Chapter 50: Caring for Clients with Disorders of the Endocrine System

A patient is having diagnostic testing for suspected hyperthyroidism. Which of the following diagnostics correlate with this endocrine disorder? Select all that apply.

Decrease in serum thyroid-stimulating hormone (TSH) Increased T3 Increased T4 Increase in radioactive iodine uptake Laboratory findings include a decrease in serum TSH (with primary disease), increased Ts and T4, and an increase in radioactive iodine uptake.

Accidental removal of one or both parathyroid glands can occur during a thyroidectomy. Which of the following is used to treat tetany?

Calcium gluconate Sometimes in thyroid surgery, the parathyroid glands are removed, producing a disturbance in calcium metabolism. Tetany is usually treated with IV calcium gluconate. Synthroid is used in the treatment of hypothyroidism. PTU and Tapazole are used in the treatment of hyperthyroidism.

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

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 middle-aged female client complains of anxiety, insomnia, weight loss, the inability to concentrate, and eyes feeling "gritty." Thyroid function tests reveal the following: thyroid-stimulating hormone (TSH) 0.02 U/ml, thyroxine 20 g/dl, and triiodothyronine 253 ng/dl. A 6-hour radioactive iodine uptake test showed a diffuse uptake of 85%. Based on these assessment findings, the nurse should suspect:

Graves' disease. Graves' disease, an autoimmune disease causing hyperthyroidism, is most prevalent in middle-aged females. In Hashimoto's thyroiditis, the most common form of hypothyroidism, TSH levels would be high and thyroid hormone levels low. In thyroiditis, radioactive iodine uptake is low (?2%), and a client with a multinodular goiter will show an uptake in the high-normal range (3% to 10%).

For a client with Graves' disease, which nursing intervention promotes comfort?

Maintaining room temperature in the low-normal range Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.

A client is undergoing a diagnostic workup for suspected thyroid cancer. What is the most common form of thyroid cancer in adults?

Papillary carcinoma Papillary carcinoma accounts for about 70% of thyroid cancer cases in adults. Follicular carcinoma accounts for roughly 15%; anaplastic carcinoma, about 5%; and medullary carcinoma, about 5%.

A client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg P.O. daily. Which finding should the nurse recognize as an adverse reaction to the drug?

Tachycardia Levothyroxine, a synthetic thyroid hormone, is given to a client with hypothyroidism to simulate the effects of thyroxine. Adverse reactions to this agent include tachycardia. Dysuria, leg cramps, and blurred vision aren't associated with levothyroxine.

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?

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.

The nurse is completing discharge teaching with a client with hyperthyroidism who has been treated with radioactive iodine at an outpatient clinic. The nurse instructs the client to

monitor for symptoms of hypothyroidism. Symptoms of hyperthyroidism may be followed later by those of hypothyroidism and myxedema. Hypothyroidism also commonly occurs in clients with previous hyperthyroidism who have been treated with radioiodine or antithyroid medications or thyroidectomy (surgical removal of all or part of the thyroid gland).

A young client has a significant height deficit and is to be evaluated for diagnostic purposes. What could be the cause of this client's disorder?

pituitary disorder Pituitary disorders usually result from excessive or deficient production and secretion of a specific hormone. Dwarfism occurs when secretion of growth hormone is insufficient during childhood.

Surgical removal of the thyroid gland is the treatment of choice for thyroid cancer. During the immediate postoperative period, the nurse knows to evaluate serum levels of __________ to assess for a serious and primary postoperative complication of thyroidectomy.

Calcium Efforts are made to spare parathyroid tissue to reduce the risk of postoperative hypocalcemia with resultant tetany.

A nurse is teaching a client with adrenal insufficiency about corticosteroids. Which statement by the client indicates a need for additional teaching?

"I may stop taking this medication when I feel better." The client requires additional teaching because he states that he may stop taking corticosteroids when he feels better. Corticosteroids should be gradually tapered by the physician. Tapering the corticosteroid allows the adrenal gland to gradually resume functioning. Corticosteroids increase the risk of infection and may mask the early signs of infection, so the client should avoid people who are sick. Corticosteroids cause muscle wasting in the extremities, so the client should increase his protein intake by eating foods such as chicken and dairy products. Corticosteroids have been linked to glaucoma and corneal lesions, so the client should visit his ophthalmologist regularly.

