MS exam 2: Chapter 62
what is the biggest risk with estrogen therapy? what increases this risk?
-biggest risk is VTE/DVT -if patient smokes they are at increased risk
what are the cardiovascular S&S of hypothyroidism?
-bradycardia -dysrhythmias -enlarged heart -decreased activity tolerance -hypotension
what neuro changes can occur with a pituitary adenoma?
-changes in mental status -visual disturbances -headache -increased ICP
what are the S&S of gonadotropin (LH and FSH) deficiency for women?
-amenorrhea -anovulation -low estrogen levels -breast atrophy -loss of bone density -decreased axillary and pubic hair -decreased libido
what prep is necessary for an angiogram?
-ask patient about iodine and shellfish allergies (angiogram uses contrast) -type 2 diabetic patients on metformin: hold the metformin
what is drug-related diabetes insipidus and what meds can lead to this?
lithium and declomycin affect the kidneys response to ADH and can cause DI
what assessments need to be done when your patient has Addison's disease?
-assess for hypoglycemia (sweating, headaches, tachycardia, and tremors -assess for fluid depletion (postural hypotension and dehydration) -assess for hyponatremia and hyperkalemia
what is pheochromocytoma?
-A catecholamine-producing tumor of the adrenal medulla (tumors produce, store, and release epinephrine and norepinephrine) -Cause unknown, rare -See episodes of HTN with HA, palpitations, profuse diaphoresis, flushing, apprehension, and sense of impending doom. -Surgery is main treatment -Action alert: do not palpate the abdomen with these patients because it can cause a sudden release of catecholamines triggering severe hypertension
what is adrenal gland hypofunction?
-Adrenocortical steroids may decrease from inadequate secretion of ACTH, dysfunction of hypothalamic-pituitary control mechanism, or direct dysfunction of adrenal gland tissue -Insufficiency of adrenocortical steroids causes problems through loss of aldosterone and cortisol -hypoglycemia (decreased cortisol), hyperkalemia (reduced aldosterone), hyponatremia, and hypovolemia
what is adrenal gland hyperfunction?
-Hypersecretion by adrenal cortex results in Cushing's syndrome/disease, hypercortisolism, or excessive androgen production -Causes: excess secretion of cortisol or from taking corticosteroids -Increases body fat and redistributes it (truncal obesity), reduced immune response (due to hyperglycemia), increased risk for infection, increased androgen production (increased body hair, acne, hair on the face-hirsutism)
what is the surgical management for hypercortisolism?
-Hypophysectomy: used when it affects pituitary gland -Adrenalectomy
what is hyperaldosteronism?
-Increased secretion of aldosterone results in mineralocorticoid excess. -Primary hyperaldosteronism (Conn's syndrome) result of excessive secretion of aldosterone from one or both adrenal glands -Pts need to wear a medical alert bracelet
what is Addison's crisis?
-Life-threatening event; need for cortisol and aldosterone is greater than available supply -Usually occurs in response to stressful event (hospitalization- patients with reduced hormone level are at risk) -With the loss of aldosterone, severe hypotension, potassium levels will rise rapidly, sodium levels will fall rapidly
what are the causes of SIADH?
-Recent head trauma -Cerebrovascular disease -Tuberculosis or other pulmonary disease -Cancer (small cell lung cancer) -opioid use -seizure medications -fluoroquinolone antibiotics
how can you prevent injury after an adrenalectomy?
-Use a soft-bristles toothbrush -Avoid tape or use as little as possible -Educate patients who are at risk for fractures -(osteoporosis) to eat foods high in calcium and vitamin D (milk, cheese, yogurt, leafy greens, and root vegetables) -Prevent GI bleeds: administer antacids, H2 blockers, or PPIs as ordered (educate patient to take these regularly and not just PRN); avoid NSAIDs, aspirin, and alcohol
what is SIADH?
-Vasopressin secretes even when plasma osmolarity is low or normal -Feedback mechanisms do not function properly -Water is retained, results in hyponatremia (worried about water toxicity- acute confusion, persistent headache, and weight gain of 2.2 lbs) -do not generally see dependent edema (because water is retained but sodium is not)
What is nephrogenic diabetes insipidus?
-a problem with the kidney's response to ADH rather than a problem with ADH production or release -any injury to the kidney can cause DI
what are the side effects of testosterone therapy?
-acne -seborrhea -baldness -prostate enlargement -gynecomastia
how should you care for hypoglycemia with Addison's crisis?
-administer IV glucose as prescribed -administer glucagon (IM) as needed and prescribed -maintain IV access -monitor blood glucose hourly
how should you care for hyperkalemia with Addison's crisis?
-administer insulin (20-50 units) with dextrose (20-50 mg) in NS to shift potassium into cells -administer potassium binding and excreting resin (Kayexalate) -give loop or thiazide diuretics -avoid potassium-sparing diuretics -initiate potassium restriction -monitor I&Os -monitor HR, rhythm, and EKG for S&S of hyperkalemia (peaked T waves)
what is the drug alert for samsca (Tolvaptan) and vaprisol (Conivaptan)?
