M/S Exam 1

Which of the following should the nurse include in the teaching plan of a female client with bilateral adrenalectomy? 1.Emphasizing that the client will need steroid replacement for the rest of her life. 2.Instructing the client about the importance of tapering steroid medication carefully to prevent crisis. 3.Informing the client that steroids will be required only until her body can manufacture sufficient quantities. 4.Emphasizing that the client will need to take steroids whenever her life involves physical or emotional stress.

1 Bilateral adrenalectomy requires lifelong adrenal hormone replacement therapy. If unilateral surgery is performed, most clients gradually reestablish a normal secretion pattern. The client and family will require extensive teaching and support to maintain self-care management at home. Information on dosing, adverse effects, what to do if a dose is missed, and follow-up examinations is needed in the teaching plan. Although steroids are tapered when given for an intermittent or one-time problem, they are not discontinued when given to clients who have undergone bilateral adrenalectomy because the clients will not regain the ability to manufacture steroids. Steroids must be taken on a daily basis, not just during periods of physical or emotional stress.

The client with Addison's disease is taking glucocorticoids at home. Which of the following statements indicate that the client understands how to take the medication? 1."Various circumstances increase the need for glucocorticoids, so I will need to adjust the dosage." 2."My need for glucocorticoids will stabilize and I will be able to take a predetermined dose once a day." 3."Glucocorticoids are cumulative, so I will take a dose every third day." 4."I must take a dose every 6 hours to ensure consistent blood levels of glucocorticoids."

1 The need for glucocorticoids changes with circumstances. The basal dose is established when the client is discharged, but this dose covers only normal daily needs and does not provide for additional stressors. As the manager of the medication schedule, the client needs to know signs and symptoms of excessive and insufficient dosages. Glucocorticoid needs fluctuate. Glucocorticoids are not cumulative and must be taken daily. They must never be discontinued suddenly; in the absence of endogenous production, addisonian crisis could result. Two-thirds of the daily dose should be taken at about 8 am and the remainder at about 4 pm. This schedule approximates the diurnal pattern of normal secretion, with highest levels between 4 and 6 am and lowest levels in the evening.

Which actions prescribed by the health care provider for the patient with Addison disease should the nurse delegate to the experienced unlicensed assistive personnel (UAP)? Select all that apply. 1. Weigh the patient every morning. 2. Obtain fingerstick glucose before each meal and at bedtime. 3. Check vital signs every 2 hours. 4. Monitor for cardiac dysrhythmias. 5. Administer oral prednisone 10 mg every morning. 6. Record intake and output.

1, 2, 3, 6 Weighing patients, recording intake and output, and checking vital signs are all within the scope of practice for a UAP. An experienced UAP would have been trained to perform fingerstick glucose monitoring. The nurse should make sure that the UAP has mastered this skill and then instruct the UAP to record and inform him or her about the results. Administering medications and monitoring for cardiac dysrhythmias are within the scope of practice of licensed nurses.

A client has an adrenal tumor and is scheduled for a bilateral adrenalectomy. During preoperative teaching, the nurse teaches the client how to do deep breathing exercises after surgery by telling the client to: 1."Sit in an upright position and take a deep breath." 2."Hold your abdomen firmly with a pillow and take several deep breaths." 3."Tighten your stomach muscles as you inhale and breathe normally." 4."Raise your shoulders to expand your chest.

2 Effective splinting for a high incision reduces stress on the incision line, decreases pain, and increases the client's ability to deep-breathe effectively. Deep breathing should be done hourly by the client after surgery. Sitting upright ignores the need to splint the incision to prevent pain. Tightening the stomach muscles is not an effective strategy for promoting deep breathing. Raising the shoulders is not a feature of deep-breathing exercises.

A client diagnosed with Cushing's syndrome is admitted to the hospital and scheduled for a dexamethasone suppression test. During this test, the nurse should 1.Collect a 24-hour urine specimen to measure serum cortisol levels. 2.Administer 1 mg of dexamethasone orally at night and obtain serum cortisol levels the next morning. 3.Draw blood samples before and after exercise to evaluate the effect of exercise on serum cortisol levels. 4.Administer an injection of adrenocorticotropic hormone (ACTH) 30 minutes before drawing blood to measure serum cortisol levels.

2 When Cushing's syndrome is suspected a 24-hour urine collection for free cortisol is performed. Levels of 50 to 100 mcg/day (1,379 to 2,756 nmol/L) in adults indicate Cushing's syndrome. If these results are borderline a high-dose dexamethasone suppression test is done. The Dexamethasone is given at 11 pm to suppress secretion of the corticotrophin-releasing hormone. A plasma cortisol sample is drawn at 8 am. Normal cortisol level less than 5 mcg/dL (140 nmol/L) indicates normal adrenal response.

A client with Addison's disease is taking corticosteroid replacement therapy. The nurse should instruct the client about which side effects of corticosteroids? Select all that apply. 1. Hyperkalemia 2. Skeletal muscle weakness 3. Mood changes 4. Hypocalcemia 5. Increased susceptibility to infection 6. Hypotension

2,3,4,5 The long-term administration of corticosteroids in therapeutic doses often leads to serious complications or side effects. Corticosteroid therapy is not recommended for minor chronic conditions; the potential benefits of treatment must always be weighed against the risks. Hypokalemia may develop; corticosteroids act on the renal tubules to increase sodium reabsorption and enhance potassium and hydrogen excretion. Corticosteroids stimulate the breakdown of protein for gluconeogenesis, which can lead to skeletal muscle wasting. CNS adverse effects are euphoria, headache, insomnia, confusion, and psychosis. The nurse watches for changes in mood and behavior, emotional stability, sleep pattern, and psychomotor activity, especially with long-term therapy. Hypocalcemia related to anti-vitamin D effect may occur. Corticosteroids cause atrophy of the lymphoid tissue, suppress the cell-mediated immune responses, and decrease the production of antibodies. The nurse must be alert to the possibility of masked infection and delayed healing (anti-inflammatory and immunosuppressive actions). Retention of sodium (and subsequently water) increases blood volume and, therefore, blood pressure.

A nurse cares for a client with diabetes mellitus who is visually impaired. The client asks, "Can I ask my niece to prefill my syringes and then store them for later use when I need them?" How should the nurse respond? A. "Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up." B. "Yes. Syringes can be filled with insulin and stored for a month in a location that is protected from light." C. "Insulin reacts with plastic, so prefilled syringes are okay, but you will need to use glass syringes." D. "No. Insulin syringes cannot be prefilled and stored for any length of time outside of the container."

Answer A Rationale: Insulin is relatively stable when stored in a cool, dry place away from light. When refrigerated, prefilled plastic syringes are stable for up to 3 weeks. They should be stored in the refrigerator in the vertical position with the needle pointing up to prevent suspended insulin particles from clogging the needle.

Which of the following urinalysis results would be consistent for a client diagnosed with type 2 diabetes mellitus that has blood glucose levels ranging from 180 to 220 mg/dL? A. Low specific gravity B. Presence of bilirubin C. Glucose in the urine D. Presence of crystals

Answer C Rationale: The client diagnosed with type 2 diabetes mellitus with blood glucose levels ranging from 180 to 22 mg/dL will most likely exhibit glucose in the urine. Choice A is incorrect because the finding of low specific gravity is consistent with the diagnosis of diabetes insipidus and not diabetes mellitus. Choice B is incorrect because the presence of bilirubin indicates liver disease or damage. Choice D is incorrect because crystals in the urine would indicate kidney and/or bladder stones.

A client with type 2 diabetes mellitus presents to the health care provider's office with glycosylated hemoglobin (HgbA1C) level of 10.5%. Which statement by the client indicates an understanding of this test and its results? A. "The results of the test are probably high because I ate a donut for breakfast this morning." B. "The results of the test are probably low because I had not eaten anything for 12 hours before my blood was drawn." C. "I know that I need to check my glycosylated hemoglobin before each meal and at bedtime, but I don't always do it. I will do it more regularly." D. "Well, I have 3 months to really work on watching my diet and lowering my blood sugar. My next glycosylated hemoglobin test should be better then."

