Endocrine Disorders
A nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following is a common clinical manifestation of this disorder? A. Decreased sodium level B. Increased serum osmolality C. Decreased blood pressure D. Increased urine output
A. Decreased sodium level
Cushing's disease (hypercortisolism) is caused by an oversecretion of the hormones the adrenal cortex produces. Cushing's disease can be the result of a tumor in the pituitary gland, resulting in release of the hormone ACTH. The ACTH then stimulates the adrenal cortex to increase the secretion of the glucocorticoid hormone cortisol. Endogenous causes of increased cortisol Adrenal hyperplasia Adrenocortical carcinoma Pituitary carcinoma that secretes adrenocorticotropic hormone (ACTH) Carcinomas of the lung, gastrointestinal (GI) tract, or pancreas (these tumors can secrete ACTH)
Adrenal Cortex Hormones: - Mineralocorticoids: Aldosterone increases sodium absorption and causes potassium excretion in the kidney. - Glucocorticoids: Cortisol affects glucose, protein, and fat metabolism; the body's response to stress; and the body's immune function. - Sex hormones: Androgens and estrogens
A nurse is assessing a client who is 12 hr postoperative following a thyroidectomy. Which of the following findings is indicative of thyroid crisis? Select all that apply. Correct: - Dyspnea - Mental confusion - Abdominal pain Excessive levels of thyroid hormone can cause the client to experience dyspnea and mental confusion. When thyroid crisis occurs, the client can experience gastrointestinal conditions, such as vomiting, diarrhea, and abdominal pain.
After surgery, indications of hypocalcemia (tingling of the fingers and toes, carpopedal spasms, convulsions). Notify of any tingling sensation of the mouth, tingling of distal extremities, or muscle twitching.
Diagnostic tests for the posterior pituitary gland include the water deprivation test, ADH, blood and urine electrolytes and osmolality, and urine specific gravity. Urine testing: Think CONCENTRATED. As urine volume decreases, urine osmolarity increases. Increased urine specific gravity Increased urine osmolarity Increased urine sodium
Blood testing: Think DILUTE. As blood volume increases, blood osmolarity decreases. Decreased blood sodium (dilutional hyponatremia) Decreased blood osmolarity (less than 270 mEq/L) Decrease in BUN, Hgb, Hct, creatinine clearance
A nurse in a provider's office is reviewing the laboratory reports of a client who is being evaluated for Graves' disease. Which of the following laboratory results is an indication of Graves' disease? A. Decreased thyrotropin receptor antibodies (TRAb) B. Decreased thyroid-stimulating hormone (TSH) C. Decreased thyroxine (T4) D. Decreased triiodothyronine (T3)
Correct Answer: B. Decreased thyroid-stimulating hormone (TSH) In the presence of Graves' disease, a low TSH level is an expected finding. The pituitary gland decreases the production of TSH when thyroid hormone levels are elevated.
ADH Increased ADH indicates SIADH, nephrogenic DI. Decreased ADH can indicate neurogenic DI. Expected Reference Range 1 to 5 pg/mL (1 to 5 ng/L) Electrolytes Low sodium and chloride are expected with SIADH. Expected Reference Range Sodium: 136 to 145 mEq/L Potassium: 3.5 to 5.0 mEq/L Chloride: 98 to 106 mEq/L Magnesium: 1.3 to 2.1 mEq/L
Decreased urine specific gravity is an expected finding of diabetes insipidus. Urine specific gravity Expected Reference Range: 1.010 to 1.025
A nurse is reviewing the laboratory findings for a client who has Cushing's disease. Which of the following findings should the nurse expect to find? Select all that apply. Correct: - Increased sodium and blood glucose - Decreased calcium, potassium and lymphocytes
Dexamethasone reduces ACTH release in normal people. Therefore, taking dexamethasone should reduce ACTH level and lead to a decreased cortisol level. If your pituitary gland produces too much ACTH, you will have an abnormal response to the low-dose test.
Plasma adrenocorticotropic hormone (ACTH) levels - Hypersecretion of ACTH by the anterior pituitary results in elevated ACTH levels. - Disorders of the adrenal cortex or medication therapy results in decreased ACTH levels.
Diagnostic Procedures - X-ray, magnetic resonance imaging, arteriography, and CT scans identify lesions of the pituitary gland, adrenal gland, lung, GI tract, and pancreas. - Radiological imaging determines the source of adrenal insufficiency (tumor, adrenal atrophy).