-administer these medications only in the hospital setting so serum sodium levels can be monitored closely for the development of hypernatremia -CNS demyelination syndrome is a risk if the sodium level rises to fast (causes neurologic changes and puts patients at risk for seizures)
what assessment questions should you ask your patient when you suspect they have hyperpituitarism?
-age -family history -changes in ring, shoe, or hat size -arthralgia (joint pain) -headaches or visual changes -difficulties in sexual functioning -menstrual cycle irregularities
what do you need to do pre-op for a patient with hypercortisolism?
-correct electrolyte imbalances: potassium, glucose -Cushing's patients at risk for fractures and infections- wash hands, fall risk -patients need to be on glucocorticoids to prevent a drop in cortisol levels- need to be on before, during, and after surgery -monitor for shock- hypotension, tachycardia
what interventions should you do if you suspect fluid overload?
-daily weights -I&Os -look for bounding pulse and high BP
what causes a deficiency of GH?
-decreased GH production -failure of the liver to produce somatomedins -failure of tissue to respond to somatomedins
what are the S&S of GH deficiencies?
-decreased bone density -pathologic fractures -decreased muscle strength -increased serum cholesterol levels
what are the S&S of gonadotropin (LH and FSH) deficiency for men?
-decreased facial hair -decreased ejaculate volume -reduced muscle mass -loss of bone density -decreased body hair -decreased libido -impotence
what are the S&S of ACTH deficiency?
-decreased serum cortisol levels -pale, swallow complexion -malaise and lethargy -anorexia -postural hypotension -headache -hypoglycemia -hyponatremia -decreased axillary and pubic hair (women)
what are the S&S of a TSH deficiency?
-decreased thyroid hormone levels -weight gain -intolerance to cold -scalp alopecia -hirsutism -menstrual abnormalities -decreased libido -slowed cognition -lethargy
what neuro changes are associated with hypopituitarism/ pituitary tumors?
-diplopia -ocular muscle paralysis -limited eye movement -temporal headaches
what is diabetes insipidus?
-disorder of the posterior pituitary gland in which water loss is caused by an ADH deficiency (either decrease in ADH synthesis or inability of kidneys to respond to ADH) -neurogenic, nephrogenic, and drug-related
how does the dosing for testosterone therapy work?
-dosing starts out high and is continued until virilization (presence of male secondary sex characteristics) -the dose may then be decreased, but therapy is lifelong
what type of drug therapy is used for hyperpituitarism?
-drugs that stimulate dopamine receptors in the brain (dopamine agonists) to inhibit the release of GH and PRL -most common is Parlodel (Bromocriptine) -if patient gets pregnant while taking this med, they need to STOP taking it immediately
what are the manifestations of hyponatremia?
-early: GI disturbances (loss of appetite, N/V) -confusion, decreased DTRs
what do you need to teach your patient about hormone replacement therapy?
-ensure that hormone replacement drugs are given as close to the prescribed time as possible -Usually 2/3 of hormone replacement is given in the AM and 1/3 is given at 6 PM to mimic normal release of hormone -Instruct patient to wear a medical alert bracelet and carry simple carbohydrates with them at all times due to hypoglycemia
when should you tell your patient that they need to go to the ED or call 911 when taking DDAVP?
-experience a weight gain of 2.2 lbs in 24 hours -if they have recurring S&S of hyperpituitarism -if they are dehydrated -if they have S&S of water intoxication
what are the S&S of Addison's disease?
-fatigue -weight loss -anorexia -hyperpigmentation -hypotension -hypoglycemia -hyponatremia -hyperkalemia -90% of the tissue is destroyed before we see S&S
what interventions should be done for SIADH?
-fluid restriction: between 500-1,000mL/day (need an order for this) -tube feedings: do saline flushes instead of tap water -frequent oral care (UAP) -drug therapy -neuro assessments every 1-2 hours (notify physician of any change) -safety: side rails up, room free of clutter, all light and belongings in reach, light on at night, reduce stimulation
what can you do for your post-op hypophysectomy patient to ensure that they are not straining during a bowel movement?
-give them stool softeners -ensure they are drinking enough water, eating a high fiber diet, and completing activities (exercise)
what is the greatest risk factor for LH, FSH, and GH deficiencies?
-head trauma -additional cause is brain infection
what diagnostic/imaging assessments are done for hypopituitarism?
-hormone measurements: serum and urine studies -CT and MRI for imaging -angiogram (looking for perfusion)
what is hyperpituitarism?
-hormone oversecretion of that occurs with anterior pituitary tumors or tissue hyperplasia (tissue overgrowth) -tumors occur most often in the anterior pituitary cells that produce GH, PRL, and ACTH (pituitary adenoma) -can also be caused by hypothalamic problems (excessive production of releasing hormones)
what are the S&S of hyperaldosertonism?
-hypokalemia (when hypokalemia becomes severe, we start to see paresthesias) -increased BP (high BP puts patient at risk for stroke, MI, and kidney damage)
with what urine output value should you start to think about diabetes insipidus?
-if urinary output is more than 4 in 24 hours or output is greater than intake, think DI -output can range from 4 L to 30 L in 24 hours
what are the S&S of dehydration?
