Chapter 49: Disorders of Endocrine Control of Growth and Metabolism

A client is diagnosed with Addison's disease. What statement by the client indicates an understanding of the discharge instructions by the nurse?

"I will have to take my medication for the rest of my life." -Addison's disease, like type I diabetes, is a chronic metabolic disorder that requires lifetime hormone replacement therapy. The daily regulation of the chronic phase of Addison disease is usually accomplished with oral replacement therapy, with higher doses being given during periods of stress.

A client with hypothyroidism has not taken medication for several months, informing the nurse that she lost her insurance and is unable to afford the medication. When assessing the client's temperature tolerance and skin, what does the nurse anticipate finding? Select all that apply.

Coarse and dry skin and hair Intolerance to cold Decreased sweating -The client with hypothyroidism experiences an intolerance to cold, decreased sweating, and coarse and dry skin and hair, related to the decrease in metabolic rate from the deficient thyroid secretion.

Hyperthyroidism that is inadequately treated can cause a life-threatening condition known as a thyroid storm. What are the manifestations of a thyroid storm? (Select all that apply.)

Tachycardia Very high fever Delirium -Thyroid storm is manifested by a very high fever, extreme cardiovascular effects (i.e., tachycardia, congestive failure, and angina), and severe CNS effects (i.e., agitation, restlessness, and delirium). The mortality rate is high.

Which of the following clinical manifestations following thyroidectomy would alert the nurse that the client is going into a life-threatening thyroid storm? Select all that apply

Temperature of 104.2°F Telemetry showing heart rate of 184 Extremely agitated -Thyroid storm, or crisis, is an extreme and life-threatening form of thyrotoxicosis, rarely seen today. When it does occur, it is seen most often in undiagnosed cases or in person with hyperthyroidism that has not been adequately treated. It often is precipitated by stress such as an infection, diabetic ketoacidosis, physical or emotional trauma, or manipulation of a hyperactive thyroid gland during thyroidectomy. It is manifested by a very high fever, extreme cardiovascular effects (tachycardia, HF, angina), and severe CNS effects (agitation, restlessness, and delirium).

The nurse is performing a health history from a client with acromegaly. The client informs the nurse that he is waking up several times a night and has been told he has sleep apnea. What does the nurse inform the client is the rationale for this syndrome?

-There is an increase in pharyngeal soft tissue accumulation. -The pathogenesis of sleep apnea syndrome is obstructive in the majority of people due to increased pharyngeal soft tissue accumulation.

Parents of a 7-year-old girl are concerned about their daughter because she has begun to develop secondary sexual characteristics. What etiologic factor is most likely to underlie the child's condition?

- Early activation of the hypothalamic--pituitary--gonadal axis -Isosexual or central precocious puberty involves early activation of the hypothalamic--pituitary--gonadal axis, resulting in the development of appropriate sexual characteristics and fertility. It is not caused by trauma such as sexual abuse and it does not involve thyroid function. Precocious puberty is not noted to be a genetic trait.

A child has been removed from a home in which she has experienced severe neglect and emotional abuse, and has been placed in foster care. The child has psychosocial dwarfism and the foster parents ask the nurse what this means for the future of the child. What is the best response by the nurse?

- "The prognosis of the child depends on an improvement in behavior and catch-up growth." -Psychosocial dwarfism involves a functional hypopituitarism and is seen in some emotionally deprived children. These children usually present with poor growth, potbelly, and poor eating and drinking habits. Typically, there is a history of disturbed family relationships in which the child has been severely neglected or disciplined. Often, the neglect is confined to one child in the family. GH function usually returns to normal after the child is removed from the constraining environment. The prognosis is dependent on improvement in behavior and catch-up growth.

A client with Graves' disease has opthalmopathy and asks the nurse if the eyes will stay like this forever. What is the best response by the nurse?

- "With treatment of the hyperthyroid state, the opthalmopathy usually tends to stabilize." -The ophlalmopathy of Graves' disease can cause severe eye problems, including tethering of the extraocular muscles resulting in diplopia; involvement of the optic nerve, with some visual loss; and corneal ulceration because the lids do not close over the protruding eyeball. The opthalmopathy usually tends to stabilize after treatment of the hyperthyroidism.