Laboratory Tests Expected Results with Hypothyroidism T3, T4: Decreased Blood thyroid-stimulating hormone (TSH) Increased with primary hypothyroidism Decreased or within the expected reference range in secondary hypothyroidism Blood cholesterol: Increased Antithyroid antibodies: Present in some cases
Diagnostic Procedures Thyroid scan: Clients who have hypothyroidism have a low uptake of the radioactive preparation. ECG: Sinus bradycardia, dysrhythmias
A nurse in a provider's office is reviewing laboratory results of a client who is being evaluated for secondary hypothyroidism. Which of the following laboratory findings is expected? Decreased T3 Decreased levels of T3 in the blood is an expected finding for a client who has secondary hypothyroidism due to an impairment of the function of the parathyroid or hypothalamus gland.
Expected Results with Hypothyroidism T3, T4: Decreased Blood thyroid-stimulating hormone (TSH): Increased with primary hypothyroidism Decreased or within the expected reference range in secondary hypothyroidism Blood cholesterol: Increased
A nurse is reviewing the manifestations of hyperthyroidism with a client. Which of the following findings should the nurse include? Select all that apply. Correct: - Irritability - Tremors - Rapid weight loss - Heat intolerance - Palpitations - Diarrhea - Tachycardia - Dysrhythmias
Expected findings:
A nurse in a provider's office is reviewing the health record of a client who is being evaluated for Graves disease. The nurse should identify that which of the following laboratory results is an expected finding? Decreased thyroid-stimulating hormone (TSH) In the presence of Graves disease, low TSH is an expected finding. The pituitary gland decreases the production of TSH when thyroid hormone levels are elevated. In the presence of Graves disease, elevated thyrotropin receptor antibodies, elevated free thyroxine index, and elevated triiodothyronine are expected findings.
Graves disease (toxic diffuse goiter) is the most common cause. Autoimmune antibodies result in hypersecretion of thyroid hormones (an increase in T3 and T4 in circulation) Methimazole and propylthiouracil inhibit the production of thyroid hormone. Thionamides are used to treat Graves disease, as an adjunct to radioactive iodine therapy, to decrease hormone levels in preparation for surgery, and to treat thyrotoxicosis.
Cushing's syndrome results from long-term use of glucocorticoids to treat other conditions (asthma or rheumatoid arthritis). Exogenous causes of increased cortisol: Therapeutic use of glucocorticoids for the following. Organ transplant Chemotherapy Autoimmune diseases Asthma Allergies Chronic fibrosis
Hypertension and hypokalemia occur in patients with Cushing's syndrome whereas aldosterone production is normal. High aldosterone levels can cause high blood pressure and low potassium levels. Low potassium levels may cause weakness, tingling, muscle spasms, and periods of temporary paralysis.
Hypothyroidism is a condition in which there is an inadequate amount of circulating thyroid hormones triiodothyronine (T3) and thyroxine (T4), causing a decrease in metabolic rate that affects all body systems. Thyroid function can decline slowly or rapidly (myxedema). Primary hypothyroidism stems from dysfunction of the thyroid gland due to autoimmune thyroiditis, use of certain medications (examples: lithium, amiodarone, thalidomide, rifampin, phenobarbital, phenytoin, carbamazepine), iodine deficiency, radioactive iodine or radiation treatment, surgical removal of the gland, Inadequate intake of iodine.
Manifestations of hypothyroidism: intolerance to cold, edema, bradycardia, increase in weight, depression, constipation, dry, flaky skin, decreased libido, impotence pallor; Fatigue, lethargy (sleeping up to 16 hr/day); Joint or muscle pain; hypotension, dysrhythmias, abnormal menstrual periods (menorrhagia/amenorrhea) Hoarse, raspy speech due to myxedema affecting the larynx
A nurse is teaching a client who has a new prescription for levothyroxine who has hypothyroidism. Which of the following information should the nurse include in the teaching? Select all that apply. Correct: - Medication should not be discontinued without the advice of the provider. - Follow-up blood TSH levels should be obtained - Take the medication on an empty stomach. The nurse should instruct the client that levothyroxine should not be discontinued without the notification of the provider. Changes in level of hormone can be dangerous. The client should schedule follow-up blood TSH levels to be checked to monitor the efficacy of the medication. Levothyroxine should be taken on an empty stomach to promote absorption.
More about Levothyroxine: - Inform the client that fiber supplements, calcium, iron, and antacids interfere with absorption. - Take the dose prescribed. Do not stop taking the medication or change the dose or brand name. - Take the medication on an empty stomach, typically 30 to 60 min before breakfast. - Monitor for and report manifestations of hyperthyroidism (irritability, tremors, tachycardia, palpitations, heat intolerance, rapid weight loss). - Treatment is considered to be lifelong, requiring ongoing medical assessment of thyroid function. - Weight loss is expected while taking this medication.