-increase in frequency of urination and excessive thirst -urine diluted with low specific gravity (<1.005) -hypotension -tachycardia -weak peripheral pulses -slower cognition (confused, forgetful, irritable) -ataxia (uncoordinated walking-risk for falls)
what changes will you see when your patient reaches virilization?
-increase in penis size -increased libido -increased muscle mass -increased bone size and strength -increased hair growth
what would the lab tests look like when your patient has hypercortisolism?
-increased blood glucose levels -decreased lymphocyte count -increased sodium level -decreased serum calcium level (when cortisol is elevated, it directly inhibits bone formation, depresses intestinal calcium absorption and increased urinary calcium excretion)
what are the immune changes that occur in hypercortisolism?
-increased chance for infection -infection may not manifest the same way (may not have inflammation, fever, purulent exudate, or redness- wash hands, aseptic technique)
what is the drug therapy for hypercortisolism?
-interferes with ACTH production or adrenal hormone synthesis for temporary relief -Korlym (Mifepristone) -monitor the patient for response to drug therapy, especially weight loss and increased urine output
what diagnostic/imaging assessments are done for hyperpituitarism?
-labs tests will be drawn for prolactin, ACTH, and GH -best diagnostic tool is MRI
what laboratory changes are associated with Addison's disease?
-low serum and salivary cortisol levels -low fasting blood glucose -low sodium -elevated potassium -increased BUN (increased when dehydrated)
what are the post-op complications of a hypophysectomy?
-meningitis -increased ICP -infection -diabetes insipidus -CSF leakage
what are the nursing interventions for Addison's disease?
-monitor fluid balance -monitor for hypoglycemia -make sure they have a cardiac monitor on when they have a potassium imbalance
what are the non-surgical interventions for hypercortisolism?
-monitor fluid balance (monitor every 2 hours) -monitor for skin breakdown (pressure reducing mattresses, assess bony prominences, check daily for red or open areas, and turn every 2 hours)
how should you care for a patient after hypophysectomy?
-monitor the patient's neurologic status hourly for the first 24 hours and then every 4 hours -monitor fluid balance, especially for output greater than intake -encourage the patient to perform deep breathing exercises -instruct the patient not to cough, blow the nose, or sneeze -instruct the patient to use dental floss and oral mouth rinses rather than toothbrushing until the surgeon gives permission -instruct the patient to avoid bending at the waist to prevent increased ICP -monitor the nasal drip pad for the type and amount of drainage -teach the patient methods to avoid constipation ad subsequent straining -teach the patient the self-administration of the prescribed hormones
what are the key features of hypercortisolism (Cushing's disease)?
-moon face -buffalo hump -truncal obesity -weight gain -hypertension -frequent dependent edema -bruising -petechiae -muscle atrophy -osteoporosis -increased risk for infection -peptic ulcers**
what is MEN1?
-multiple endocrine neoplasia type 1 -leads to excessive production of GH, which leads to acromegaly -ask patients with acromegaly if their parents have had this problem
what are the key features of adrenal insufficiency (Addison's disease)?
-muscle weakness -fatigue -joint/muscle pain -anorexia -N/V -abdominal pain -constipation or diarrhea -weight loss -salt craving -vitiligo -hyperpigmentation -anemia -hypotension -hyponatremia -hyperkalemia -hypercalcemia
what should you tell the patient to expect post-op after a hypophysectomy?
-nasal packing (cannot breath through their nose) -decreased sense of smell (lasts 3-4 months) -they need to avoid brushing their teeth, coughing, bending over, blowing their nose, or any other straining -post-op lung exercises will be deep breathing and IS -teach the patient to report excess swallowing -hormone replacement is lifelong -patient should report recurring signs hyperpituitarism to physician immediately -may have numbness in the area of incision -may need vasopressin replacements
what do you need to assess regarding the condition of operative site after a nasal hypophysectomy?
-observe nasal area for drainage -if present, note color, clarity, and odor -test clear drainage for the presence of glucose
what kidney function assessments need to be done after a nasal hypophysectomy?
-observe urine specimen for color, odor, cloudiness, and amount -ask about headaches, visual disturbances, ease of bowel movements, 24-hour fluid intake and output, and medication taken
what are the side effects for bromocrytpine (parlodel)?
-orthostatic hypotension, abdominal cramping, headache, constipation, and nausea -if patient is experiencing nausea, tell them to take med with food
what does a deficiency of gonadotropin (LH and FSH) do to women?
-ovarian failure -amenorrhea -infertility
what are the causes of secondary adrenal insufficiency (Addison's disease)?
-pituitary tumors -postpartum pituitary necrosis -hypophysectomy -high-dose pituitary or whole-brain radiation -cessation of long-term corticosteroid therapy**
what causes you to become thirsty and how does this affect diabetes insipidus?
-plasma osmolarity and serum sodium levels increase (thirst is triggered) -normally, osmo receptors respond to increased plasma osmolarity and you get thirsty -if osmo receptors are not functioning normally (older adults), they are at increased risk for dehydration
what are the characteristics of diabetes insipidus?
-polyuria (excretion of large amounts of dilute urine) -output will be greater than intake -thirst -can lead to dehydration
what is Sheehan's syndrome?