Which condition should a nurse expect to find in a client diagnosed with hyperparathyroidism?

Hypercalcemia Hypercalcemia is the hallmark of excess parathyroid hormone levels. Serum phosphate will be low (hypophosphatemia), and there will be increased urinary phosphate (hyperphosphaturia) because phosphate excretion is increased.

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?

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.

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?

Restricting fluids To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load.

A nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication?

Tetany Tetany may result if the parathyroid glands are excised or damaged during thyroid surgery. Hemorrhage is a potential complication after thyroid surgery but is characterized by tachycardia, hypotension, frequent swallowing, feelings of fullness at the incision site, choking, and bleeding. Thyroid storm is another term for severe hyperthyroidism — not a complication of thyroidectomy. Laryngeal nerve damage may occur postoperatively, but its signs include a hoarse voice and, possibly, acute airway obstruction.

A nurse is assessing a client with hyperthyroidism. What findings should the nurse expect?

Weight loss, nervousness, and tachycardia Weight loss, nervousness, and tachycardia are signs of hyperthyroidism. Other signs of hyperthyroidism include exophthalmos, diaphoresis, fever, and diarrhea. Weight gain, constipation, lethargy, decreased sweating, and cold intolerance are signs of hypothyroidism.

When assessing a client with pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, the nurse is most likely to detect:

a blood pressure of 176/88 mm Hg. Pheochromocytoma causes hypertension, tachycardia, hyperglycemia, hypermetabolism, and weight loss. It isn't associated with hypotension, hypoglycemia, or bradycardia.

A nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse expects to find:

deposits of adipose tissue in the trunk and dorsocervical area. Because of changes in fat distribution, adipose tissue accumulates in the trunk, face (moon face), and dorsocervical areas (buffalo hump). Hypertension is caused by fluid retention. Skin becomes thin and bruises easily because of a loss of collagen. Muscle wasting causes muscle atrophy and thin extremities.

A client with adrenal insufficiency is gravely ill and presents with nausea, vomiting, diarrhea, abdominal pain, profound weakness, and headache. The client's family reports that the client has been doing strenuous yard work all day and was sweating profusely. Nursing management of this client would include observation for signs of:

hyponatremia and hyperkalemia. The client's history and presenting symptoms suggest the onset of adrenal crisis. Laboratory findings that support adrenal deficiency and crisis include low serum sodium (hyponatremia) and high serum potassium (hyperkalemia) levels.

An incoherent client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and periorbital area. Knowing that these findings suggest severe hypothyroidism, the nurse prepares to take emergency action to prevent the potential complication of:

myxedema coma. Severe hypothyroidism may result in myxedema coma, in which a drastic drop in the metabolic rate causes decreased vital signs, hypoventilation (possibly leading to respiratory acidosis), and nonpitting edema. Thyroid storm is an acute complication of hyperthyroidism. Cretinism is a form of hypothyroidism that occurs in infants. Hashimoto's thyroiditis is a common chronic inflammatory disease of the thyroid gland in which autoimmune factors play a prominent role.

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?

"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 patient is suspected of having a pheochromocytoma and is having diagnostic tests done in the hospital. What symptoms does the nurse recognize as most significant for a patient with this disorder?

Blood pressure varying between 120/86 and 240/130 mm Hg Hypertension associated with pheochromocytoma may be intermittent or persistent. Blood pressures exceeding 250/150 mm Hg have been recorded. Such blood pressure elevations are life threatening and can cause severe complications, such as cardiac dysrhythmias, dissecting aneurysm, stroke, and acute kidney failure.

The physician has ordered a fluid deprivation test for a client suspected of having diabetes insipidus. During the test, the nurse should prioritize what assessments?

Heart rate and blood pressure The fluid deprivation test is carried out by withholding fluids for 8 to 12 hours or until 3% to 5% of the body weight is lost. The client's condition needs to be monitored frequently during the test, and the test is terminated if tachycardia, excessive weight loss, or hypotension develops. Consequently, blood pressure and heart rate monitoring are priorities over the other listed assessments.

Thyroid storm is a severe form of hyperthyroidism that can be fatal if not treated. Medical management includes pharmacotherapy. Which of the following drugs have proved helpful? Select all that apply.