A nurse is providing medication teaching for a client who has Addison's disease and is taking hydrocortisone. Which of the following instructions should the nurse include? Select all that apply. Correct: - Take hydrocortisone with food to decrease GI distress. - Do not discontinue the medication suddenly - Report any manifestations of weakness or dizziness; are indications of adrenal insufficiency - Notify the provider of any infection, trauma, or stress that can increase the need for adrenocorticoids. - Might require sodium supplementation
Physical and emotional stress increase the need for hydrocortisone. The provider can increase the dosage when stress occurs. Rapid discontinuation can result in adverse effects, including acute adrenal insufficiency. If hydrocortisone is to be discontinued, the dose should be tapered. Because Addison's disease causes hyponatremia, the client might require sodium supplementation, especially if experiencing diaphoresis or vomiting.
Manifestations of chronic Addison's disease develop slowly, and manifestations of acute adrenal insufficiency develop rapidly. Expected findings: Weight loss Craving for salt Hyperpigmentation of the skin and mucous membranes Weakness and fatigue Nausea, anorexia, and vomiting Abdominal pain Constipation or diarrhea Severe hypotension (acute adrenal insufficiency) Hypovolemia Hyponatremia Hyperkalemia Hypoglycemia Hypercalcemia
Report manifestations of adrenal insufficiency (fever, fatigue, muscle weakness, anorexia). If your adrenal glands aren't making aldosterone, you will take a medicine called fludrocortisone link, which helps balance the amount of sodium and fluids in your body. People with secondary adrenal insufficiency usually make enough aldosterone, so they don't need to take this medicine. Medications that can help treat hyperaldosteronism include: Spironolactone (Aldactone®). Eplerenone (Inspra®).
A nurse is preparing care for client who is postoperative following a thyroidectomy. Which of the following items should the nurse have available? Select all that apply. Suction equipment Humidified oxygen Tracheostomy tray
Supplemental oxygen, and a tracheostomy tray are available at the bedside. The client can experience respiratory obstruction due to laryngeal edema. The nurse should ensure that suctioning equipment, supplemental oxygen, and a tracheostomy tray are available at the bedside.
A nurse is planning to teach a client who is being evaluated for primary Addison's disease about the adrenocorticotropic hormone (ACTH) stimulation test. Which of the following statements should the nurse make? Correct: - "ACTH is a hormone produced by the pituitary gland." Secretion of corticotropin-releasing hormone from the hypothalamus prompts the pituitary gland to secrete ACTH.
The ACTH stimulation test measures the response by the adrenal glands. In the presence of primary adrenal insufficiency, plasma cortisol levels do not rise in response to administration of ACTH. ACTH is administered IV during the testing process, and plasma cortisol levels are measured 30 min and 1 hr after the injection.
ATI review modules. A nurse is reviewing the laboratory findings for a client who has SIADH. Which of the following findings should the nurse anticipate? Select all that apply. Correct: - Low sodium - Increased urine osmolality - Increased urine specific gravity - High urine sodium
The nurse should anticipate the client's sodium to be low (dilutional hyponatremia); the urine osmolality to be increased due to a decrease in urine volume; the urine sodium and urine specific gravity to be elevated due to increased urine concentration.
A nurse is providing instructions to a client who has Graves disease and has a new prescription for propranolol. Which of the following information should the nurse include? "Take your pulse before each dose." Propranolol can cause bradycardia. The client should take their pulse before each dose. If there is a significant change, they should withhold the dose and consult the provider.
The purpose of propranolol is to suppress tachycardia, diaphoresis, and other effects of Graves disease.
A nurse is reviewing the manifestations of hyperthyroidism with a client. Which of the following findings should the nurse include? Select all that apply. Heat intolerance Palpitations Weight loss Diarrhea tachycardia Hand tremors
emotional lability increased appetite Insomnia and interrupted sleep Menstrual irregularities (amenorrhea or decreased menstrual flow) and decreased fertility Libido decreases as the condition progresses Warm, sweaty, flushed skin with velvety-smooth texture Hair thins and develops a fine, soft, silky texture Exophthalmos (Graves disease only) Goiter (common in Grave's disease)
A nurse is assessing for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse expect? (Select all that apply) Select all that apply. - Increased urine osmolarity - Distended neck veins - Weight gain In the presence of SIADH, too much ADH is produced resulting in fluid retention. Therefore, hyponatremia is an expected finding (dilutional hyponatremia). Increased fluid volume leads to tachycardia, weight gain, and distended neck veins, as well as crackles in the lungs. Water retention causes a decrease in urine output and urine osmolarity to increase.
weight gain (without edema because water, not sodium, is retained).
A nurse is reviewing laboratory results for a client who has Addison's disease. Which of the following laboratory results should the nurse expect for this client? Select all that apply. Correct: - Sodium 130 mEq/L - Potassium 6.1 mEq/L - Calcium 11.6 mg/dL - Blood urea nitrogen (BUN) 28 mg/dL
- Hyponatremia is an expected finding. In the presence of Addison's disease, insufficient glucose can cause sodium and water excretion. - Hyperkalemia is an expected finding for a client who has Addison's disease. - Hypercalcemia is an expected finding for a client who has Addison's disease. - BUN level above the expected reference due to dehydration. - Hypoglycemia or blood glucose in the normal range is an expected finding for a client who has Addison's disease.