A client is to have a serum thyroxine and thyroid stimulating laboratory test performed to assess the baseline status of the hypothalamic-pituitary target cell hormones. When educating the client about the laboratory tests, when would the the nurse inform him the test should be obtained?

- Before 0800 -The assessment of hypothalamic-pituitary function has been made possible by many newly developed imaging and radioimmunoassay methods. Assessment of the baseline status of the hypothalamic-pituitary target cell hormones involves measuring the following: ideally the laboratory specimens are obtained before 0800: serum cortisol, serum prolactin, serum thyroxine and TSH, serum testosterone and estrogen and serum LH/FSH, serum GH, and plasma and urine osmolality.

Which complication of acromegaly can be life threatening?

- Cardiac structures increase in size -While all the complications can exist, it is the enlargement of the heart and accelerated atherosclerosis that may lead to an early death. The teeth become splayed, causing a disturbed bite and difficulty in chewing. Vertebral changes often lead to kyphosis, or hunchback. Bone overgrowth often leads to arthralgias and degenerative arthritis of the spine, hips, and knees. Virtually every organ of the body is increased in size.

The nurse is caring for an adult client with growth hormone deficiency. When performing an assessment of this client, which system should the nurse be sure to assess for complications related to this disorder?

- Cardiovascular system -Evidence shows that cardiovascular mortality increases in GH-deficient adults. A higher prevalence of atherosclerotic plaques and endothelial dysfunction has been reported in both childhood and adult GH deficiency. The GH deficiency syndrome is associated with a cluster of cardiovascular risk factors, including central adiposity, insulin resistance, and dyslipidemia.

The newborn-nursery nurse is obtaining a blood sample to determine if a newborn has congenital hypothyroidism. What long-term complication is the nurse aware can occur if this test is not performed and the infant has congenital hypothyroidism?

- Cretinism -Congenital hypothyroidism is a common cause of preventable intellectual disability. It affects approximately 1 in 4000 infants. The manifestations of untreated congenital hypothyroidism are referred to as cretinism.

Which disorder is a result of excess cortisol?

- Cushing syndrome -The term Cushing syndrome refers to the manifestations of hypercortisolism from any cause. Turner's and Marfan syndromes are chromosomal disorders that affect height while Hashimoto disease is a thyroid disorder

Which effect of thyroid hormone deficit alters the function of all major organs in the body?

- Decreases metabolism -Thyroid hormone has two major functions: it increases metabolism and protein synthesis, and it is necessary for growth and development in children, including mental development and attainment of sexual maturity. Altered levels of thyroid hormone affect all the major organs in the body; hypothyroidism decreases metabolism and protein synthesis. Thyroid hormone deficit decreases the absorption of glucose from the gastrointestinal tract. Because vitamins are essential parts of metabolic enzymes and coenzymes, an increase (rather than decrease) in metabolic rate causes the use of vitamins and tends to cause vitamin deficiency.

Which of the following individuals displays the precursors to acromegaly?

-An adult with an excess of growth hormone due to an adenoma -When growth hormone (GH) excess occurs in adulthood or after the epiphyses of the long bones have fused, it causes a condition called acromegaly, which represents an exaggerated growth of the ends of the extremities.

A nurse on a medical unit is providing care for a 37-year-old female client who has a diagnosis of Graves' disease. Which assessments should the nurse prioritize?

- Eye health and visual acuity -The ophthalmopathy of Graves' disease can cause severe eye problems, including tethering of the extraocular muscles resulting in diplopia; involvement of the optic nerve, with some visual loss; and corneal ulceration because the lids do not close over the protruding eyeball (due to the exophthalmos). Eye assessment is consequently a priority over assessment of skin integrity, cognition, or musculoskeletal status.

Which test can the nurse prepare the client for to determine the differentiation between a benign and a malignant thyroid disease?