-postpartum hemorrhage is the most common cause of pituitary infarction, which results in decreased hormone secretion -can develop right after birth or years later
what is the non-surgical management for hyperpituitarism?
-psychosocial support -drug therapy (Parlodel, Dostinex, Permax, Sandostatin, Somavert) -radiation -gamma knife procedure
what is a gamma knife procedure?
-radiation therapy that is very precise -decreases the long-term side effects of radiation
what neuromuscular assessments need to be done after a nasal hypophysectomy?
-reactivity of patellar and biceps reflex -oral temperature -handgrip strength -steadiness of gait -distant and near vision acuity -pupillary responses to light -assess cognition and mental status
what is the general appearance of someone who has hypercortisolism?
-redistributed fat pads on the neck, back, and shoulders, trunk becomes enlarged (truncal obesity) -blood vessels become more fragile and we see bruising and striae (stretch marks- on the abdomen) -fine coating of hair over the face and body -edema formation (sodium and water are both retained)
what does excessive ACTH do?
-results in excessive production of glucocorticoids, mineralocorticoids, and androgens, leading to Cushing's
what is acromegaly?
-slow progression -increased skeletal thickness -hypertrophy of the skin -enlargement of the heart and liver -increased lip and nose size, prominent brow ridge -increase in head, hand, and foot sizes -skeletal changes are permanent
how should you care for hormone replacement with Addison's crisis?
-start rapid infusion of NS or dextrose 5% in NS -initial dose of hydrocortisone sodium (solucortef) is 100-300 mg or dexamethasone 4-12 mg as IV bolus -administer additional 100 mg of hydrocortisone sodium by continuous IV infusion over the next 8 hours -give hydrocortisone 50 mg IM concomitantly with hydration every 12 hours -initiate an H2 histamine blocker (ranitidine) IV for ulcer prevention
what do you need to do with your patient that is suspected to be dehydrated?
-strict I&Os (at least hourly) -daily weights -dehydration and hypertonic saline tests used for diagnosis
how do you assess the patient's understanding of the illness and adherence with treatment after a nasal hypophysectomy?
-symptoms to report to the health care provider -drug plan (correct timing and dose)
what is DDAVP?
-synthetic form of vasopressin given for DI -given orally, sublingually, or intranasal -usually a measured dose of 10 mcg; mild DI you may need 1 or 2 doses in 24 hours period
what do you need to educate your patient about when they are on a DDAVP?
-teach patients to wear a medical alert bracelet -teach patients to weigh themselves daily to identify weight gain -lifelong vasopressin therapy with permanent condition
what does a deficiency of gonadotropin (LH and FSH) do to men?
-testicular failure -decreased testosterone production -may lead to sterility
what education do you need to provide to your patient going home following an adrenalectomy?
-they will be on lifelong hormone replacement with a bilateral adrenalectomy -with unilateral adrenalectomy, they may need hormone replacement initially -wear a medical alert bracelet
what are the S&S of excess GH?
-thickened lips -coarse facial features -increasing head size -lower jaw protrusion -enlarged hands and feet -joint pain -barrel-shaped chest -hyperglycemia -sleep apnea -enlarged heart, lungs, and liver
what are the side effects of intranasal DDAVP?
-ulcerations in the mucus membranes -allergies -sensation of chest tightness -lung inhalation
what are the laboratory findings associated with SIADH?
-urine volume decreases -urine osmolarity increases -plasma volume increases -plasma osmolarity decreases
what drug therapy is used for SIADH?
-vaprisol and samsca (ADH agonists that promote water excretion without causing sodium loss) -can sometimes use diuretics when sodium level is normal and CHF is present -declomycin for mild SIADH -hypertonic IV solution (3% sodium chloride) can be used if sodium is low- watch patient's sodium levels so they do not rise too fast (usually run at a slow rate)
what causes hypopituitarism?
-varies -benign or malignant pituitary tumors can compress and destroy pituitary tissue -malnutrition or rapid loss of body fat -shock or severe hypotension -head trauma -brain tumors or infection -radiation or surgery of the head and brain -AIDS -idiopathic hypopituitarism: no known etiology
how can you prevent infection after an adrenalectomy?
-wash your hands -aseptic technique -monitor WBC -monitor temperature -assess the lungs for crackles and decreased lung sounds to prevent post-op pneumonia -monitor urine for S&S of UTI (odor, cloudiness)
what are seizure precautions and when do you need to initiate these?
-when sodium reaches 110-115 mmol/L -pad side rails and set up suction at the bedside
how should you monitor a patient's fluids when they have SIADH?
-worried about pulmonary edema because it can happen quickly (crackles, decreased breath sounds, pink frothy sputum- blood-tinged) -increase assessments to every 2 hours if you suspect someone sounds wet or has decreased breath sounds
what do you need to consider when your patient has a GH deficiency?
-your patient with a GH deficiency may have osteoporosis and an increased risk for fractures -handle these patients carefully -make sure there is a DRAW SHEET under them
Which statements made by a client who has DI indicates to the nurse that more teaching is needed? SATA 1. If I gain more than 2 lb (1 kg) in a day, I'll limit my fluid intake 2. If I become thirstier, I'll take another dose of the drug 3. I'll avoid aspirin and aspirin-containing substances 4. I'll stop taking the drug for 24 hours before I have any dental work performed 5. I'll limit my intake of salt and sodium to no more than 2 g daily 6. I'll wear my medical alert bracelet at all times
1, 3, 4, 5
what is the normal BUN level?