Acute adrenal insufficiency (Addisonian crisis) Acute adrenal insufficiency (Addisonian crisis) occurs when there is an acute drop in adrenocorticoids due to sudden discontinuation of glucocorticoid medications or when induced by severe trauma, infection, or stress. Nursing Actions: - Establish an IV access and initiate a rapid infusion of 0.9% sodium chloride or dextrose 5% in normal saline. - Administer hydrocortisone sodium as IV bolus, initially and then as a continuous infusion. It can be administered IM as well. - Administer insulin and dextrose to move potassium into cells. - Administer calcium to counteract the effects of hyperkalemia and protect the heart; and sodium polystyrene sulfonate, a resin that absorbs potassium.
- If acidosis occurs, administer sodium bicarbonate to promote alkalinity and increase uptake of and move potassium into cells. - Loop or thiazide diuretics are used to manage hyperkalemia. - Monitor vital signs. - Monitor for manifestations of hyperkalemia (bradycardia, heart block, and peaked T waves). - Monitor electrolytes. Administer an H2 antagonist (famotidine, cimetidine) intravenously for ulcer prevention. - Position the client in a recumbent position with legs elevated. - Administer vasopressors to increase blood pressure.
A nurse in a provider's office is planning care for a client who has a new diagnosis of Graves disease and a new prescription for methimazole. Which of the following interventions should the nurse include in the plan of care? Select all that apply. Monitor CBC Monitor triiodothyronine (T3) Advise the client to take the medication at the same time every day
- Methimazole can cause several hematologic effects, including leukopenia and thrombocytopenia - Methimazole reduces thyroid hormone production - To maintain blood levels, instruct the client to take the methimazole at the same time every day.
Hypophysectomy - Client Education Use caution preoperatively to prevent infection or fractures. The surgeon will perform a transsphenoidal hypophysectomy through the sphenoid sinus via the nasal cavity or under the upper lip and to expect nasal packing postoperatively. There will be a drip pad under the nose for bloody drainage, so breathing must be through the mouth. Avoid coughing, blowing the nose, and sneezing. Numbness at the surgical site and a diminished sense of smell can occur for 3 to 4 months after surgery. Avoid bending over at the waist and straining to prevent increased intracranial pressure. If picking up an object or to tying shoes, bend at the knees.
Avoid brushing teeth for 2 weeks, and floss and rinse the mouth with warm water. QEBP Notify the provider of increased swallowing, drainage that makes a halo (yellow on the edge and clear in the middle), or clear drainage from the nose, which can indicate a CSF leak. Another indication is a headache. Notify the provider of excessive bleeding, confusion, or headache. To avoid constipation, which contributes to increased intracranial pressure, eat high-fiber food, and take docusate.
A nurse is caring for a client who asks why the provider bases the medication regime on HbA1c results instead of the log of morning fasting blood glucose levels. Which of the following responses should the nurse make? "HbA1c indicates how well you have regulated your blood glucose over the past 120 days." HbA1c 5.9% or less indicates no diabetes mellitus. HbA1c less than 7% indicates good diabetes control. HbA1c 8% to 9% indicates fair diabetes control. HbA1c 9% or greater indicates poor diabetes control
Capillary glucose monitoring evaluates how well insulin regulates your blood glucose between meals and makes an overall determination of how well insulin regulates your blood glucose. Two tests are used to diagnose diabetes mellitus, a fasting glucose and a glucose tolerance tests.
Causes of primary Addison's disease: Idiopathic autoimmune dysfunction (majority of cases) - Tuberculosis - Histoplasmosis - Adrenalectomy - Metastatic cancers (breast, lung, colon, melanoma - Radiation therapy of the abdomen e.g. Autoimmune dysfunction, adrenalectomy and tuberculosis
Causes of secondary Addison's disease: - Steroid withdrawal - Hypophysectomy - Pituitary neoplasm - High dose radiation of pituitary gland or entire brain e.g. Long-time use of prednisone without dosage tapering
A nurse is caring for an 8-year-old child diagnosed with diabetic ketoacidosis who is receiving an insulin infusion and an infusion of normal saline. Which of the following findings does the nurse consider most concerning? A. Potassium level of 4.8 mEq/L B. BUN of 16 mg/dL and creatinine of 0.8 mg/dL ✔ Correct answer CC. Changes in T waves on the cardiac monitor D. Heart rate of 115/minute Check Answer Perfect! Close Explanation Correct Answer: C. Changes in T waves on the cardiac monitor Correct Answer: red highlighted C. Changes in T waves on the cardiac monitor
Changes in the T wave on the cardiac monitor can indicate hypokalemia or hyperkalemia. Peaked T waves occur with hyperkalemia, but flattening of the T wave and lengthening of the QT interval indicate low serum potassium. Potassium levels can change with an insulin infusion in clients with diabetic ketoacidosis (DKA), as insulin drives potassium into cells. Because of whole body potassium depletion, potassium supplementation is normally needed when the client is normokalemic and voiding. A change in T waves is significant for possible shifts in potassium during therapy.