- Fine-needle aspiration biopsy -Ultrasonography can be used to differentiate cystic from solid thyroid lesions, and CT and MRI scans are used to demonstrate tracheal compression or impingement on other neighboring structures. Fine-needle aspiration biopsy of a thyroid nodule has proved to be the best method for differentiation of benign from malignant thyroid disease

Abnormal stimulation of the thyroid gland by TSH-receptor antibodies is implicated in cases of which of the following?

- Graves' disease -Graves' disease is an autoimmune disorder characterized by abnormal stimulation of the thyroid gland by thyroid-stimulating antibodies (TSH-receptor antibodies) that act through the normal TSH receptors.

The nurse is performing an assessment for a client who has hyperthyroidism that is untreated. When obtaining vital signs, what is the expected finding?

- Heart rate 110 and bounding -Cardiovascular and respiratory functions are strongly affected by thyroid function. With an increase in metabolism, there is a rise in oxygen consumption and production of metabolic end products, with an accompanying increase in vasodilation. Blood volume, cardiac output, and ventilation are all increased. Heart rate and cardiac contractility are enhanced as a means of maintaining the needed cardiac output. Blood pressure is likely to change little because the increase in vasodilation tends to offset the increase in cardiac output.

A nurse is assessing an elderly woman diagnosed with chronic hypothyroidism who has developed myxedematous coma. The nurse will likely assess which lab and clinical manifestations in this client? Select all that apply.

- Hypoventilation Hyponatremia Hypoglycemia Lactic acidosis -Myxedematous coma is a life-threatening, end-stage expression of hypothyroidism. It is characterized by coma, hypothermia, cardiovascular collapse, hypoventilation, and severe metabolic disorders, including hyponatremia, hypoglycemia, and lactic acidosis.

When the nurse is performing a health history for a client who is being admitted for hyperthyroidism, what symptoms does the client report that the nurse would find associated with this disorder?

- Increase in appetite -Thyroid hormone enhances gastrointestinal function, causing an increase in motility and production of GI secretions that often results in diarrhea. An increase in appetite and food intake accompanies the higher metabolic rate that occurs with increased thyroid hormone levels. At the same time, weight loss occurs because of the increased use of calories.

A client comes to the clinic with fatigue and muscle weakness. The client also states she has been having diarrhea. The nurse observes the skin of the client has a bronze tone and when asked, the client says she has not had any sun exposure. The mucous membranes of the gums are bluish-black. When reviewing laboratory results from this client, what does the nurse anticipate seeing?

- Increased levels of ACTH -Hyperpigmentation results from elevated levels of ACTH. The skin looks bronzed or suntanned in exposed and unexposed areas, and the normal creases and pressure points tend to become especially dark. The gums and oral mucous membranes may become bluish-black. The amino acid sequence of ACTH is strikingly similar to that of melanocyte stimulating hormone; hyperpigmentation occurs in greater than 90 percent of persons with Addison's disease and is helpful in distinguishing the primary and secondary forms of adrenal insufficiency.

The immune suppressive and anti-inflammatory effects of cortisol cause:

- Inhibition of prostaglandin synthesis -Large quantities of cortisol are required for an effective anti-inflammatory action. The increased cortisol blocks inflammation at an early stage by decreasing capillary permeability and stabilizing the lysosomal membranes so that inflammatory mediators are not released. Cortisol suppresses the immune response by reducing humoral and cell-mediated immunity. Cortisol also inhibits prostaglandin synthesis, which may account in large part for its anti-inflammatory actions. Cortisol stimulates glucose production by the liver; as glucose production by the liver rises and peripheral glucose use falls, a moderate resistance to insulin and hyperglycemia develop.

The most common cause of thyrotoxicosis is Graves disease. When assessing this client, the nurse should put priority on which of the following signs/symptoms?