Answer D Rationale: The HgbA1C test provides a measurement of glycemic control over the previous 2 to 3 months, with increases in the HgbA1C reflecting elevated blood glucose levels. An HgbA1C of less than 6% is recommended by most healthcare providers. Thus, option 4 is the correct one. Options 1 and 2 are incorrect, as HgbA1Cmeasures glycemic control over a few months, and thus having fasted for a long time or having just eaten something does not affect HgbA1C. Option 3 is incorrect because clients check their blood glucose levels, not their HgbA1C, before meals and at bedtime.

An elderly adult male with type 1 diabetes mellitus (DM) is admitted for an emergency cholecystectomy. The client tells the nurse that it has been difficult keeping his blood glucose levels under 200 ml/dl (11.1 mmol/L SI). To prevent the client from developing diabetic ketoacidosis (DKA), which intervention is most important for the nurse to include in the plan of care? A. Check fingerstick glucose Q 6 hour B. Teach the client how to manage sick days C. Ensure IV fluids are infusing continuously D. Use a dipstick to measure urine for ketone

Answer: A

When obtaining subjective data from a patient during assessment of the endocrine system, the nurse asks specifically about: A. Energy level B. Intake of vitamin C C. Employment history D. Frequency of sexual intercourse

Answer: A

The nurse is concerned that a client with type 2 diabetes mellitus is experiencing a complication of the disease. What did the nurse most likely assess in this client? A. Erectile dysfunction B. Recent onset of rheumatoid arthritis C. Increasing hemoglobin A2c D. Hypothyroidism

Answer: A Rationale: A complication is a problem that arises as a result of an underlying condition, treatment or procedure. Erectile dysfunction is a common complication of type 2 diabetes mellitus that arises due to the glycoxidation of microvessels and small nerves, leading to microvascular and autonomic nervous system damage. Choice B and D are incorrect because even though clients with type 2 diabetes mellitus have an increased risk of developing other autoimmune diseases, this is considered to be due to "genetic predisposition" rather than disease-induced changes to the micro-environment. Choice C is incorrect because hemoglobin A1c is a marker for glucose control. Elevation in A1c levels is associated with a greater risk of complications but is not a complication.

A client diagnosed with type 2 diabetes mellitus tells the nurse that she has a goal of losing 50lbs in one month. The client currently weighs 175lbs with a BMI of 26. Which of the following should the nurse respond to this client? A. Since your BMI is 26, a weight loss of 50 lbs is not necessary to achieve a normal weight. B. That sounds like a great goal C. I think you should be able to lose 50 lbs in one month D. Maybe you should consider losing more weight

Answer: A Rationale: Considering the client's BMI, the client is currently overweight. However, a weight loss of 50lbs could potentially create additional health and nutritional issues for the client. The nurse should state that since the client is overweight and not obsessed, a weight loss goal of 50lbs in not necessary. Choice B is incorrect because a weight loss of 50 lbs is not necessary for this client to achieve normal weight. Choice C is incorrect because a weight loss of 50 lbs is too dramatic. Ideal weight loss should be between 1-2 lbs a week. Choice D is incorrect because the client does not need to lose more than 50 lbs to achieve normal weight.

The nurse is teaching a group of clients diagnosed with diabetes mellitus. Which lesson regarding foot care should be included? Select all that apply. A. Cut toenails across and file along the curves of the toes B. Rub fee vigorously with a towel after bathing to ensure dryness C. Use mild foot powder on perspiring feet D. Use cotton or lamb's wool to separate overlapping toes E. Use an over the counter corn removal kit to remove corns or calluses

Answer: A. C, D Rationale: Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet. This is due to the chronic complication of peripheral neuropathy, which results from nerve damage in the extremities. Instructions for diabetic foot care include: Wash feet daily with warm water and mild soap; test water temperature with a thermometer beforehand. Gently pat feet dry, particularly between the toes (Option 2). Use lanolin to prevent dry and cracked skin, but do not apply between the toes. Inspect for abrasions, cuts, or sores. Have others inspect the feet if their eyesight is poor. To prevent injury, use cotton or lamb's wool to separate overlapping toes. Cut toenails straight across and use a nail file to file along the curves of the toes. Avoid going barefoot and wear sturdy leather shoes. Use mild foot powder to absorb perspiration and wear clean, absorbent socks with seams aligned (Options 1, 3, and 4). Avoid using over-the-counter products (eg, iodine, alcohol, strong adhesives) on cuts or abrasions (Option 5).

The nurse caring for a patient who recently underwent removal of a pituitary adenoma via the transphenoidal approach knows that which of the following routine post-operative interventions will be contraindicated for this patient: A.Turn every 2 hours B.Cough and deep breath C.Ambulation D.HOB 30 degrees

Answer: B

The nurse is providing teaching to a young adult client with type I diabetes mellitus. Which statement indicates teaching has been effective? A. If I lose enough weight there is a chance I can stop taking insulin B. I'll need to take less insulin before I exercise C. There is a big chance that if I get children they will develop type I diabetes too D. If I feel light-headed and dizzy, I should sit down and drink some diet coke

Answer: B Rationale: Exercise will decrease the blood sugar levels and insulin doses will need to be adjusted. Choice A is incorrect because type I diabetes mellitus is treated with insulin-producing cells in the pancreas being destroyed. Choice C is incorrect because the risk of passing on the disease to one's children varies between 3 and 5%. Choice D is incorrect because in the event of hypoglycemia the client should be instructed to ingest a source of sugar and not a diet drink.

The nurse is caring for an adolescent client diagnosed with type 1 diabetes. The client exhibits hot, dry skin and glucose levels of 350mg/dL. Arterial blood gases show a pH 7.27. STAT serum chemistry labs have been drawn. Cardiac monitoring shows a sinus rhythm with peaked T waves, and the client has minimal urine output. What is the nurse's next priority action? A. Administer IV regular insulin B. Administer normal saline infusion C. Obtain urine for urinalysis D. Request a prescription for potassium infusion

Answer: B Rationale: This client has diabetic ketoacidosis (DKA). All clients with DKA experience dehydration due to osmotic diuresis. Prompt and adequate fluid therapy restores tissue perfusion and suppresses the elevated levels of stress hormones. The initial hydrating solution is 0.9% saline infusion. (Option 1) Insulin therapy should be started after the initial rehydration bolus as serum glucose levels fall rapidly after volume expansion. (Option 3) Urinalysis is important but not a priority. (Option 4) Potassium should never be given until the serum potassium level is known to be normal or low and urinary voiding is observed. Peaked T waves indicate hyperkalemia in this client. Clients with insulin deficiency frequently have increased serum potassium levels due to the extracellular shift despite having total body potassium deficit from urinary losses. Once insulin is given, serum potassium levels drop rapidly, often requiring potassium replacement. Potassium is never given as a rapid IV bolus, as cardiac arrest may result.

A patient with diabetes insipidus is treated with 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 (1.003-1.030) D. Oral intake greater than urinary output

Answer: C

A potential adverse effect of palpating the thyroid gland is: A. Carotid artery obstruction B. Damage to the cricoid cartilage C. Release of excessive thyroid hormone D. Hoarseness from pressure on the laryngeal nerve

Answer: C

The nurse cares for a client diagnosed with type I diabetes mellitus who came to the emergency department with the acute complication of diabetic ketoacidosis (DKA). After checking the blood glucose, which prescription should the nurse implement first? A. Insert an indwelling urinary catheter for accurate output calculation B. Obtain serum potassium level results and report to the primary health care provider. C. Prepare an insulin drip for intravenous (IV) infusion as prescribed D. Start an IV line and infuse normal saline as prescribed

Answer: D Rationale: DKA is a life-threatening complication of type I diabetes characterized by hyperglycemia (>250 mg/dL) that results in ketosis, a metabolic acidosis. Glucose cannot be taken out of the bloodstream and used for energy without insulin. The body begins to break down fat stores into ketones, as it does in a state of starvation, causing metabolic acidosis (low pH and low HCO3). The lack of insulin also results in increased glucose production in the liver, worsening hyperglycemia. Hyperglycemia causes osmotic diuresis, and clients are severely dehydrated. The cardinal signs of dehydration are poor skin turgor, dry mucosal membranes, tachycardia, orthostatic hypotension, weakness, and lethargy. Despite laboratory values showing hyperkalemia on admission, clients with DKA have a net potassium deficiency and will need careful replacement after fluid resuscitation. (Option 1) Although it is important to insert an indwelling catheter to monitor fluid balance, rehydrating the client is a life-saving measure with higher priority. (Option 2) Although it is important to monitor serum potassium results before and during insulin administration, rehydrating the client is the highest priority. Dilution will also improve the hyperkalemia. (Option 3) The priority intervention in DKA is to start an IV infusion for bolus rehydration therapy with normal saline. This should occur before insulin infusion as insulin will result in water, potassium, and glucose entering the cells, worsening dehydration and electrolyte imbalances.

