NCLEX practice: endocrine
A client undergoes a subtotal thyroidectomy. The nurse ensures that which priority item is at the client's bedside upon arrival from the operating room? a. an apnea monitor b. a suction unit and oxygen c. a blood transfusion warmer d. An ampule of phytonadione (Vitamin K)
B Rationale: After thyroidectomy, respiratory distress can occur from tetany, tissue swelling, or hemorrhage. It is important to have oxygen and suction equipment readily available and in working order if such an emergency were to arise. Apnea is not a problem associated with thyroidectomy, unless the client experienced respiratory arrest. Blood transfusions can be administered without a warmer, if necessary. Vitamin K would not be administered for a client who is hemorrhaging, unless deficiencies in clotting factors warrant its administration.
The nurse is preparing the bedside for a postoperative parathyroidectomy client who is expected to return to the nursing unit from the recovery room in 1 hour. The nurse should ensure that which specific item is at the client's bedside? a. cardiac monitor b. Tracheotomy set c. Intermittent gastric suction d. Underwater seal chest drainage system
B Rationale: Respiratory distress caused by hemorrhage and swelling and compression of the trachea is a primary concern for the nurse managing the care of a postoperative parathyroidectomy client. An emergency tracheotomy set is always routinely placed at the bedside of the client with this type of surgery, in anticipation of this potential complication. Although a cardiac monitor may be attached to the client in the postoperative period, it is not specific to this type of surgery. Options 3 and 4 also are not specifically needed with the surgical procedure. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Planning Content Area: Adult Health: Endocrine Strategy(ies): Subject Priority Concepts: Clinical Judgment, Safety
A client is diagnosed with hypothyroidism. The nurse performs an assessment on the client, expecting to note which findings? Select all that apply. a.)weight loss b.bradycardia c. hypotension d. dry, scaly skin e.Heat tolerance f. Decreased body temperature
B,C,D,F Rationale: The manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormones. Some of these manifestations are bradycardia; hypotension; cool, dry, scaly skin; decreased body temperature; dry, coarse, brittle hair; decreased hair growth; cold intolerance; slowing of intellectual functioning; lethargy; weight gain; and constipation.
The nurse is caring for a client who is scheduled to have a thyroidectomy and provides instructions to the client about the surgical procedure. Which statement by the client would indicate an understanding of the nurse's instructions? a. "I will have to take antithyroid medication after this surgery" b. "I need to put my hands behind my neck when I have to cough or change postions" c. I need to turn my head and neck front, back and side to side every hour for 12 hrs after surgery" d. "I will immediately report to the emergency room if I experience tingling of the toes, fingers, and lips after surgery.
Answer: B Rationale: The client is taught that following thyroidectomy tension needs to be avoided on the suture line because hemorrhage may develop. One way of reducing incisional tension is to teach the client how to support the neck when coughing or being repositioned. Likewise, during the postoperative period, the client should avoid any unnecessary movement of the neck; that is why sandbags and pillows are frequently used to support the head and neck. The removal of the thyroid does not mean that the client will be taking antithyroid medications postoperatively. If a client experiences tingling in the fingers, toes, and lips, it is probably a result of injury to the parathyroid gland during surgery, resulting in hypocalcemia. These signs and symptoms need to be reported immediately.
The nurse is developing a discharge plan for a postoperative client who had one adrenal gland removed. What should the nurse include in the plan? a.)Teaching client to maintain a diabetic diest b.)teaching client proper application of an ostomy pouch c.)Providing a list of the early signs of a wound infection d.)Explaining the need for lifelong replacement therapy
Answer: C A client who had a unilateral adrenalectomy will be placed on corticosteroids temporarily to avoid a cortisol deficiency; lifelong replacement is not necessary. Corticosteroids will be gradually weaned in the postoperative period until they are discontinued. Also, because of the anti-inflammatory properties of corticosteroids produced by the adrenals, clients who undergo an adrenalectomy are at increased risk of developing wound infections. Because of this increased risk of infection, it is important for the client to know measures to prevent infection, early signs of infection, and what to do if an infection seems to be present. The client does not need to maintain a diabetic diet, and the client will not have an ostomy after this surgery.
A client with the diagnosis of hyperparathyroidism says to the nurse, "I can't stay on this diet. It is too difficult for me." How should the nurse best respond when intervening in this situation? a. "why do you thing you are having a difficult time with this diet?" b. "It really isn't difficult to stick to this diet. Just avoid milk prodcts" c. "You are having a difficult time staying on this plan. Let's discuss this" d. "It is very important that you stay on this diet to avoid forming renal calculi"
Answer: C. Rationale: By paraphrasing the client's statement, the nurse can encourage the client to verbalize emotions. The nurse also sends feedback to the client that the message was understood. An open-ended statement or question such as this prompts a thorough response from the client. Option 1 requests information that the client may not be able to express. Option 2 devalues the client's feelings. Option 4 gives advice, which blocks communication. Priority Nursing Tip: After the nurse determines the cause of a client's difficulty in adhering to a prescribed diet, the nurse can develop a plan of care and refer the client to appropriate community support programs, such as nutritional programs.
The nurse is caring for a client scheduled for a bilateral adrenalectomy for treatment of an adrenal tumor that is producing excessive aldosterone (primary hyperaldosteronism). What should the nurse tell the client about the surgery? a.)"You will need to wear an abdominal binder after surgery." b.)"You will most likely need to undergo chemotherapy after surgery." c.)"You will not require any special long-term treatment after surgery." d.)"You will need to take hormone replacements for the rest of your life."