- Ophthalmopathy -Graves disease is characterized by a triad of hyperthyroidism, goiter, ophthalmopathy (exophthalmos), or less commonly, dermopathy (pretibial edema due to accumulation of fluid and glycosaminoglycans). Even in persons without exophthalmos (i.e., bulging of the eyeballs seen in ophthalmopathy), there is an abnormal retraction of the eyelids and infrequent blinking such that they appear to be staring. Although the myxedema of hypothyroidism is most obvious in the face and other superficial parts, it also affects many of the body organs. Common to all types of thyrotoxicosis, rather than unique to Graves disease, cholesterol blood levels are decreased; muscle proteins are broken down and used as fuel, which accounts for the muscle fatigue that occurs with all types of hyperthyroidism.

A client with severe hypothyroidism is presently experiencing hypothermia. What nursing intervention is a priority in the care of this client?

- Slow rewarming of the client to prevent vasodilation and vascular collapse -If hypothermia is present, active rewarming of the body is contraindicated because it may induce vasodilation and vascular collapse. Prevention is preferable to treatment and entails special attention to high risk populations, such as women with a history of Hashimoto thyroiditis.

A client has developed the facial appearance that is characteristic of myxedema, along with an enlarged tongue, bradycardia, and voice changes. Which of the following treatment modalities is most likely to benefit this client?

- Synthetic preparations of T3 or T4 -Myxedema and the client's other signs are associated with hypothyroidism, which necessitates thyroid hormone replacement. β-Adrenergic blocking drugs and antithyroid drugs are indicated in the treatment of hyperthyroidism,

The nurse is educating a newly diagnosed client with Hashimoto thyroiditis who is to be discharged from the acute care facility. What should the nurse be sure to include in the education to prevent complications?

- The client should be informed about the signs and symptoms of severe hypothyroidism and the need for early intervention. -Prevention is preferable to treatment and entails special attention to high-risk populations, such as women with a history of Hashimoto thyroiditis. These persons should be informed about the signs and symptoms of severe hypothyroidism and the need for early medical treatment.

The nurse is providing education to a client with Addison's disease who has been treated for hyponatremia and hypoglycemia related to the disease. What should the nurse inform the client should be done to ensure control of these conditions?

- The client should eat and exercise on a regular schedule. -Because people with Addison's disease are likely to have episodes of hyponatremia and hypoglycemia, they need to have a regular schedule for meals and exercise. It is not necessary to limit carbohydrate and fat intake or salt related to this disorder.

A child is born with dwarfism to normal-sized parents. The physician is explaining how growth hormone (GH) plays a central role in the increase in stature that characterizes childhood and adolescence. What is the first step in the growth hormone chain of events

- The hypothalamus secretes GHRH. -Like other pituitary functions, hypothalamic stimulation precedes hormone release. In the case of GH, stimulation is the result of GHRH by the hypothalamus. GH is then released by the pituitary gland, stimulating the liver to release IGFs, which ultimately causes the epiphyseal plates of long bones to grow.

A client's low serum T4 level has led to a diagnosis of hypothyroidism. When planning this client's care, the nurse should:

- teach the client about the safe and effective use of synthetic thyroid hormones. -Hypothyroidism is treated by replacement therapy with synthetic preparations of T3 or T4. Graves disease is associated with hyperthyroidism, not hypothyroidism. Surgery is not a usual treatment modality.

When educating a client with possible glucocorticoid dysfunction, the nurse will explain that the CRH controls the release of ACTH. The best time to perform the blood test to measure peak ACTH levels would be:

-06:00 to 08:00 AM -Levels of cortisol increase as ACTH levels rise and decrease as ACTH levels fall. There is considerable diurnal variation in ACTH levels, which reach their peak in the early morning (around 6 to 8 AM) and decline as the day progresses.

Which client does the nurse recognize is at the most risk for the development of subacute thyroiditis?

-A 32-year-old postpartum client -The transient hyperthyroid state is caused by leakage of preformed thyroid hormone from damaged cells of the gland. Subacute thyroiditis, which can occur in postpartum (postpartum thyroiditis) can also result in hypothyroidism.

A client is diagnosed with hyperthyroidism and is exhibiting weight loss, diarrhea, and tachycardia. What does the nurse understand that these clinical manifestations are related to?

