What does the nurse understand is the significance of this finding?

The lower neck anterior to the trachea The thyroid gland is located in the lower neck anterior to the trachea. It is divided into two lateral lobes joined by a band of tissue called the isthmus.

The nurse is attempting to locate the thyroid gland in order to determine if it is enlarged. Where should the nurse palpate the thyroid gland?

Phenytoin, Metoclopramide, Furosemide, Amphetamine

The nurse is preparing a client for a thyroid test. Which medications that the client is taking should be documented on the laboratory slip as possibly affecting the thyroid test?

Gigantism When oversecretion of GH occurs before puberty, gigantism results. Dwarfism occurs when secretion of GH is insufficient during childhood. Oversecretion of GH during adulthood results in acromegaly. An absence of pituitary hormonal activity causes Simmonds disease.

The nurse is reviewing a client's history which reveals that the client has had an oversecretion of growth hormone (GH) that occurred before puberty. The nurse interprets this as resulting in which condition?

by occluding the blood flow to the arm for 3 minutes with the use of a blood pressure cuff.

Trousseau sign is elicited

Cretinism During fetal and neonatal development, undersecretion of thyroid hormone may cause cretinism (stunted growth and mental development). In adults, hyposecretion of thyroid hormone causes myxedema or hypothyroidism. Diabetes insipidus is caused by undersecretion of antidiuretic hormone (ADH/vasopressin).

Undersecretion of thyroid hormone during fetal and neonatal development can cause which of the following?

vasopressin. Because diabetes insipidus results from decreased antidiuretic hormone (vasopressin) production, the nurse should expect to administer synthetic vasopressin for hormone replacement therapy. Furosemide, a diuretic, is contraindicated because a client with diabetes insipidus experiences polyuria. Insulin and dextrose are used to treat diabetes mellitus and its complications, not diabetes insipidus.

When caring for a client with diabetes insipidus, the nurse expects to administer:

Calcitonin Calcitonin, secreted in response to high plasma levels of calcium, reduces the calcium level by increasing its deposition in the bone.

When high levels of plasma calcium occur, the nurse is aware that the following hormone will be secreted:

TH may increase the effect of digitalis preparation. Thyroid hormones may increase the pharmacologic effects of digitalis glycosides, anticoagulant agents, and indomethacin, necessitating careful observation and assessment by the nurse for side effects.

When teaching a client diagnosed with hypothyroidism about medical intervention, which is important for the nurse to communicate?

fresh fruits. Cushing's syndrome causes sodium retention, which increases urinary potassium loss. Therefore, the nurse should advise the client to increase the intake of potassium-rich foods, such as fresh fruit. The client should restrict the consumption of dairy products, processed meats, cereals, and grains because they contain significant amounts of sodium. Although the client should consume foods high in calcium and protein, the client should find these nutrients in low-sodium foods.

When teaching a client with Cushing's syndrome about dietary changes, the nurse should instruct the client to increase intake of:

Computed tomography

Which diagnostic test is done to determine a suspected pituitary tumor?

A computed tomography or magnetic resonance imaging scan is done to detect a suspected pituitary tumor. Radiographs of the chest or abdomen are taken to detect tumors. Radiographs also determine the size of the organ and their location. Measuring blood hormone levels helps determine the functioning of endocrine glands. A radioimmunoassay determines the concentration of a substance in plasma.

Which diagnostic test is done to determine suspected pituitary tumor?

computed tomography scan A computed tomography or magnetic resonance imaging scan is done to detect a suspected pituitary tumor. Radiographs of the chest or abdomen are taken to detect tumors. Radiographs also determine the size of the organ and their location. Measuring blood hormone levels helps determine the functioning of endocrine glands. A radioimmunoassay determines the concentration of a substance in plasma.

Which diagnostic test is done to determine suspected pituitary tumor?

Have regular follow-up care. The nurse should instruct the client with Graves' disease to have regular follow-up care because most cases of Graves' disease eventually result in hypothyroidism. Annual thyroid-stimulating hormone tests and the client's ability to recognize signs and symptoms of thyroid dysfunction will help detect thyroid abnormalities early. Recording intake and output is important for clients with fluid and electrolyte imbalances but not thyroid disorders. DDAVP is used to treat diabetes insipidus. Although exercise to improve cardiovascular fitness is important, the importance of regular follow-up is most critical for this client.

Which instruction should be included in the discharge teaching plan for a client after thyroidectomy for Graves' disease?

Observe the color of stool. The nurse should observe the color of each stool and test the stool for occult blood. Bowel patterns, vital signs, and urine output do not help in determining the development of peptic ulcers.

Which of the following assessments should the nurse perform to determine the development of peptic ulcers when caring for a patient with Cushing's syndrome?

Handle body fluids carefully. The nurse handles body fluids carefully to prevent spread of contamination. Corticosteroids are not prescribed for thyroid tumor. Monitoring the respiratory status and administering prescribed medicines at the same time each day are unrelated to the care of a client receiving RAI.

Which of the following precautions would be most appropriate when caring for a client being treated with radioactive iodine (RAI) for a thyroid tumor?

Symptoms seen in older adults include weight loss and atrial fibrillation. Older adults may not experience restlessness or hyperactivity.

Which symptom of thyroid disease is seen in older adults?

Alpha The alpha cells of the pancreas secret the hormone glucagon. It promotes gluconeogenesis, thus increasing the blood glucose level. The beta cells of the pancreas secrete insulin. Delta cells secrete somatostatin, which reduces the rate at which food is absorbed from the gastrointestinal tract.

Which type of cell secretes glucagon and promotes gluconeogenesis?