The nurse is instructing a client diagnosed with type 2 diabetes mellitus on foot care. Which of the following client statements would indicate that instruction has been effective? A. "I should buy new tight-fitting shoes to ensure proper fit." B. "Walking barefoot at home is fine as long as I am walking on carpet." C. "I should wear tight socks all day to protect my feet adequately." D. "I should avoid exercises that involved running or jumping."

Answer: D. Rationale: The client with type 2 diabetes mellitus is prone to developing peripheral neuropathy. Sensations of pain are diminished, predisposing the client to a foot injury, ulceration and infection. Although exercise itself will help promote blood flow, high-impact sports like running or jumping should be avoided to prevent trauma to the feet. Choice A is incorrect because new tight-fitting shoes come with a risk of blistering and skin laceration. Choice B is incorrect because the client should be instructed to never walk barefoot, regardless of the floor surface. Choice C is incorrect because tight-fitting socks may impair the blood flow to the client's feet and should be avoided.

The nurse is teaching a client recovering from addisonian crisis about the need to take fludrocortisone acetate and hydrocortisone at home. Which statement by the client indicates an understanding of the instructions? 1. "I'll take my hydrocortisone in the late afternoon, before dinner." 2. "I'll take all of my hydrocortisone in the morning, right after I wake up." 3. "I'll take two-thirds of the dose when I wake up and one-third in the late afternoon." 4. "I'll take the entire dose at bedtime."

RATIONALES (3): Hydrocortisone, a glucocorticoid, should be administered according to a schedule that closely reflects the body's own secretion of this hormone; therefore, two-thirds of the dose of hydrocortisone should be taken in the morning and one-third in the late afternoon. This dosage schedule reduces adverse effects.

The nursing care for the client in addisonian crisis should include which intervention? 1. Encouraging independence with activities of daily living (ADLs) 2. Allowing ambulation as tolerated 3. Offering extra blankets and raising the heat in the room to keep the client warm 4. Placing the client in a private room

RATIONALES(4): The client in addisonian crisis has a reduced ability to cope with stress due to an inability to produce corticosteroids. Compared to a multibed room, a private room is easier to keep quiet, dimly lit, and temperature controlled. Also, visitors can be limited to reduce noise, promote rest, and decrease the risk of infection. The client should be kept on bed rest, receiving total assistance with ADLs to avoid stress as much as possible. Because extremes of temperature should be avoided, measures to raise the body temperature, such as extra blankets and turning up the heat, should be avoided.

Before discharge, what should a client with Addison's disease be instructed to do when exposed to periods of stress? 1. administer hydrocortisone I.M. 2. Drink 8 oz of fluids. 3. Perform capillary blood glucose monitoring four times daily 4. Continue to take his usual dose of hydrocortisone.

RATIONALES: (1) Clients with Addison's disease and their family members should know how to administer I.M. hydrocortisone during periods of stress. It's important to keep well hydrated during stress, but the critical component in this situation is to know how and when to use I.M. hydrocortisone. Capillary blood glucose monitoring isn't indicated in this situation because the client doesn't have diabetes mellitus. Hydrocortisone replacement doesn't cause insulin resistance.

When teaching a client with Cushing's syndrome about dietary changes, the nurse should instruct the client to increase intake of: 1. fresh fruits 2. dairy products 3. processed meats 4. cereals and grains

RATIONALES: (1) Cushing's syndrome causes sodium retention, which increases urinary potassium loss. Therefore, the nurse should advise the client to increase intake of potassium-rich foods, such as fresh fruit. The client should restrict consumption of dairy products, processed meats, cereals, and grains because they contain significant amounts of sodium.

In a 28-year-old female client who is being successfully treated for Cushing's syndrome, the nurse would expect a decline in: 1. serum glucose level 2. hair loss 3. bone mineralization 4. menstrual flow

RATIONALES: (1) Hyperglycemia, which develops from glucocorticoid excess, is a manifestation of Cushing's syndrome. With successful treatment of the disorder, serum glucose levels decline. Hirsutism is common in Cushing's syndrome; therefore, with successful treatment, abnormal hair growth also declines. Osteoporosis occurs in Cushing's syndrome; therefore, with successful treatment, bone mineralization increases. Amenorrhea develops in Cushing's syndrome. With successful treatment, the client experiences a return of menstrual flow, not a decline in it.

The nurse is planning care for a 52-year-old male client in acute Addisonian crisis. Which nursing diagnosis should receive the highest priority? 1. Risk for Infection 2. Decreased cardiac output 3. Impaired physical mobility 4. Imbalanced nutrition: less than body requirement

RATIONALES: (2) 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 is also an appropriate nursing diagnosis for the client with Addison's disease, but it isn't a priority in a crisis. Imbalanced nutrition: Less than body requirements is also an important nursing diagnosis for the client with Addison's disease but not a priority during a crisis.

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: 1. an ectopic corticotropin-secreting tumor 2. adrenal carcinoma 3. a corticotropin-secreting pituitary adenoma 4. an inborn error of metabolism.

RATIONALES: (3) 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 often 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 client with Addison's disease is scheduled for discharge after being hospitalized for an adrenal crisis. Which statements by the client would indicate that client teaching has been effective? 1. "I have to take my steroids for 10 days." 2. "I need to weigh myself daily to be sure I don't eat too many calories." 3. "I need to call my doctor to discuss my steroid needs before I have dental work." 4. "I will call the doctor if I suddenly feel profoundly weak or dizzy." 5. "If I feel like I have the flu, I'll carry on as usual because this is an expected response." 6. "I need to obtain and wear a Medic Alert bracelet."

RATIONALES:(3, 4, 6) Dental work can be a cause of physical stress; therefore, the client's physician needs to be informed about the dental work and an adjusted dosage of steroids may be necessary. Fatigue, weakness, and dizziness are symptoms of inadequate dosing of steroid therapy; the physician should be notified if these symptoms occur. A Medic Alert bracelet allows health care providers to access the client's history of Addison's disease if the client is unable to communicate this information. A client with Addison's disease doesn't produce enough steroids, so routine administration of steroids is a lifetime treatment. Daily weights should be monitored to monitor changes in fluid balance, not calorie intake. Influenza is an added physical stressor and the client may require an increased dosage of steroids. The client shouldn't "carry on as usual."

The nurse caring for a patient admitted with SIADH can anticipate which of the following physician orders: A.0.45% NS at 100 ml/hr B.D5W at 100 ml/hr C.Fluid restriction of 1000 ml/day D.DDAVP IVP

Answer: C

Which of the following would be an expected finding in a client with adrenal crisis (addisonian crisis)? 1.Fluid retention. 2.Pain. 3.Peripheral edema. 4.Hunger.

2 Adrenal hormone deficiency can cause profound physiologic changes. The client may experience severe pain (headache, abdominal pain, back pain, or pain in the extremities). Inhibited gluconeogenesis commonly produces hypoglycemia, and impaired sodium retention causes decreased, not increased, fluid volume. Edema would not be expected. Gastrointestinal disturbances, including nausea and vomiting, are expected findings in Addison's disease, not hunger.