10-20 mg/dL
what is the normal bicarbonate level?
23-30 mEq/L
To monitor for a temporary but common post-surgical complication of a transsphenoidal resection of the pituitary gland, the nurse should regularly perform which assessment? 1. Pulse rate 2. Temperature 3. Urine output 4. Oxygen saturation
3
what is the normal calcium level?
9-10.5 mg/dL
A client has been admitted to the medical intensive care unit with a diagnosis of diabetes insipidus (DI) secondary to lithium overdose. The client has a prescription for Desmopressin (DDAVP). Which outcome indicates a positive response to treatment? a. Urine output of 60-80 mL/hour b. Blood glucose level of 110 mg/dL (6.1 mmol/L) c. Ability to sit quietly and read a magazine d. Potassium level within expected range
A
A client presents to the emergency department with a history of adrenal insufficiency. The following laboratory values are obtained: Na+ 130 mEq/L (130 mmol/L), K+ 6.6 mEq/L (6.6 mmol/L), and glucose 72 mg/dL (4 mmol/L). Which prescription will the nurse implement first? a. Administer insulin with dextrose in normal saline. b. Give spironolactone (Aldactone) orally. c. Initiate ulcer prophylaxis protocol with a histamine2 (H2) blocker d. Obtain arterial blood gases.
A
A client with iatrogenic Cushing's disease is a resident in a long-term care facility. Which nursing action included in the plan of care is most appropriate to delegate to unlicensed assistive personnel (UAP)? a. Assist with personal hygiene and skin care. b. Develop a plan of care to minimize risk for infection. c. Instruct the client on the reasons to avoid overeating. d. Monitor for signs and symptoms of fluid retention.
A
A client with syndrome of inappropriate antidiuretic hormone (SIADH) is admitted with a serum sodium level of 105 mEq/L (105 mmol/L). Which request by the health care provider does the nurse carry out first? a. Administer infusion of 150 mL of 3% NaCl over 3 hours. b. Draw blood for hemoglobin and hematocrit (H&H). c. Insert an indwelling catheter and monitor urine output. d. Weigh the client on admission and daily thereafter.
A
A nurse cares for a patient with chronic hypercortisolism. What action will the nurse take? a. Wash hands when entering the room b. Keep the patient in airborne isolation c. Observe the patients for signs of infection d. Assess the patient's daily chest x-ray
A
A patient with hyperaldosteronism is being treated with spironolactone (aldactone) before surgery. Which precautions does the nurse teach this patient? a. Read the label before using salt substitutes (some salt substitutes contain potassium) b. Do not add salt to your food when you eat c. Avoid exposure to sunlight d. Take acetaminophen instead of aspirin for pain
A
After receiving change-of-shift report about these four clients, which client does the nurse attend to first? a. Client with acute adrenal insufficiency who has a blood glucose of 36 mg/dL (2.0 mmol/L) b. Client with diabetes insipidus who has a dose of desmopressin (DDAVP) due c. Client with hyperaldosteronism who has a serum potassium of 3.4 mEq/L (3.4 mmol/L) d. Client with pituitary adenoma who is reporting a severe headache
A
The nurse and nursing student are caring for a client with pheochromocytoma who is admitted for surgery. Which of these statements by the student requires immediate intervention by the nurse? a. "When performing the gastrointestinal assessment, I need to palpate the client's abdomen." b. "I will review the chest x-ray results for pulmonary edema." c. "I will initiate a 24-hour urine collection now." d. "I have requested the client be placed with a roommate for distraction."
A
The nurse is planning to administer medications to a client with diabetes insipidus (DI) who has dry lips and mucous membranes and poor skin turgor. Which intervention will the nurse provide first? a. Encourage oral fluid intake b. Offer lip balm c. Perform a 24-hour urine test d. Withhold desmopressin acetate (DDAVP)
A
The nurse is teaching a client about the expected outcome for treatment of syndrome of inappropriate antidiuretic hormone (SIADH). What does the nurse tell the client to look for? a. Decrease in difficulty in breathing b. Dry mucous membranes c. Increasing heart rate d. Muscle spasms
A
Which key interventions should be implemented postoperatively for the patient after undergoing a hypophysectomy? (Select all that apply.) A. Report any postnasal drip. B. Keep the head of the bed elevated. C. Have the patient avoid coughing soon after surgery. D. Monitor for a light-yellow color at the edge of clear drainage. E. Instruct the patient to take thyroid and glucocorticoid replacement for at least 6 months.