A nurse is admitting a client who has acute adrenal insufficiency. Which of the following prescriptions should the nurse expect? Select all that apply. Correct: - Regular insulin - Sodium polystyrene sulfonate - Furosemide - Hydrocortisone sodium succinate - IV therapy with 0.9% sodium chloride
Clients who have acute adrenal insufficiency are hyperkalemic. Insulin can be administered to shift potassium into the cells. Sodium polystyrene sulfonate can be administered because it binds with potassium for elimination through the feces. Loop and thiazide diuretics promote potassium excretion and can also be administered to treat hyperkalemia. Hydrocortisone sodium succinate is administered as replacement therapy of both glucocorticoid and mineralocorticoid. Clients who have acute adrenal insufficiency are hyponatremic. Anticipate a prescription for a solution that contains 0.9% sodium chloride.
Laboratory Tests - Comprehensive metabolic panel: increased K+, increased WBC, decreased Na+, increased BUN and creatinine, glucose is within expected rage or decreased, and increased calcium - Blood/salivary cortisol: decreased - Adrenocorticotropic hormone (ACTH) stimulation test (provocation test): ACTH is administered intravenously, and the cortisol response is measured 30 min and 1 hr after the injection. With primary adrenal insufficiency, plasma cortisol levels do not rise. With secondary adrenal insufficiency, plasma cortisol levels are increased. ACTH test cannot be performed if the client is experiencing an acute crisis.
Diagnostic Procedures Electrocardiogram (ECG) Used to assess for ECG changes or dysrhythmias associated with electrolyte imbalance. X-ray, CT scan, and MRI scan Radiological imaging to determine source of adrenal insufficiency (a tumor or adrenal atrophy)
A nurse in provider's office is reviewing the health history of a client who has Addison's disease. Identify the most common cause and two additional causes of primary Addison's disease. - Risk Factors: Most common: autoimmune dysfunction Additional causes: tuberculosis, histoplasmosis, adrenalectomy, cancer
Expected Findings Weight loss Craving for salt Hyperpigmentation of the skin and mucous membranes Weakness and fatigue Nausea, anorexia, and vomiting Abdominal pain Constipation or diarrhea Severe hypotension (acute adrenal insufficiency) Hypovolemia Hyponatremia Hyperkalemia Hypoglycemia Hypercalcemia
A nurse is assessing a client who is 12 hr postoperative following a thyroidectomy. Which of the following findings is indicative of thyroid crisis? Select all that apply. Dyspnea Mental confusion Abdominal pain
Findings are hyperthermia, hypertension, delirium, vomiting, diarrhea, abdominal pain, tachydysrhythmias, chest pain, dyspnea, and palpitations.
A deficiency of ADH causes diabetes insipidus, which is the excretion of a large quantity of dilute urine. Causes of polyuria, including diabetes insipidus (DI). - Nephrogenic DI: failure of the kidneys to respond to ADH for a variety of reasons (hypokalemia, hypocalcemia, or medication use [lithium, demeclocycline]) - Central (neurogenic) DI: head injury, tumor, irradiation of the pituitary gland, or serious infection; the body does not produce ADH - Psychogenic polydipsia: compulsive fluid intake, associated with conditions (schizophrenia)
For neurogenic DI, lifelong self-administration of vasopressin therapy is required. Desmopressin (DDAVP), which is a synthetic ADH, or aqueous vasopressin administered intranasally, orally, or parenterally. Vasopressin can be administered intranasally or by injection. This results in increased water absorption from kidneys and decreased urine output Chlorpropamide and thiazide diuretics facilitate vasopressin action (for clients who have neurogenic DI). Clients who have nephrogenic DI are prescribed prostaglandin inhibitors and thiazide diuretics, and mild salt depletion.
A nurse is teaching a client who has bilateral adrenal hyperplasia and a new prescription for hydrocortisone. Explain why the client needs to take this medication. Hydrocortisone is a glucocorticoid that treats adrenal insufficiency resulting from adrenalectomy surgery. Identify three teaching points to include about this medication: - Carry emergency identification about corticosteroid use. - Report abdominal pain or black, tarry stools. - Notify the provider for any manifestations of infection. Take the medication without skipping any doses. - Consume a diet high in calcium and vitamin D. - Consult the provider before taking any OTC medications or supplements. - Avoid infection by using good hygiene and avoiding crowds or individuals who have an infection.