The nurse is caring for a patient with Grave's disease and assessment reveals exophthalmos. Which of the following interventions are indicated to prevent injury to the eye: (Select all that apply) A. Elevate HOB B. Apply eye patches during sleep C. Have patient blink frequently D. Lubricating eyedrops

A and D

Important Nursing interventions when caring for a patient with Cushing syndrome include (select all that apply) A. restricting protein intake. B. monitoring blood glucose levels. C. administering medication in equal doses. D. protecting patient from exposure to infection.

B and D

The nurse caring for a patient admitted with an ADH secreting lung cancer would anticipate which lab finding: A. Serum sodium 150 B. Serum osmolality elevated C. Urine specific gravity 1.002 D. Serum sodium 125

D

The client is admitted to rule out Cushing's syndrome. Which laboratory tests should the nurse anticipate being ordered? 1. Plasma drug levels of quinidine, digoxin, and hydralazine. 2. Plasma levels of ACTH and cortisol. 3. A 24-hour urine for metanephrine and catecholamine. 4. Spot urine for creatinine and white blood cells (WBCs).

2 The adrenal gland secretes cortisol and the pituitary gland secretes adrenocorti- cotropic hormone (ACTH), a hormone used by the body to stimulate the produc- tion of cortisol.

Which of the following is the priority for a client in addisonian crisis? 1.Controlling hypertension. 2.Preventing irreversible shock. 3.Preventing infection. 4.Relieving anxiety.

2. Addison's disease is caused by a deficiency of adrenal corticosteroids and can result in severe hypotension and shock because of uncontrolled loss of sodium in the urine and impaired mineralocorticoid function. This results in loss of extracellular fluid and dangerously low blood volume. Glucocorticoids must be administered to reverse hypotension. Preventing infection is not an appropriate goal of care in this life-threatening situation. Relieving anxiety is appropriate when the client's condition is stabilized, but the calm, competent demeanor of the emergency department staff will be initially reassuring.

Following a hypophysectomy for acromegaly, postoperative nursing care should focus on: A. Frequent monitoring of serum and urine osmolarity B. Parenteral administration of a GH-receptor antagonist C. Keeping the patient in a recumbent position at all times D. Patient education regarding the need for lifelong ACTH, TSH, FSH, LH hormone replacement

A

The nurse caring for a patient who recently underwent removal of a pituitary adenoma via the transphenoidal approach knows that a common complication with this surgery is a headache. In order to prevent this complication the nurse will: A.Provide pain medication routinely B.Keep the patient in the supine position C.Assess VS every 2 hours D.Keep the patient's HOB at 30 degrees

Answer. D

A client diagnosed with diabetic ketoacidosis is demonstrating metabolic acidosis. Which of the following arterial blood gas values would validate the presence of metabolic acidosis? A. pH 7.29; HCO3- 20 mEq/l B. pH 7.40: HCO3- 35mEq/l C. pH 7.30; PaCO2 50mmHg D. pH 7.48; PaCO2 30mm Hg

Answer: A Rationale: in metabolic acidosis, the pH is below 7.35 and the bicarbonate value is less than 22mEq/L. Choice B would be seen in metabolic alkalosis. Choice C would be seen in respiratory acidosis. Choice D would be seen in respiratory alkalosis.

A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this client's teaching? A. "When ill, avoid eating or drinking to reduce vomiting and diarrhea." B. "Monitor your blood glucose levels at least every 4 hours while sick." C. "If vomiting, do not use insulin or take your oral antidiabetic agent." D. "Try to continue your prescribed exercise regimen even if you are sick."

Answer: B Rationale: When ill, the client should monitor his or her blood glucose at least every 4 hours. The client should continue taking the medication regimen while ill. The client should continue to eat and drink as tolerated but should not exercise while sick.

Manifestations of endocrine problems in the older adult that are commonly attributed to the aging process are: (Select all that apply) A. tremors B. fatigue C. fluid retention D. mental impairment

Answer: B and D

In the intensive care unit, the nurse cares for a client who has been admitted with diabetic ketoacidosis. The client is on a continuous infusion of regular insulin at 5 units/hr via IV pump. Which action should the nurse expect to implement? A. Check serum BUN and creatinine levels every hour B. Discontinue insulin infusion when blood glucose is <350 mg/dL C. Increase insulin infusion rate when blood glucose level decreases D. Initiate potassium IV when serum potassium is 3.5-5.0mEq/L

Answer: D Rationale: Diabetic ketoacidosis (DKA) is an acute, serious complication generally due to lack of insulin in clients with type 1 diabetes. DKA is characterized by hyperglycemia, ketosis, and acidosis. Hyperglycemia causes osmotic diuresis, resulting in profound dehydration. Clients with DKA may initially develop hyperkalemia as a compensatory response to acidosis despite having a total body potassium deficit from urinary loss. Management of DKA includes fluid resuscitation, IV insulin, and hourly blood glucose monitoring. When serum glucose is <250 mg/dL (13.9 mmol/L), D5W is administered to prevent hypoglycemia until ketoacidosis is resolved. Hypokalemia often occurs with a resolution of acidosis and administration of IV insulin, which shifts potassium from the intravascular to the intracellular space. Therefore, potassium is administered even when the client is normo-kalemic (3.5-5.0 mEq/L [3.5-5.0 mmol/L]) to prevent hypokalemia and subsequent life-threatening arrhythmias (Option 4). (Option 1) Serum potassium, glucose, and anion gap or bicarbonate levels are regularly monitored in DKA to monitor treatment effectiveness. Although serum creatinine and BUN levels may be elevated due to dehydration and may be monitored, hourly monitoring is not indicated. (Option 2) IV insulin infusion may be discontinued on the resolution of acidosis and ketosis, which generally occurs with a blood glucose level of <200 mg/dL (11.1 mmol/L). (Option 3) As blood glucose is reduced, the insulin infusion rate is decreased to prevent a hypoglycemic event.

After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the pt indicates a correct understanding of the need for eye examinations? A. "At my age, I should continue seeing the ophthalmologist as I usually do." B. "I will see the eye doctor when I have a vision problem and yearly after age 40." C. "My vision will change quickly. I should see the ophthalmologist twice a year." D. "Diabetes can cause blindness, so I should see the ophthalmologist yearly."

Answer: D Rationale: Diabetic retinopathy is a leading cause of blindness in North America. All clients with diabetes, regardless of age, should be examined by an ophthalmologist (rather than an optometrist or optician) at diagnosis and at least yearly thereafter.

Common nonspecific manifestations that may alert the nurse to endocrine dysfunction include: A. Goiter and alopecia B. Exophthalmos and tremors C. Weight loss, fatigue, depression D. Polyuria, polydipsia, and polyphagia

C

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

The nurse is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately? 1. pitting edema of the legs 2. an irregular apical pulse 3. dry mucous membranes 4. frequent urination

RATIONALES (2): 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.

The nurse is assessing a group of clients in the community health clinic for metabolic syndrome. Which clients exhibit features of the syndrome? Select all that apply A. Female with a low-density lipoprotein (LDL) level of 96mg/dL B. Female with a waist circumference of 38 inches C. Female with a blood pressure of 148/90mmHg D. Male with a fasting blood glucose of 99mg/dL E. Male with a triglyceride level of 201mg/dL

Q2 Answer: B, C Rationale: Individuals with metabolic syndrome (insulin resistance syndrome) have an increased risk of diabetes and coronary artery disease. The presence of abdominal obesity causes increased insulin production (hyperinsulinemia); this excess insulin leads to insulin resistance, the primary feature of metabolic syndrome.

For a client in addisonian crisis, it would be very risky for a nurse to administer: 1. potassium chloride 2. normal saline solution 3. hydrocortisone 4. fludrocortisone

RATIONALES: (1) Addisonian crisis results in hyperkalemia; therefore, administering potassium chloride is contraindicated. Because the client will be hyponatremic, normal saline solution is indicated. Hydrocortisone and fludrocortisone are both useful in replacing deficient adrenal cortex hormones.