Answer: D. Rationale: The major cause of primary hyperaldosteronism is an aldosterone-secreting tumor called an aldosteronoma. Surgery is the treatment of choice. Clients undergoing a bilateral adrenalectomy require permanent replacement of adrenal hormones. Options 1, 2, and 3 are inaccurate.
The nurse is admitting a client with a diagnosis of hypothyroidism to the hospital. What action should the nurse perform to obtain data related to this diagnosis? a.) Inspect facial feautures b.) ascultate lung sounds 3.) percuss the thyroid gland d.) asess the pts ability to ambulate
Answer: a.) inspect facial features Rationale: Inspection of facial features will reveal the characteristic coarse features, presence of edema around the eyes and face, and the blank expression that are characteristic of hypothyroidism. The assessment techniques in options 2, 3, and 4 will not reveal information related to the diagnosis of hypothyroidism.
The nurse provides home care instructions to a client with Cushing's syndrome. The nurse determines that the client understands the hospital discharge instructions if the client makes which statement? a. "I need to eat foods low in potassium" b. "I need to check the color of my stool" c." I need to check the temperature of my legs twice a day" d. "I need to take Aspirin rather than Tylenol for a HA"
B Cushing's syndrome results in an increased secretion of cortisol. Cortisol stimulates the secretion of gastric acid, and this can result in the development of peptic ulcers and gastrointestinal bleeding. The client should be encouraged to eat potassium-rich foods to correct the hypokalemia that occurs with this disorder. Cushing's syndrome does not affect temperature changes in the lower extremities. Aspirin can increase the risk for gastric bleeding and skin bruising.
The nurse is caring for a client with a diagnosis of Cushing's syndrome. The nurse should plan which of these measures to prevent complications from this medical condition? a. monitoring glucose levels b.encouraging jogging c.monitoring epinephrine levels d.encouraging visits from friends
a. Monitoring glucose levels Rationale: Cushing's syndrome is a metabolic disorder resulting from the chronic and excessive production of cortisol by the adrenal cortex or the administration of glucocorticoids in large doses for several weeks or longer. In the client with Cushing's syndrome, increased levels of glucocorticoids can result in hyperglycemia and signs and symptoms of diabetes mellitus. Clients experience activity intolerance related to muscle weakness and fatigue; therefore, option 2 is incorrect. Epinephrine levels are not affected. Visitors should be limited because of the client's impaired immune response.
The nurse develops a postoperative plan of care for a client scheduled for hypophysectomy. Which interventions should be included in the plan of care? SELECT ALL THAT APPLY a.) Obtain daily weights b.) Monitor I&O's c.) Elevate the head of the bed d.)) Use a soft toothbrush e.) Encourage coughing and deep breathing
a.,b., c. Rationale: A hypophysectomy is done to remove a pituitary tumor. Because temporary diabetes insipidus or syndrome of inappropriate antidiuretic hormone can develop after this surgery, obtaining daily weights and monitoring intake and output are important interventions. The head of the bed is elevated to assist in preventing increased intracranial pressure. Toothbrushing, sneezing, coughing, nose blowing, and bending are activities that should be avoided postoperatively in the client who underwent a hypophysectomy because of the risk of increasing intracranial pressure. These activities interfere with the healing of the incision and can disrupt the graft.
A client is admitted to the hospital with a suspected diagnosis of Graves' disease. On assessment, which manifestation related to the client's menstrual cycle should the nurse expect the client to most likely report?
a.Amenorrhea Rationale: Amenorrhea or a decreased menstrual flow is common in the client with Graves' disease.
While a client with myxedema is being admitted to the hospital, the client reports having experienced a lack of energy, cold intolerance, and puffiness around the eyes and face. The nurse plans care knowing that these clinical manifestations are caused by a lack of production of which hormones? a.ACTH b. T3 and T4 c.prolactin d.LH
b. T3 and T4 rationale: Although all of these hormones originate from the anterior pituitary, only T3 and T4 are associated with the client's symptoms. Myxedema results from inadequate thyroid hormone levels (T3 and T4). Low levels of thyroid hormone result in an overall decrease in the basal metabolic rate, affecting virtually every body system and leading to weakness, fatigue, and a decrease in heat production. A decrease in LH results in the loss of secondary sex characteristics. A decrease in ACTH is seen in Addison's disease. PRL stimulates breast milk production by the mammary glands, and GH affects bone and soft tissue by promoting growth through protein anabolism and lipolysis.
A client is admitted to the hospital with a diagnosis of Cushing's syndrome. The nurse monitors the client for which problem that is likely to occur with this diagnosis? a.hpovolemia b.hypoglycemia c.Mood disturbances d.deficient fluid volume
c.) Mood disturbances Rationale: Cushing's syndrome is a metabolic disorder resulting from the chronic and excessive production of cortisol. When Cushing's syndrome develops, the normal function of the glucocorticoids becomes exaggerated and the classic picture of the syndrome emerges. This exaggerated physiological action can cause mood disturbances, including memory loss, poor concentration and cognition, euphoria, and depression. It can also cause persistent hyperglycemia along with sodium and water retention (hypernatremia), producing edema (hypervolemia; fluid volume excess) and hypertension.