A, B, C, D
which statements made by the client who has diabetes insipidus indicates to the nurse that more teaching is needed? select all that apply. a. if i gain more than 2 lb (1 kg) in a day, i'll limit my fluid intake b. if i become thirstier, i'll take another dose of the drug c. i'll avoid aspirin and aspirin-containing substances d. i'll stop taking the drug for 24 hours before i have any dental work performed e. i'll limit my intake of salt and sodium to no more than 2 g daily f. i'll wear my medical alert bracelet at all times
A, C, D, E
A nurse cares for a patient with adrenal hyperfunction. The patient screams at her husband, bursts into tears, and throws her water pitcher against the wall. She then tells the nurse, "I feel like I am going crazy." How would the nurse respond? a. I will ask your doctor to order a psychiatric consult for you b. You feel this way because of your hormone levels c. Can I bring you information about support groups? d. I will close the door to your room and restrict visitors
B
A nurse cares for a male patient with hypopituitarism who is prescribed testosterone hormone replacement therapy. The patient asks "how long will I need to take this medication?" How would the nurse respond? a. When your blood levels of testosterone are normal, the therapy is no longer needed b. When your beard thickens and your voice deepens, the dose is decreased, but treatment will continue forever c. When your sperm count is high enough to demonstrate fertility, you will no longer need this therapy d. With age, testosterone levels naturally decrease, so the medication can be stopped when you are 50 years old
B
A 56-year-old woman is admitted to the ED with a blood pressure of 168/92 and reports of fatigue and muscle weakness. She has bruising on her arms and 2+ swelling in her ankles. Her weight has gone from 150 to 185 lbs over the past 6 months. Assessment reveals that she has truncal obesity and thin extremities. Which diagnosis does the nurse suspect? A. Hyperpituitarism (acromegaly) B. Hypercortisolism (Cushing's disease) C. Hyperaldosteronism (Conn's syndrome) D. Adrenal insufficiency (Addison's disease)
B
A client has undergone a transsphenoidal hypophysectomy. Which intervention does the nurse implement to avoid increasing intracranial pressure (ICP) in the client? a. Encourage the client to cough and deep-breathe. b. Instruct the client not to strain during a bowel movement. c. Instruct the client to blow the nose if there is any postnasal drip. d. Place the client in the Trendelenburg position.
B
A client presents to the emergency department with acute adrenal insufficiency and the following vital signs: P 118 beats/min, R 18 breaths/min, BP 84/44 mm Hg, pulse oximetry 98%, and T 98.8°F oral. Which nursing intervention is the highest priority for this client? a. Administering furosemide (Lasix) b. Providing isotonic fluids c. Replacing potassium losses d. Restricting sodium
B
A nurse assesses patients for potential endocrine dysfunction. Which patient is at greatest risk for a deficiency of gonadotropin and GH? a. 36-year-old female who has used oral contraceptives for 5 years b. 42-year-old male who experienced head trauma 3 years ago c. 55-year-old female with a severe allergy to shellfish and iodine d. 64-year-old male with adult-onset DM
B
A nurse cares for a patient who possibly has syndrome of inappropriate ADH (SIADH). The patient's serum sodium level is 114 mEq/L. What action would the nurse take first? a. Consult with the dietician about increased dietary sodium b. Restrict the patient's fluid intake to 600 mL/day c. Handle the patient gently by using turn sheets for repositioning d. Instruct UAP to measure intake and output
B
A nurse is caring for a patient who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The patient's symptoms have now resolved and the patient asks "when can I stop taking these medications?" How would the nurse respond? a. It is possible for the inflammation to recur if you stop the medication b. Once you start corticosteroids, you have to be weaned off them c. You must decrease the dose slowly so your hormones will work again d. The drug suppresses your immune system, which must be built back up
B
A nurse teaches a patient with a cortisol deficiency who is prescribed cortisol replacement therapy. Which statement would the nurse include in this patient's instructions? a. You will need to learn how to rotate the injection sites b. If you are vomiting you will have to use injectable cortisol c. You need to follow a diet with strict potassium restrictions d. Take one tablet in the morning and two tablets at night
B
The client is taking fludrocortisone (Florinef) for adrenal hypofunction. The nurse instructs the client to report which symptom while taking this drug? a. Anxiety b. Headache c. Nausea d. Weight loss
B
Which post-operative assessment concerns the nurse the most? a. 12 hour intake - 2, 400 ml output - 1, 700 b. No bowel movement as of POD #2 c. Sleeps more than 12 hours a day, easy to arouse and oriented d. No drainage on the mustache dressing
B
The student nurse is creating a care plan for the patient. Which priority problems should be the focus of the care plan? (Select all that apply.) A. Fatigue B. Fluid overload C. Sleep deprivation D. Potential for infection E. Predisposition to injury
B, D, E
when should a patient take another dose of DDAVP?
if they are experiencing polyuria or polydipsia
A client with Cushing's disease begins to laugh loudly and inappropriately, causing the family in the room to be uncomfortable. What is the nurse's best response? a. "Don't mind this. The disease is causing this." b. "I need to check the client's cortisol level." c. "The disease can sometimes affect emotional responses." d. "Medication is available to help with this."