A client is admitted to the health care facility for evaluation for Addison's disease. Which laboratory test result best supports a diagnosis of Addison's disease? 1. BUN level of 12 mg/dl 2. Blood glucose level of 90 mg/dl 3. Serum sodium level of 134 mEq/L 4. Serum potassium level of 5.8 mEq/L

RATIONALES: (4) Addison's disease decreases the production of aldosterone, cortisol, and androgen, causing urinary sodium and fluid losses, an increased serum potassium level, and hypoglycemia. Therefore, an elevated serum potassium level of 5.8 mEq/L best supports a diagnosis of Addison's disease. A BUN level of 12 mg/dl and a blood glucose level of 90 mg/dl are within normal limits. In a client with Addison's disease, the serum sodium level would be much lower than 134 mEq/L, a nearly normal level.

Which nursing diagnosis is most appropriate for a client with Addison's disease? 1. Risk for infection 2. Excessive fluid volume 3. Urinary retention 4. Hypothermia

RATIONALES:(1) Addison's disease decreases the production of all adrenal hormones, compromising the body's normal stress response and increasing the risk of infection. Other appropriate nursing diagnoses for a client with Addison's disease include Deficient fluid volume and Hyperthermia. Urinary retention isn't appropriate because Addison's disease causes polyuria.

A nurse assesses a client who has diabetes mellitus and notes the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup of orange juice, the client's clinical manifestations have not changed. Which action should the nurse take next? A. Administer another half-cup of orange juice. B. Administer a half-ampule of dextrose 50% intravenously. C. Administer 10 units of regular insulin subcutaneously. D. Administer 1 mg of glucagon intramuscularly.

Answer A Rationale: This client is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, the nurse should administer oral glucose in the form of orange juice. If the symptoms do not resolve immediately, the treatment should be repeated. The client does not need intravenous dextrose, insulin, or glucagon.

After stabilization of Addison's disease, the nurse teaches the client about stress management. The nurse should instruct the client to: 1.Remove all sources of stress from daily life. 2.Use relaxation techniques such as music. 3.Take antianxiety drugs daily. 4.Avoid discussing stressful experiences.

2 Finding alternative methods of dealing with stress, such as relaxation techniques, is a cornerstone of stress management. Removing all sources of stress from one's life is not possible. Antianxiety drugs are prescribed for temporary management during periods of major stress, and they are not an intervention in stress management classes. Avoiding discussion of stressful situations will not necessarily reduce stress.

The nurse is planning the care of a client diagnosed with Addison's disease. Which intervention should be included? 1. Administer steroid medications. 2. Place the client on fluid restriction. 3. Provide frequent stimulation. 4. Consult physical therapy for gait training.

1 Clients diagnosed with Addison's disease have adrenal gland hypofunction. The hormones normally produced by the gland must be replaced. Steroids and androgens are produced by the adrenal gland.

The nurse is performing discharge teaching for a client diagnosed with Cushing's disease. Which statement by the client demonstrates an understanding of the instructions? 1. "I will be sure to notify my health-care provider if I start to run a fever." 2. "Before I stop taking the prednisone, I will be taught how to taper it off." 3. "If I get weak and shaky, I need to eat some hard candy or drink some juice." 4. "It is fine if I continue to participate in weekend games of tackle football."

1 Cushing's syndrome/disease predisposes the client to develop infections as a result of the immunosuppressive nature of the disease.

A nurse is caring for a patient after hypophysectomy. The nurse notices clear nasal drainage from the patient's nostril. The initial nursing action would be to: A. Lower the head of the bed B. Test the drainage for glucose C. Obtain a culture of the drainage D. Continue to observe the drainage

Answer: B

Which of the following is a priority outcome for the client with Addison's disease? 1.Maintenance of medication compliance. 2.Avoidance of normal activities with stress. 3.Adherence to a 2-g sodium diet. 4.Prevention of hypertensive episodes.

1 Medication compliance is an essential part of the self-care required to manage Addison's disease. The client must learn to adjust the glucocorticoid dose in response to the normal and unexpected stresses of daily living. The nurse should instruct the client never to stop taking the drug without consulting the health care provider to avoid an addisonian crisis. Regularity in daily habits makes adjustment easier, but the client should not be encouraged to withdraw from normal activities to avoid stress. The client does not need to restrict sodium. The client is at risk for hyponatremia. Hypotension, not hypertension, is more common with Addison's disease.

The client has developed iatrogenic Cushing's disease. Which statement is the scientific rationale for the development of this diagnosis? 1. The client has an autoimmune problem causing the destruction of the adrenal cortex. 2. The client has been taking steroid medications for an extended period for another disease process. 3. The client has a pituitary gland tumor causing the adrenal glands to produce too much cortisol. 4. The client has developed an adrenal gland problem for which the health-care provider does not have an explanation.

2 "iatrogenic" means a problem has been caused by a medical treatment or procedure—in this case, treatment with steroids for another problem. Clients taking steroids over a period of time develop the clinical manifestations of Cushing's disease. Disease processes for which long-term steroids are prescribed include chronic obstructive pulmonary disease, cancer, and arthritis.

Bone resorption is a possible complication of Cushing's disease. Which of the following interventions should the nurse recommend to help the client prevent this complication? 1.Increase the amount of potassium in the diet. 2.Maintain a regular program of weight-bearing exercise. 3.Limit dietary vitamin D intake. 4.Perform isometric exercises.

2 Osteoporosis is a serious outcome of prolonged cortisol excess because calcium is resorbed out of the bone. Regular daily weight-bearing exercise (eg, brisk walking) is an effective way to drive calcium back into the bones. The client should also be instructed to have a dietary or supplemental intake of calcium of 1,500 mg daily. Potassium levels are not relevant to prevention of bone resorption. Vitamin D is needed to aid in the absorption of calcium. Isometric exercises condition muscle tone but do not build bones.

Because of steroid excess after a bilateral adrenalectomy, the nurse should assess the client for: 1.Postoperative confusion. 2.Delayed wound healing. 3.Emboli. 4.Malnutrition.

2 Persistent cortisol excess undermines the collagen matrix of the skin, impairing wound healing. It also carries an increased risk of infection and of bleeding. The wound should be observed and documentation performed regarding the status of healing. Confusion and emboli are not expected complications after adrenalectomy. Malnutrition also is not an expected complication after adrenalectomy. Nutritional status should be regained postoperatively.

In the early postoperative period after a bilateral adrenalectomy, the client has an increased temperature. The nurse should assess the client further for signs of: 1.Dehydration. 2.Poor lung expansion. 3.Wound infection. 4.Urinary tract infection.

2 Poor lung expansion from bed rest, pain, and retained anesthesia is a common cause of slight postoperative temperature elevation. Nursing care includes turning the client and having the client cough and deep-breathe every 1 to 2 hours, or more frequently as prescribed. The client will have postoperative IV fluid replacement prescribed to prevent dehydration. Wound infections typically appear 4 to 7 days after surgery. Urinary tract infections would not be typical with this surgery.

The nurse should monitor the client with Cushing's disease for which of the following? 1.Postprandial hypoglycemia. 2.Hypokalemia. 3.Hyponatremia. 4.Decreased urine calcium level.

2 Sodium retention is typically accompanied by potassium depletion. Hypertension, hypokalemia, edema, and heart failure may result from the hypersecretion of aldosterone. The client with Cushing's disease exhibits postprandial or persistent hyperglycemia. Clients with Cushing's disease have hypernatremia, not hyponatremia. Bone resorption of calcium increases the urine calcium level.

The nurse is conducting discharge education with a client newly diagnosed with Addison's disease. Which information should be included in the client and family teaching plan? Select all that apply. 1.Addison's disease will resolve over a few weeks, requiring no further treatment. 2.Avoiding stress and maintaining a balanced lifestyle will minimize risk for exacerbations. 3.Fatigue, weakness, dizziness, and mood changes need to be reported to the physician. 4.A medical identification bracelet should be worn. 5.Family members need to be informed about the warning signals of adrenal crisis. 6.Dental work or surgery will require adjustment of daily medication.