Hydrocortisone. For replacement therapy for clients who have adrenocortical insufficiency as a result of the treatment of Cushing's disease Hydrocortisone - Nursing actions This medication can be used in conjunction with ketoconazole to avoid adrenal insufficiency. Monitor potassium and glucose levels. Measure daily weight. Notify the provider of weight gain greater than 2.3 kg (5 lb)/week. Monitor blood pressure and pulse. Monitor for manifestations of infection (increased temperature, increased WBC).
A patient who is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) has the serum sodium levels below 120 mEq/L and presents with neurologic manifestations such as seizures. What would be the most appropriate nursing Administration of intravenous hypertonic saline solution
Hypertonic Sodium Chloride IV Fluid The goal is to elevate the sodium level enough to alleviate neurologic compromise. Nursing Actions In severe hyponatremia/water intoxication, administer 200 to 300 mL hypertonic IV fluid (3% sodium chloride). Monitor for fluid overload and heart failure (distended neck veins, crackles in lungs)
A nurse is caring for a client who is 6 hr postoperative following a transsphenoidal hypophysectomy. The nurse should test the client's nasal drainage for the presence of which of the following? Correct: - Glucose The nurse should test the client's nasal drainage for the presence of glucose which is an indication a leakage of cerebral spinal fluid. Assess drainage for the presence of glucose or a halo sign (yellow on the edge and clear in the middle), which can indicate CSF.
Hypophysectomy Surgical removal of the pituitary gland (depending on the cause of Cushing's disease) Other nursing interventions: - Protect the client from developing an infection by using good hand hygiene and making sure the client avoids contact with individuals who have infections. Use caution to prevent a fracture by aiding getting out of bed and raising side rails. - Assess neurologic status every hour for the first 24 hr and then every 4 hr. - Administer glucocorticoids before, during, and after surgery to prevent an abrupt drop in cortisol level. - Administer stool softeners to prevent straining. - Maintain a high caloric and protein diet.
A nurse in a provider's office is reviewing the health record of a client who is being evaluated for Graves disease. The nurse should identify that which of the following laboratory results is an expected finding? Decreased thyroid-stimulating hormone (TSH)
In the presence of Graves disease, low TSH is an expected finding. The pituitary gland decreases the production of TSH when thyroid hormone levels are elevated. In the presence of Graves disease, elevated thyrotropin receptor antibodies, elevated free thyroxine index, and elevated triiodothyronine are expected findings.
A nurse is comparing the pathophysiology of diabetes insipidus (DI)with the pathophysiology of syndrome of inappropriate antidiuretic hormone (SIADH). Sort the manifestations below into manifestations of DI and manifestations of SIADH. In the presence of DI there is a decreased amount of antidiuretic hormone which results in excessive amounts of urine. Most of the manifestations of DI are related to dehydration, therefore hypernatremia, and tachycardia occurs.
In the presence of SIADH which is the opposite of DI, there is fluid retention which leads to hyponatremia and weight gain.
A nurse is caring for a client who is twelve hours postoperative following a thyroidectomy. Which of the following findings indicates the client might be experiencing thyroid storm? (Select all that apply.) Correct Answers: Hypertension Abdominal pain Mental confusion Thyroid storm can occur as a result of excess thyroid hormone being released with a dramatic increase in metabolism.
Manifestations will include: Fever Tachycardia Increased systolic blood pressure Abdominal pain Nausea Vomiting Diarrhea Anxiousness with tremors Restlessness, confusion, psychotic behavior Seizures Death can occur
A nurse is providing information to a client who has a new prescription for demeclocycline to treat syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following statements should the nurse make? "You should notify the provider if you experience diarrhea." The tetracyclines, including demeclocycline, can cause bacterial superinfection of the bowel which can result in severe diarrhea; therefore, the client should inform the provide if diarrhea is experienced.
Medications: Tetracycline Derivative (Demeclocycline) Unlabeled use to correct fluid and electrolyte imbalances in mild SIADH by stimulating urine flow. It acts on collecting tubule cells to diminish their responsiveness to ADH, in effect essentially inducing nephrogenic diabetes insipidus. Contraindicated in clients who have impaired kidney function. ADH release is inhibited by atrial natriuretic peptide (ANP), which is released by stretched atria in response to increases in blood pressure, as well as alcohol and certain medications.
A nurse in a provider's office is planning care for a client who has a new diagnosis of Graves disease and a new prescription for methimazole. Which of the following interventions should the nurse include in the plan of care? Select all that apply. Correct: - Monitor CBC - Monitor triiodothyronine (T3) - Advise the client to take the medication at the same time every day - Limit iodine containing foods (shellfish).