Hydrocortisone Acetaminophen Methimazole Iodine Salicylates (i.e., aspirin) are contradicted because they displace thyroid hormone from binding to proteins and make hypermetabolism worse.

A client receiving thyroid replacement therapy develops influenza and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication puts the client at risk for developing which life-threatening complication?

Myxedema coma Myxedema coma, severe hypothyroidism, is a life-threatening condition that may develop if thyroid replacement medication isn't taken. Exophthalmos (protrusion of the eyeballs) is seen with hyperthyroidism. Although thyroid storm is life-threatening, it's caused by severe hyperthyroidism. Tibial myxedema (peripheral mucinous edema involving the lower leg) is associated with hypothyroidism but isn't life-threatening.

The nurse assesses a patient who has been diagnosed with Addison's disease. Which of the following is a diagnostic sign of this disease?

Potassium of 6.0 mEq/L Addison's disease is characterized by hypotension, low blood glucose, low serum sodium, and high serum potassium levels. The normal serum potassium level is 3.5 to 5 mEq/L.

A client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which "related-to" phrase should the nurse add?

Related to bone demineralization resulting in pathologic fractures Poorly controlled hyperparathyroidism may cause an elevated serum calcium level. This increase, in turn, may diminish calcium stores in the bone, causing bone demineralization and setting the stage for pathologic fractures and a risk for injury. Hyperparathyroidism doesn't accelerate the metabolic rate. A decreased thyroid hormone level, not an increased parathyroid hormone level, may cause edema and dry skin secondary to fluid infiltration into the interstitial spaces. Hyperparathyroidism causes hypercalcemia, not hypocalcemia; therefore, it isn't associated with tetany.

Patients with hyperthyroidism are characteristically:

Sensitive to heat Those with hyperthyroidism tolerate heat poorly and may perspire unusually freely. Their condition is characterized by symptoms of nervousness, hyperexcitability, irritability, and apprehension.

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:

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.

After a thyroidectomy, the client develops a carpopedal spasm while the nurse is taking a BP reading on the left arm. Which action by the nurse is appropriate?

Administer IV calcium gluconate as ordered. When hypocalcemia and tetany occur after a thyroidectomy, the immediate treatment is administration of IV calcium gluconate. If this does not immediately decrease neuromuscular irritability and seizure activity, sedative agents such as pentobarbital may be administered.

What should the nurse teach a client on corticosteroid therapy in order to reduce the client's risk of adrenal insufficiency?

Always have enough medication on hand to avoid running out. The client and family should be informed that acute adrenal insufficiency and underlying symptoms will recur if corticosteroid therapy is stopped abruptly without medical supervision. The client should be instructed to have an adequate supply of the corticosteroid medication always available to avoid running out. Doses should not be skipped or added without explicit instructions to do so. Corticosteroids should normally be taken in the morning to mimic natural rhythms.

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?

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

A client is returned to his room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside?

Tracheostomy set After a subtotal thyroidectomy, swelling of the surgical site (the tracheal area) may obstruct the airway. Therefore, the nurse should keep a tracheostomy set at the client's bedside in case of a respiratory emergency. Although an indwelling urinary catheter and a cardiac monitor may be used for a client after a thyroidectomy, the tracheostomy set is more important. A humidifier isn't indicated for this client.

A client on corticosteroid therapy needs to be taught that a course of corticosteroids of 2 weeks' duration can suppress the adrenal cortex for how long?

Up to 1 year Suppression of the adrenal cortex may persist up to 1 year after a course of corticosteroids of only 2 weeks' duration.

A patient with thyroiditis has undergone surgery and is concerned about the barely visible scar. Which of the following suggestions should the nurse give the patient to cope with the condition?

Wear clothing that covers the neck. The nurse may suggest that the patient wear clothing that covers the neck, making the scar almost invisible. Application of medicines, skin graft, and cosmetic surgery are not the appropriate suggestions.

A nurse is caring for a client with hypoparathyroidism. During assessment, the nurse elicits a positive Trousseau's sign. What does the nurse observe to verify this finding?

hand flexing inward The nurse observes the client for spasm of the hand (carpopedal spasm), which is evidenced by the hand flexing inward.