2, 3, 4, 5, 6. Addison's disease occurs when the client does not produce enough steroids from the adrenal cortex. Lifetime steroid replacement is needed. The client should be taught lifestyle management techniques to avoid stress and maintain rest periods. A medical identification bracelet should be worn and the family should be taught signs and symptoms that indicate an impending adrenal crisis, such as fatigue, weakness, dizziness, or mood changes. Dental work, infections, and surgery commonly require an adjusted dosage of steroids.

The nurse writes a problem of "altered body image" for a 34-year-old client diagnosed with Cushing's disease. Which intervention should be implemented? 1. Monitor blood glucose levels prior to meals and at bedtime. 2. Perform a head-to-toe assessment on the client every shift. 3. Use therapeutic communication to allow the client to discuss feelings. 4. Assess bowel sounds and temperature every four (4) hours.

3 Allowing the client to ventilate feelings about the altered body image is the most appropriate intervention. The nurse cannot do anything to help the client's buffalo hump or moon face.

The nurse should assess a client with Addison's disease for which of the following? 1. Weight gain. 2. Hunger. 3. Lethargy. 4. Muscle spasms.

3 Although many of the disease signs and symptoms are vague and nonspecific, most clients experience lethargy and depression as early symptoms. Other early signs weight loss, muscle weakness, fatigue, nausea, and vomiting. Most clients experience a loss of appetite. Muscles become weak, not spastic, because of adrenocortical insufficiency.

A client with Cushing's disease tells the nurse that the physician said the morning serum cortisol level was within normal limits. The client asks, "How can that be? I'm not imagining all these symptoms!" The nurse's response will be based on which of the following concepts? 1.Some clients are very sensitive to the effects of cortisol and develop symptoms even with normal levels. 2.A single random blood test cannot provide reliable information about endocrine levels. 3.The excessive cortisol levels seen in Cushing's disease commonly result from loss of the normal diurnal secretion pattern. 4.Tumors tend to secrete hormones irregularly, and the hormones are generally not present in the blood.

3 Cushing's disease is commonly caused by loss of the diurnal cortisol secretion pattern. The client's random morning cortisol level may be within normal limits, but secretion continues at that level throughout the entire day. Cortisol levels should normally decrease after the morning peak. Analysis of a 24-hour urine specimen is often useful in identifying the cumulative excess. Clients will not have symptoms with normal cortisol levels. Hormones are present in the blood.

A client with Addison's disease is admitted to the medical unit. The client has fluid and electrolyte loss due to inadequate fluid intake and to fluid loss secondary to inadequate adrenal hormone secretion. As the client's oral intake increases, which of the following fluids would be most appropriate? 1.Milk and diet soda. 2.Water and eggnog. 3.Bouillon and juice. 4.Coffee and milkshakes.

3 Electrolyte imbalances associated with Addison's disease include hypoglycemia, hyponatremia, and hyperkalemia. Salted bouillon and fruit juices provide glucose and sodium to replenish these deficits. Diet soda does not contain sugar. Water could cause further sodium dilution. Coffee's diuretic effect would aggravate the fluid deficit. Milk contains potassium and sodium.

Cortisone acetate and fludrocortisone acetate are prescribed as replacement therapy for a client with Addison's disease. What administration schedule should be followed for this therapy? 1.Take both drugs three times a day. 2.Take the entire dose of both drugs first thing in the morning. 3.Take all the fludrocortisone acetate and two-thirds of the cortisone acetate in the morning, and take the remaining cortisone acetate in the afternoon. 4.Take half of each drug in the morning and the remaining half of each drug at bedtime.

3 Fludrocortisone acetate can be administered once a day, but cortisone acetate administration should follow the body's natural diurnal pattern of secretion. Greater amounts of cortisol are secreted during the day to meet the increased demand of the body. Typically, baseline administration of cortisone acetate is 25 mg in the morning and 12.5 mg in the afternoon. Taking it three times a day would result in an excessive dose. Taking the drug only in the morning would not meet the needs of the body later in the day and evening.

The client with Addison's disease should anticipate the need for increased glucocorticoid supplementation in which of the following situations? 1.Returning to work after a weekend. 2.Going on vacation. 3.Having oral surgery. 4.Having a routine medical checkup.

3 Illness or surgery places tremendous stress on the body, necessitating increased glucocorticoid dosage. Extreme psychological stress also necessitates dosage adjustment. Increased dosages are needed in times of stress to prevent drug-induced adrenal insufficiency. Returning to work after the weekend, a vacation, or a routine checkup usually will not alter glucocorticoid dosage needs.

A client who is recovering from a bilateral adrenalectomy has a patient-controlled analgesia (PCA) system with morphine sulfate. Which of the following actions is a priority nursing intervention for the client? 1.Observing the client at regular intervals for opioid addiction. 2.Encouraging the client to reduce analgesic use and tolerate the pain. 3.Evaluating pain control at least every 2 hours. 4.Increasing the amount of morphine if the client does not administer the medication.

3 Pain control should be evaluated at least every 2 hours for the client with a PCA system. Addiction is not a common problem for the postoperative client. A client should not be encouraged to tolerate pain; in fact, other nursing actions besides PCA should be implemented to enhance the action of opioids. One of the purposes of PCA is for the client to determine frequency of administering the medication; the nurse should not interfere unless the client is not obtaining pain relief. The nurse should ensure that the client is instructed on the use of the PCA control button and that the button is always within reach.

When teaching a client newly diagnosed with primary Addison's disease, the nurse should explain that the disease results from: 1.Insufficient secretion of growth hormone (GH). 2.Dysfunction of the hypothalamic pituitary. 3.Idiopathic atrophy of the adrenal gland. 4.Oversecretion of the adrenal medulla.

3 Primary Addison's disease refers to a problem in the gland itself that results from idiopathic atrophy of the glands. The process is believed to be autoimmune in nature. The most common causes of primary adrenocortical insufficiency are autoimmune destruction (70%) and tuberculosis (20%). Insufficient secretion of GH causes dwarfism or growth delay. Hyposecretion of glucocorticoids, aldosterone, and androgens occur with Addison's disease. Pituitary dysfunction can cause Addison's disease, but this is not a primary disease process. Oversecretion of the adrenal medulla causes pheochromocytoma.

Which of the following indicates that the client with Addison's disease is receiving too much glucocorticoid replacement? 1.Anorexia. 2.Dizziness. 3.Rapid weight gain. 4.Poor skin turgor.

3 Rapid weight gain, because it reflects excess fluids, is a warning sign that the client is receiving too much hormone replacement. It may be difficult to individualize the correct dosage for a client taking glucocorticoids, and the therapeutic range between underdosage and overdosage is narrow. Maintaining the client on the lowest dose that provides satisfactory clinical response is always the goal of pharmacotherapeutics. Fluid balance is an important indicator of the adequacy of hormone replacement. Anorexia is not present with glucocorticoid therapy because these drugs increase the appetite. Dizziness is not specific to the effects of glucocorticoid therapy. Poor skin turgor is a late sign of fluid volume deficit.

A client reports that she has gained weight and that her face and body are "rounder," while her legs and arms have become thinner. A tentative diagnosis of Cushing's disease is made. The nurse should further assess the client for: 1.Orthostatic hypotension. 2.Muscle hypertrophy in the extremities. 3.Bruised areas on the skin. 4.Decreased body hair.

3 Skin bruising from increased skin and blood vessel fragility is a classic sign of Cushing's disease. Hyperpigmentation and bruising are caused by the hypersecretion of glucocorticoids. Fluid retention causes hypertension, not hypotension. Muscle wasting occurs in the extremities. Hair on the head thins, while body hair increases.

After a bilateral adrenalectomy for Cushing's disease, the client will receive periodic testosterone injections. The expected outcome of these injections is: 1.Balanced reproductive cycle. 2.Restored sodium and potassium balance. 3.Stimulated protein metabolism. 4.Stabilized mood swings.

3 Testosterone is an androgen hormone that is responsible for protein metabolism as well as maintenance of secondary sexual characteristics; therefore, it is needed by both males and females. Removal of both adrenal glands necessitates replacement of glucocorticoids and androgens. Testosterone does not balance the reproductive cycle, stabilize mood swings, or restore sodium and potassium balance.