C
A nurse assesses a patient who is recovering from a transsphenoidal hypophysectomy. The nurse notes nuchal rigidity. Which action would the nurse take first? a. Encourage ROM exercises b. Document the finding and monitor the patient c. Take vital signs, including the temperature d. Assess pain and administer pain medications
C
During evening shift, the patient's MRI reveals the presence of a pituitary adenoma. The following day, surgery is performed to remove the tumor. What is the nurse's priority concern for the patient postoperatively? A. Airway management B. Assessing for systemic infection C. Monitoring for neurologic changes D. Development of transient diabetes mellitus
C
The next day, a student nurse is caring for the patient, who is scheduled for an MRI of the head. The student nurse asks why a patient with Cushing's disease needs this test. What is the nurse's best response? A. "They are looking for brain cancer which may have caused the disease." B. "The patient may have had headaches and they are looking for the cause." C. "The most common cause of Cushing's is a pituitary tumor called an adenoma." D. "A tumor of the adrenal gland can cause about 15% of Cushing's disease cases."
C
The nurse is assessing a client who had a transsphenoidal hypophysectomy yesterday. Which finding requires immediate notification to the primary health care provider? a. Dry lips and oral mucosa on examination b. Nasal drainage that tests negative for glucose c. Client report of a headache and stiff neck d. Urine specific gravity of 1.016
C
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH) admitted with change in mental status. To determine whether fluid restrictions have been effective, for which of these outcomes will the nurse monitor? a. Decreased hematocrit b. Decreased serum osmolality c. Increased serum sodium d. Increased urine specific gravity
C
The nurse is providing discharge instructions to a client receiving spironolactone (Aldactone) therapy. Which comment by the client indicates a need for further teaching? a. "I must call the primary health care provider if I am more tired than usual." b. "I need to increase my salt intake." c. "I will eat a banana every day." d. "This drug will not control my heart rate."
C
Which priority question should the nurse ask a patient with a pituitary tumor? A. "Have you had an unexpected weight loss?" B. "Have you noticed a change in your libido?" C. "Do you have any changes in your visual acuity?" D. "Have you experienced a change in growth of your facial hair?"
C
when reviewing the laboratory values of a client who has COPD and pneumonia, the nurse observes these findings. which one does the nurse report to the provider immediately? a. INR 2.1 b. serum chloride 96 mEq/L c. serum sodium 117 mEq/L d. pH 7.28
C
what does excessive PRL do?
inhibits the secretion of gonadotropins and sex hormones in men and women
what imaging tests are needed for hypercortisolism?
CT, MRI, and angiogram/ arteriography (trying to identify lesions on the adrenal or pituitary glands), look for lesions in the lung, GI tract, or pancreas
what are the nursing implications for prednisone?
instruct the patient to report illness because the usual daily dosage may not be adequate during periods of illness or severe stress
A client is referred to a home health agency after a transsphenoidal hypophysectomy. Which action does the RN case manager delegate to the home health aide who will see the client daily? a. Document symptoms of incisional infection or meningitis. b. Give over-the-counter laxatives if the client is constipated. c. Set up medications as prescribed for the day. d. Test any nasal drainage for the presence of glucose.
D
A client with Cushing's disease says that she has lost 1 pound (0.5 kg) What does the nurse do next? a. Auscultate the lungs for crackles. b. Check urine for specific gravity. c. Check the blood pressure. d. Weigh the client.
D
A client with a possible adrenal gland tumor is admitted for testing and treatment. Which nursing action is most appropriate for the charge nurse to delegate to the nursing assistant? a. Assess skin turgor and mucous membranes for hydration status. b. Discuss the dietary restrictions for 24-hour urine testing. c. Plan ways to control the environment that will avoid stimulating the client. d. Remind the client to not order coffee with meals
D
The charge nurse is making client assignments for the medical-surgical unit. Which client will be best to assign to an RN who has floated from the pediatric unit? a. Client who is receiving IV hydrocortisone for an Addisonian crisis b. Client admitted with syndrome of inappropriate antidiuretic hormone (SIADH) secondary to lung cancer c. Client being discharged after a unilateral adrenalectomy to remove a pheochromocytoma d. Client with Cushing's syndrome who requires frequent glucose monitoring and administration of insulin
D
The nurse is caring for a patient diagnosed with small cell lung cancer. The nurse understands the patient may also present with which endocrine disorder? A. Adrenal crisis B. Cushing's syndrome C. Diabetes insipidus (DI) D. Syndrome of inappropriate antidiuretic hormone (SIADH)
D
The nurse knows which patient with Cushing's disease is at greatest risk for developing heart failure? A. 60-year-old with pneumonia B. 59-year-old with a history of hypertension C. 32-year-old with a history of hepatitis B infection D. 42-year-old with a serum creatinine level of 3.7 mg/dL
D
The patient is admitted to the acute medical care unit for a workup for Cushing's disease. When she is assessed, she is found sitting at the bedside crying. She states, "I just don't know what to do. I feel so confused and down in the dumps." What is the nurse's best response? A. "Would you like to speak with a pastor or priest?" B. "Have you experienced this kind of confusion before?" C. "It's going to be fine. We'll find out what's wrong and take care of it." D. "Have you noticed if your mood goes quickly from happy to sad?"
D
When caring for a client with hypercortisolism the nurse notices that the phlebotomist, who plans to draw blood from the client, displays symptoms of a cold. What would the nurse do? a. Request another phlebotomist be sent from the laboratory. b. Monitor the client for cold-like symptoms. c. Refuse to allow the phlebotomist to enter the client's room. d. Ensure the phlebotomist wears a facemask.