Methimazole can cause several hematologic effects, including leukopenia and thrombocytopenia. Methimazole reduces thyroid hormone production, the nurse should also monitor the T3. Take the methimazole at the same time every day to maintain blood levels Take the medication with meals, in divided doses at regular intervals to maintain an even therapeutic medication level. Do not stop taking abruptly. Report fever, sore throat, jaundice, or bruising to the provider. Follow the provider's instructions about dietary intake of iodine
Treatment depends on the cause. For Cushing's syndrome, tapering off glucocorticoids and managing findings are necessary. Ketoconazole An adrenal corticosteroid inhibitor, ketoconazole is an antifungal agent that inhibits adrenal corticosteroid synthesis in high dosages. Client Education The medication can cause nausea, vomiting, fatigue, skin changes, and dizziness. Relief is temporary. Findings will return after stopping taking the medication. Take the medication with food to relieve gastric effects
Mitotane Produces selective destruction of adrenocortical cells Nursing Actions Mitotane treats inoperable adrenal carcinoma. Monitor for indications of shock, renal damage, and hepatotoxicity. Monitor for orthostatic hypotension. Client Education The purpose of the medication is to reduce the size of the tumor. Notify the provider for adverse effects (visual disturbances, hematuria). Use caution when driving or operating heavy machinery. Lifelong replacement with glucocorticoids is likely.
Thyroid storm/crisis results from a sudden surge of large amounts of thyroid hormones into the bloodstream, causing an even greater increase in body metabolism. This is a medical emergency with a high mortality rate. Findings are hyperthermia, hypertension, delirium, vomiting, abdominal pain, tachydysrhythmias, chest pain, dyspnea, and palpitations. Nursing Actions Maintain a patent airway. Monitor vital signs frequently. Provide continuous cardiac monitoring for dysrhythmias. Administer acetaminophen to decrease temperature.
Precipitating factors include uncontrolled hyperthyroidism occurring most often with Graves disease, infection, trauma, emotional stress, diabetic ketoacidosis, and digitalis toxicity, all of which increase demands on body metabolism. It also can occur following a surgical procedure or a thyroidectomy as a result of manipulation of the gland during surgery. ! Salicylate antipyretics (aspirin) are contraindicated because they release thyroxine from protein-binding sites and increase free thyroxine levels.
Addison's Disease and Acute Adrenal Insufficiency (Addisonian Crisis) Addison's disease is an adrenocortical insufficiency. It is caused by damage or dysfunction of the adrenal cortex. With Addison's disease, the production of mineralocorticoids and glucocorticoids is diminished, resulting in decreased aldosterone and cortisol. Acute adrenal insufficiency, also known as Addisonian crisis, has a rapid onset. It is a medical emergency. If it is not quickly diagnosed and properly treated, the prognosis is poor.
Produced by the adrenal cortex: - Mineralocorticoids: Aldosterone increases sodium absorption and causes potassium excretion in the kidney. - Glucocorticoids: Cortisol affects glucose, protein, and fat metabolism; the body's response to stress; and the body's immune function. - Sex hormones: Androgens and estrogens
A nurse is providing instructions to a client who has Graves disease and has a new prescription for propranolol. Which of the following information should the nurse include? "Take your pulse before each dose."
Propranolol can cause bradycardia. The client should take their pulse before each dose. If there is a significant change, they should withhold the dose and consult the provider. The purpose of propranolol is to suppress tachycardia, diaphoresis, and other effects of Graves disease.
A nurse is caring for a client who is about to begin taking propylthiouracil (PTU) to treat hyperthyroidism. The nurse should instruct the client to report which of the following adverse effects? (Select all that apply.) Sore throat Joint pain Bradycardia
Propylthiouracil, an antithyroid drug, can cause agranulocytosis. Propylthiouracil can cause arthralgia and myalgia. The nurse should instruct the client to report these effects and take over-the-counter analgesics for pain relief.
A nurse is caring for a client who is taking propylthiouracil (PTU) and reports weight gain, drowsiness, and depression. The nurse should identify that the client is experiencing which of the following adverse reactions to the drug? Hypothyroidism
Propylthiouracil, an antithyroid drug, can cause hypothyroidism, which manifests as drowsiness, depression, weight gain, edema, and bradycardia. The nurse should request that the provider prescribe a lower dosage of the drug for the client.
A nurse is providing teaching with a client who is scheduled to receive radioactive iodine therapy. What should the nurse include in the teaching? Client Education - Do not use same toilet as others for 2 weeks. - Sit down to urinate. - Flush the toilet three times after use. - Take a laxative 2 to 3 days after treatment to rid the body of stool contaminated with radiation. - Wear clothing that is washable, wash clothing separate from clothing of others, and run the washing machine for a full cycle after washing contaminated clothing. - Avoid close contact with infants, young children, and pregnant individuals for the first week following treatment. - Do not share a toothbrush, and use disposable food service items (paper plates).