A priority in the first 24 hours after a bilateral adrenalectomy is: 1.Beginning oral nutrition. 2.Promoting self-care activities. 3.Preventing adrenal crisis. 4.Ambulating in the hallway.

3 The priority in the first 24 hours after adrenalectomy is to identify and prevent adrenal crisis. Monitoring of vital signs is the most important evaluation measure. Hypotension, tachycardia, orthostatic hypotension, and arrhythmias can be indicators of pending vascular collapse and hypovolemic shock that can occur with adrenal crisis. Beginning oral nutrition is important, but not necessarily in the first 24 hours after surgery, and it is not more important than preventing adrenal crisis. Promoting self-care activities is not as important as preventing adrenal crisis. Ambulating in the hallway is not a priority in the first 24 hours after adrenalectomy

The nurse is caring for a client who is scheduled for an adrenalectomy. Which of the following drugs may be included in the preoperative prescriptions to prevent Addison's crisis following surgery? 1.Prednisone orally. 2.Fludrocortisones subcutaneously. 3.Spironolactone intramuscularly. 4.Methylprednisolone sodium succinate intravenously.

4 A glucocorticoid preparation will be administered intravenously or intramuscularly in the immediate preoperative period to a client scheduled for an adrenalectomy. Methylprednisolone sodium succinate protects the client from developing acute adrenal insufficiency (Addison's crisis) that occurs as a result of the adrenalectomy. Spironolactone is a potassium-sparing diuretic. Prednisone is an oral corticosteroid. Fludrocortisones is a mineral corticoid.

The nurse is instructing a college student with Addison's disease how to adjust the dose of glucocorticoids. The nurse should explain that the client may need an increased dosage of glucocorticoids in which situation 1. completing the spring semester of school 2. gaining 4 lb (1.8 kg) 3. becoming engaged 4. having wisdom teeth extracted

4 Adrenal crisis can occur with physical stress, such as surgery, dental work, infection, flu, trauma, and pregnancy. In these situations, glucocorticoid and mineralocorticoid dosages are increased. Weight loss, not gain, occurs with adrenal insufficiency. Psychological stress has less effect on corticosteroid need than physical stress.

After surgery for bilateral adrenalectomy, the client is kept on bed rest for several days to stabilize the body's need for steroids postoperatively. Which of the following exercises will be most effective for preparing a client for ambulation after a period of bed rest? 1.Alternately flexing and extending the knees. 2.Alternately abducting and adducting the legs. 3.Alternately stretching the Achilles tendons. 4.Alternately flexing and relaxing the quadriceps femoris muscles.

4 Alternately flexing and relaxing the quadriceps femoris muscles helps prepare the client for ambulation. This exercise helps maintain the strength in the quadriceps, which is the major muscle group used when walking. The other exercises listed do not increase a client's readiness for walking

The normal response to increased serum osmolality is the release of: A. Aldosterone from the adrenal cortex, which stimulates sodium excretion by the kidney. B. ADH from the posterior pituitary gland, which stimulates the kidney to reabsorb water. C. Mineralocorticoids from the adrenal gland, which stimulates the kidney to excrete potassium. D. Calcitonin from the thyroid gland, which increases bone resorption and decreases serum calcium levels.

Answer: B

The nurse should teach the client with Addison's disease that the bronze-colored skin is thought to be caused by which of the following? 1.Hypersensitivity to sun exposure. 2.Increased serum bilirubin level. 3.Adverse effects of the glucocorticoid therapy. 4.Increased secretion of adrenocorticotropic hormone (ACTH).

4 Bronzing, or general deepening of skin pigmentation, is a classic sign of Addison's disease and is caused by melanocyte-stimulating hormone produced in response to increased ACTH secretion. The hyperpigmentation is typically found in the distal portion of extremities and in areas exposed to the sun. Additionally, areas that may not be exposed to the sun, such as the nipples, genitalia, tongue, and knuckles, become bronze-colored. Treatment of Addison's disease usually reverses the hyperpigmentation. Bilirubin level is not related to the pathophysiology of Addison's disease. Hyperpigmentation is not related to the effects of the glucocorticoid therapy.

A client newly diagnosed with type 2 diabetes mellitus tells the nurse of the fear of going blind. What should the nurse respond to this client? A. You should schedule an appointment with the eye doctor in about a year B. You should try to keep your HbA1c level around 10% C. If the diabetic retinopathy does not manifest itself in the first 10 years you're probably fine D. Controlling elevated blood pressure and cholesterol will help reduce the risk of vision loss.

Answer: D Rationale: Research has shown that treating elevated blood pressure and cholesterol can reduce the risk of developing diabetic retinopathy. Choice A is incorrect because clients with newly diagnosed type 2 diabetes mellitus should have an immediate eye examination since it is unclear how long the disease has been present and untreated. The first ophthalmologic visit sets a baseline for future reference. Choice B is incorrect because in order to prevent diabetic retinopathy, glucose levels should be controlled tightly, and target HbA1c levels should be, 5.9%. Choice C is incorrect because diabetic retinopathy is a long-term complication of the disease, which can manifest at any time.

During the first 24 hours after a client is diagnosed with Addisonian crisis, which intervention should the nurse perform frequently? 1. Weigh the client 2. Test urine for ketones 3. Assess vital signs 4. Administer oral hydrocortisone

RATIONALES (3): 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.

The nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find: 1. Hypotension 2. Thick, coarse skin 3. deposits of adipose tissue in the trunk and dorsocervical area 4. weight gain in arms and legs

Rationale: (3)Because of changes in fat distribution, adipose tissue accumulates in the trunk, face (moonface), 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.

Which topic is most important to include in the teaching plan for a client newly diagnosed with Addison's disease who will be taking corticosteroids? 1.The importance of watching for signs of hyperglycemia. 2.The need to adjust the steroid dose based on dietary intake and exercise. 3.To notify the health care provider when the blood pressure is suddenly high. 4.How to decrease the dose of the corticosteroids when the client experiences stress.

1 Since Addison's disease can be life threatening, treatment often begins with administration of corticosteroids. Corticosteroids, such as prednisone, may be taken orally or intravenously, depending on the client. A serious adverse effect of corticosteroids is hyperglycemia. Clients do not adjust their steroid dose based on dietary intake and exercise, insulin is adjusted based on diet and exercise. Addisonian crisis can occur secondary to hypoadrenocorticism resulting in a crisis situation of acute hypotension, not increased blood pressure. Addison's disease is a disease of inadequate adrenal hormone and therefore the client will have inadequate response to stress. If the client takes more medication than prescribed, there can be a potential increase in potassium depletion, fluid retention, and hyperglycemia. Taking less medication than was prescribed can trigger Addisonian crisis state which is a medical emergency manifested by signs of shock.

The client diagnosed with Addison's disease is admitted to the emergency department after a day at the lake. The client is lethargic, forgetful, and weak. Which intervention should the nurse implement? 1. Start an IV with an 18-gauge needle and infuse NS rapidly. 2. Have the client wait in the waiting room until a bed is available. 3. Obtain a permit for the client to receive a blood transfusion. 4. Collect urinalysis and blood samples for a CBC and calcium level.

1 The client was exposed to wind and sun at the lake during the hours prior to being admitted to the emergency department. This predisposes the client to dehydration and an addisonian crisis. Rapid IV fluid replacement is necessary.

The client with Cushing's disease needs to modify dietary intake to control symptoms. In addition to increasing protein, which strategy would be most appropriate? 1.Increase calories. 2.Restrict sodium. 3.Restrict potassium. 4.Reduce fat to 10%.

2 A primary dietary intervention is to restrict sodium, thereby reducing fluid retention. Increased protein catabolism results in loss of muscle mass and necessitates supplemental protein intake. The client may be asked to restrict total calories to reduce weight. The client should be encouraged to eat potassium-rich foods because serum levels are typically depleted. Although reducing fat intake as part of an overall plan to restrict calories is appropriate, fat intake of less than 20% of total calories is not recommended.