D
Which part of routine post-op care is contraindicated for clients after hypophysectomy? a. Elevation of the head of the bed at least 30 degrees. b. Early ambulation c. Athrombic compression device application d. Cough and deep breath every 2 hours
D
in the preoperative holding area, the client who is scheduled to have an adrenalectomy for hypercortisolism is prescribed to receive cortisol by IV infusion. what is the nurse's best action? a. request a time-out to determine whether this is a valid prescription b. ask the client whether he or she usually takes prednisone c. hold the dose because the client has a high cortisol level d. administer the drug as prescribed
D
what are the nursing implications for hydrocortisone?
instruct the patient to report the following signs or symptoms of excessive drug therapy, which indicate Cushing's syndrome and a possible need for a dosage adjustment: -rapid weight gain -round face -fluid retention
what happens to the patient with hypercortisolism's emotions?
Emotional instability- crying or laughing inappropriately or not feeling like themselves (reassure patient that this is due to imbalanced hormone levels)
what are the nursing implications for cortisone?
instruct the patient to take this drug with meals or a snack to avoid gastric irritation
what is the drug alert for Korlym (Mifepristone)?
Korlym cannot be used during pregnancy because it also blocks progesterone receptors and would cause termination of the pregnancy
what imaging assessments need to be done on a patient with adrenal insufficiency (Addison's disease)?
MRI, CT, and angiogram/ arteriography
what does excessive GH do?
leads to acromegaly
what is SIADH also known as?
Swartz-Bartter Syndrome
which hormone deficiencies are the most life-threatening?
TSH and ACTH
what is panhypopituitarism?
absence of all anterior pituitary hormones
what is the earliest sign of increased ICP that you need to watch for after a hypophysectomy?
change in LOC- confusion, agitated, restless
what are the musculoskeletal changes present in hypercortisolism?
decreased muscle mass (atrophy) and osteoporosis (cortisol directly inhibits bone formation)
what is selective hypopituitarism?
deficiency of 1 pituitary hormone
what are the complications of diabetes insipidus?
dehydration, which can lead to hypovolemic shock
what is the action alert for diabetes insipidus patients in the hospital?
ensure that no patient suspected of having diabetes insipidus is deprived of fluids for more than 4 hours because they cannot reduce urine output and severe dehydration can result
how often do you need to do neuro assessments post-op for a hypophysectomy?
every hour for the first 24 hours then it goes to q4 if they are progressing normally
how do you treat meningitis?
give antibiotics, analgesics (for headache), and antipyretics (for fever)
what should you do if intranasal side effects of DDAVP occur or if your patient has an upper respiratory infection?
give the medication orally or sublingually
what is the incidence of Cushing's syndrome?
happens more often in women except when it is due to exogenous glucocorticoid therapy (prescribed)- this case is equal in men and women
what can SIADH and diabetes insipidus both be caused by?
head trauma or tumor
what changes happen to the glucose metabolism in hypercortisolism?
hyperglycemia because liver releases glucose and insulin receptors are less sensitive so blood glucose does not move as easily into the tissues
what are the cardiac changes that are present in hypercortisolism?
hypervolemia, high BP
what are the S&S of meningitis?
nuchal rigidity (stiff neck), fever, and headache
who is testosterone therapy contraindicated for?
patients with prostate cancer
what are the S&S of water toxicity?
persistent headache, acute confusion, and weight gain of 2.2 lbs
what is the drug alert for prednisone/prednisolone?
prednisone and prednisolone are sound-alike drugs, and care is needed not to confuse them. although they are both corticosteroids, they are not interchangeable because prednisolone is several times more potent than prednisone and dosages are not the same
what nutrition therapy is needed for hypercortisolism?
restrictions for fluid and sodium intake (2-4 g/day allowed, patients need to read food labels
what is the drug alert for bromocriptine (parlodel)?
seek medical attention for chest pain, dizziness, watery nasal drainage- can be caused by cardiac dysrhythmias, coronary artery spasm, and CSF fluid leaking
what is the surgical management of hyperpituitarism?
surgical removal of the pituitary gland and tumor (hypophysectomy)
how can you prevent acute adrenal insufficiency after an adrenalectomy?
talk to them about how to take hormone replacement (glucocorticoid), not to stop it, and to taper when the physician tells them they can stop taking it
what is the action alert for DDAVP?
the parenteral form of desmopressin (DDAVP) is 10 times stronger than the oral form, and the dosage must be reduced
what happens if they cannot reach the tumor through a hypophysectomy?
they will need to do a craniotomy
what are somatomedins?
trigger growth and maintain bone, cartilage, and other tissues
what cardiovascular assessments need to be done for a patient who has undergone nasal hypophysectomy?
vital signs, including apical pulse, pulse pressure, presence or absence of orthostatic hypotension, and the quality/rhythm of peripheral pulses
what can DDAVP cause?
water intoxication (S&S: persistent headache and acute confusion)
when is there too much ADH?
with SIADH (syndrome of inappropriate ADH)
when is there too little ADH?
with diabetes insipidus
what happens when the sodium level reaches 110-115 mmol/L?
you start to notice acute confusion, should be worried about seizures