Radioactive iodine is administered. While it is used for thyroid scan, it is a small amount for testing. For therapy, larger amounts are given for cell destruction. The thyroid absorbs the radiation, which results in destruction of cells that produce thyroid hormone. Take medication as directed. The effects of the therapy might not be evident for 6 to 8 weeks. Follow precautions to prevent radiation exposure to others.
A nurse is reviewing information about hypothyroidism with a client. What information should the nurse include in the discussion? Alteration in health (diagnosis): Hypothyroidism is a condition in which there is an inadequate amount of circulating thyroid hormones triiodothyronine (T3) and thyroxine (T4), causing a decrease in metabolic rate that affects all body systems.
Risk Factors Female clients age 30 to 60 years Use of lithium or amiodarone Laboratory tests Blood T3 Blood T4 Free T4 index Thyroid antibodies TSH Blood cholesterol
Hyperthyroidism and hypothyroidism are disorders in which there are inappropriate amounts of the thyroid hormones triiodothyronine (T3) and thyroxine (T4) circulating. These inappropriate amounts of T3 and T4 cause an increase or decrease in metabolic rate that affects all body systems. The anterior pituitary gland secretes thyroid stimulating hormone (TSH) which prompts the thyroid to release T3 and T4. Hyposecretion of TSH can lead to secondary hypothyroidism, and hypersecretion of TSH can cause secondary hyperthyroidism. Hyperthyroidism is a clinical syndrome caused by excessive circulating thyroid hormones. Because thyroid activity affects all body systems, excessive thyroid hormone exaggerates normal body functions and produces a hypermetabolic state. Dietary intake of protein and iodine is necessary for the production of thyroid hormones.
T3 and T4 Low and high levels of each indicate hypothyroidism and hyperthyroidism, respectively. A high level of T3 is a better indicator hyperthyroidism than is T4. TSH An increased value indicates primary hypothyroidism due to thyroid dysfunction or thyroiditis. A decreased value indicates hyperthyroidism (Graves' disease) or secondary hypothyroidism (due to pituitary or hypothalamus dysfunction). What levels of TSH are concerning? TSH levels below 0.4mU/L indicate hyperthyroidism, while levels of about 4.0mU/L and above indicate hypothyroidism.
A nurse is providing teaching with a client who is scheduled to receive radioactive iodine therapy. What should the nurse include in the teaching? Radioactive iodine is administered. While it is used for thyroid scan, it is a small amount for testing. For therapy, larger amounts are given for cell destruction. The thyroid absorbs the radiation, which results in destruction of cells that produce thyroid hormone. The effects of the therapy might not be evident for 6 to 8 weeks. Take medication as directed. Follow precautions to prevent radiation exposure to others. Do not use same toilet as others for 2 weeks.Sit down to urinate.Flush the toilet three times after use.
Take a laxative 2 to 3 days after treatment to rid the body of stool contaminated with radiation.Wear clothing that is washable, wash clothing separate from clothing of others, and run the washing machine for a full cycle after washing contaminated clothing.Avoid close contact with infants, young children, and pregnant individuals for the first week following treatment.Do not share a toothbrush, and use disposable food service items (paper plates).
A nurse in an intensive care unit is planning care for a client who has myxedema coma. Which of the following actions should the nurse include? Select all that apply. Correct: - Monitor for dysrhythmias. - Assist with ventilator support - Initiate IV fluids using 0.9% sodium chloride. - Administer a levothyroxine IV bolus. More interventions: Monitor mental status.; Provide continuous ECG monitoring.; Treat hypoglycemia with glucose.; Administer corticosteroids; Initiate aspiration precautions; Check for possible sources of infection (blood, sputum, urine) that might have precipitated the coma. Treat any underlying illness.
The nurse should monitor the client's heart rate because dysrhythmias can be a manifestation of myxedema coma. A client who has myxedema can have a flat or inverted T wave as well as ST deviations. The nurse should assist with ventilator support because myxedema coma can cause respiratory failure. Hyponatremia is a a manifestation of myxedema coma; therefore, IV therapy should be administered using 0.9% sodium chloride. Levothyroxine should be administered IV bolus to treat the condition.
A nurse is planning care for a client who has SIADH with mild manifestations. The nurse should expect the provider to prescribe which of the following medications? Tolvaptan
Vasopressin antagonists (tolvaptan, conivaptan) Promote water excretion without causing sodium losses used in acute (inpatient) setting because it rapidly increases sodium levels. Nursing Actions: Monitor blood glucose levels. Monitor blood sodium levels. Monitor intake and output. Monitor bowel patterns.