The client who has undergone a bilateral adrenalectomy is concerned about persistent body changes and unpredictable moods. The nurse should tell the client that: 1.The body changes are permanent and the client will not be the same as before this condition. 2.The body and mood will gradually return to normal. 3.The physical changes are permanent, but the mood swings will disappear. 4.The physical changes are temporary, but the mood swings are permanent.

2 As the body readjusts to normal cortisol levels, mood and physical changes will gradually return to a normal state. The body changes are not permanent, and the mood swings should level off.

The nurse is admitting a client diagnosed with primary adrenal cortex insufficiency (Addison's disease). Which clinical manifestations should the nurse expect to assess? 1. Moon face, buffalo hump, and hyperglycemia. 2. Hirsutism, fever, and irritability. 3. Bronze pigmentation, hypotension, and anorexia. 4. Tachycardia, bulging eyes, and goiter.

3 Bronze pigmentation of the skin, particu- larly of the knuckles and other areas of skin creases, occurs in Addison's disease. Hypotension and anorexia also occur with Addison's disease.

The client diagnosed with Cushing's disease has undergone a unilateral adrenalectomy. Which discharge instructions should the nurse discuss with the client? 1. Instruct the client to take the glucocorticoid and mineralocorticoid medications as prescribed. 2. Teach the client regarding sexual functioning and androgen replacement therapy. 3. Explain the signs and symptoms of infection and when to call the health-care provider. 4. Demonstrate turn, cough, and deep-breathing exercises the client should perform every two (2) hours.

3 Notifying the HCP if signs/symptoms of infection develop is an instruction given to all surgical clients on discharge.

The health care provider prescribes Levothyroxine for a patient with hypothyroidism. Following teaching regarding this medication, the nurse determines that further teaching is needed when the patient says: A. "I can expect the medication dose may need to be increased" B. "I can expect to return to normal function with the use of this drug" C. "I will only need to take this medication until my symptoms are improved" D. I will report any chest pain or difficulty breathing to the doctor right away"

Answer: C

Which of the following is the best indicator for determining whether a client with Addison's disease is receiving the correct amount of glucocorticoid replacement? 1.Skin turgor. 2.Temperature. 3.Thirst. 4.Daily weight.

4 Measuring daily weight is a reliable, objective way to monitor fluid balance. Rapid variations in weight reflect changes in fluid volume, which suggests insufficient control of the disease and the need for more glucocorticoids in the client with Addison's disease. Nurses should instruct clients taking oral steroids to weigh themselves daily and to report any unusual weight loss or gain. Skin turgor testing does supply information about fluid status, but daily weight monitoring is more reliable. Temperature is not a direct measurement of fluid balance. Thirst is a nonspecific and very late sign of weight loss.

The nurse should tell the client to do which of the following when teaching the client about taking oral glucocorticoids? 1."Take your medication with a full glass of water." 2."Take your medication on an empty stomach." 3."Take your medication at bedtime to increase absorption." 4."Take your medication with meals or with an antacid."

4 Oral steroids can cause gastric irritation and ulcers and should be administered with meals, if possible, or otherwise with an antacid. Only instructing the client to take the medication with a full glass of water will not help prevent gastric complications from steroids. Steroids should never be taken on an empty stomach. Glucocorticoids should be taken in the morning, not at bedtime.

The nurse is instructing a young adult with Addison's disease how to adjust the dose of glucocorticoids. The nurse should explain that the client may need an increased dosage of glucocorticoids in which of the following situations? 1.Completing the spring semester of school. 2.Gaining 4 lb (1.8 kg). 3.Becoming engaged. 4.Undergoing a root canal.

4. Adrenal crisis can occur with physical stress, such as surgery, dental work, infection, flu, trauma, and pregnancy. In these situations, glucocorticoid and mineralocorticoid dosages are increased. Weight loss, not gain, occurs with adrenal insufficiency. Psychological stress has less effect on corticosteroid need than physical stress.

A male client with diabetes mellitus is transferred from the hospital to a rehabilitation facility following treatment for a brain attack with resulting right hemiplegia. He tells the nurse that his feet are always uncomfortably cool at night, preventing him from falling asleep. What action should the nurse implement? A. Place warm blankets next to the client's feet B. Medicate the client with a prescribed sedative C. Provide a warming pad (Aqua pad or K pad) to feet D. Use bed cradle to hold the covers off feet

Answer: A

The nurse is conducting a health screening clinic at an industrial work site. The nurse must be concerned about which client's risk for metabolic syndrome? A. 27-year-old woman with triglycerides of 210mg/dL (2.4mmol/L), blood pressure of 128/82mmHG, and fasting blood glucose of 98mg/dL (5.4mmol?l) B. 45-year-old man with a waist circumference of 38 inches (96.5cm), high-density lipoprotein of 40mg/dL, and a fasting blood glucose of 118mg/dL C. 55-year-old woman with a waist circumference of 37 inches, triglycerides of 190mg/dL, and a fasting blood glucose of 120mg/dL D. 82-year-old man with a high-density lipoprotein of 45mg/dL blood pressure of 148/88mmHg, and fasting blood glucose of 104mg/dl

Answer: C Rationale: Metabolic syndrome is the presence of ≥3 metabolic health factors that increase a client's risk for stroke, diabetes mellitus, and cardiovascular disease.

Following 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 severe tachycardia C. Hypertension and difficulty swallowing D. Laryngeal stridor and tingling in the hands and feet

Answer: D

When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, "I will never be able to stick myself with a needle." How should the nurse respond? A. "I can give your injections to you while you are here in the hospital." B. "Everyone gets used to giving themselves injections. It really does not hurt." C. "Your disease will not be managed properly if you refuse to administer the shots." D. "Tell me what it is about the injections that are concerning you."

Answer: D Rationale: Devote as much teaching time as possible to insulin injection and blood glucose monitoring. Clients with newly diagnosed diabetes are often fearful of giving themselves injections. If the client is worried about giving the injections, it is best to try to find out what specifically is causing the concern, so it can be addressed. Giving injections to the client does not promote self-care ability. Telling the client that others give themselves injections may cause the client to feel bad. Stating that you don't know another way to manage the disease is dismissive of the client's concerns.

A client with Cushing's syndrome is admitted to the medical-surgical unit. During the admission assessment, the nurse notes that the client is agitated and irritable, has poor memory, reports loss of appetite, and appears disheveled. These findings are consistent with which problem? 1. depression 2. neuropathy 3. hypoglycemia 4. hyperthyroidism

RATIONALES (1): Agitation, irritability, poor memory, loss of appetite, and neglect of one's appearance may signal depression, which is common in clients with Cushing's syndrome. Neuropathy affects clients with diabetes mellitus — not Cushing's syndrome. Although hypoglycemia can cause irritability, it also produces increased appetite, rather than loss of appetite. Hyperthyroidism typically causes such signs as goiter, nervousness, heat intolerance, and weight loss despite increased appetite.

The nurse is caring for a client in acute addisonian crisis. Which laboratory data would the nurse expect to find? 1. hyperkalemia 2. reduced BUN 3. hypernatremia 4. hyperglycemia

RATIONALES (1): In adrenal insufficiency, the client has hyperkalemia due to reduced aldosterone secretion. BUN increases as the glomerular filtration rate is reduced. Hyponatremia is caused by reduced aldosterone secretion. Reduced cortisol secretion leads to impaired glyconeogenesis and a reduction of glycogen in the liver and muscle, causing hypoglycemia.

A client with a history of Addison's disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. When he awoke this morning, his wife noticed that he acted confused and was extremely weak. 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 would the nurse expect to administer by I.V. infusion? 1. Insulin 2. Hydrocortisone 3. Potassium 4. Hypotonic saline

RATIONALES (2) : Emergency treatment for acute adrenal insufficiency (Addisonian crisis) is I.V. 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 the client's 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 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: 1. calcium and phosphorus abnormalities 2. chloride and magnesium abnormalities 3. sodium and chloride abnormalities 4. sodium and potassium abnormalities

RATIONALES:(4) 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.