-A hypermetabolic state -Many of the manifestations of hyperthyroidism are related to the increase in oxygen consumption and use of metabolic fuels associated with the hypermetabolic state, as well as to the increase in sympathetic nervous system activity that occurs.

A lung cancer client with small cell carcinoma may secrete an excess of which hormone causing an ectopic form of Cushing syndrome due to a nonpituitary tumor?

-ACTH -The third form (of Cushing syndrome) is ectopic Cushing syndrome, caused by a nonpituitary ACTH-secreting tumor. Certain extra pituitary malignant tumors such as small cell carcinoma of the lung may secrete ACTH or, rarely, CRH and produce Cushing syndrome. The adrenal sex hormone dehydroepiandrosterone (DHEA) contributes to the pubertal growth of body hair, particularly pubic and axillary hair in women. Thyroid-stimulating hormone (TSH) levels are used to differentiate between primary and secondary thyroid disorders. Although secretion of growth hormone (GH) has diurnal variations over a 24-hour period, with nocturnal sleep bursts occurring 1 to 4 hours after onset of sleep, it is unrelated to ACTH and/or CRH secretion.

The health care provider is reviewing diurnal variation pattern in adrenocorticotropic (ACTH) levels. Select the typical diurnal variation pattern in adrenocorticotropic (ACTH) levels.

-ACTH peaks in the morning and declines throughout the day. -ACTH levels have diurnal variation in which they reach their peak in the early morning (around 6 to 8 AM) and decline as the day progresses related to rhythmic activity of the CNS. The diurnal pattern is reversed in people who work during the night and sleep during the day. The rhythm also may be changed by physical and psychological stresses, endogenous depression, and liver disease or other conditions that affect cortisol metabolism.

At times, it is necessary to give medications that suppress the adrenal glands on a long-term basis. When the suppression of the adrenals becomes chronic, the adrenal glands atrophy. What does the abrupt withdrawal of these suppressive drugs cause?

-Acute adrenal insufficiency -Chronic suppression causes atrophy of the adrenal gland, and the abrupt withdrawal of drugs can cause acute adrenal insufficiency.

The nurse is performing an assessment for a client with Cushing syndrome and observes a "buffalo hump" on the back, a moon face, and a protruding abdomen. What does the nurse understand contributes to the distribution of fat in these areas?

-Altered fat metabolism -The major manifestations of Cushing syndrome represent an exaggeration of the many actions of cortisol. Altered fat metabolism causes a peculiar deposition of fat characterized by a protruding abdomen, subclaviclar fat pads or "buffalo hump" on the back, and a round, plethoric "moon face."

Which of the following residents of a long-term facility is exhibiting clinical manifestations of hypothyroidism?

-An 80-year-old woman who has uncharacteristically lost her appetite of late and often complains of feeling cold -Loss of appetite and cold intolerance are characteristic symptoms of hypothyroidism. Arrhythmias, agitation, and infections are not typically associated with hypofunction of the thyroid gland.

A client is to have a serum thyroxine and thyroid stimulating laboratory test performed to assess the baseline status of the hypothalamic-pituitary target cell hormones. When educating the client about the laboratory tests, when would the the nurse inform him the test should be obtained

-Before 0800 -he assessment of hypothalamic-pituitary function has been made possible by many newly developed imaging and radioimmunoassay methods. Assessment of the baseline status of the hypothalamic-pituitary target cell hormones involves measuring the following: ideally the laboratory specimens are obtained before 0800: serum cortisol, serum prolactin, serum thyroxine and TSH, serum testosterone and estrogen and serum LH/FSH, serum GH, and plasma and urine osmolality.

A client is diagnosed with adrenocorticotropic hormone deficiency (ACTH) and is to begin replacement therapy. Regarding which type of replacement will the nurse educate the client?

-Cortisol replacement therapy -Cortisol replacement is started when ACTH deficiency is present; thyroid replacement when TSH deficiency is detected; and sex hormone replacement when LH and FSH are deficient. GH replacement is indicated for pediatric GH deficiency, and is increasingly being used to treat GH deficiency in adults.

The nurse is preparing a client for a test that will measure negative feedback suppression of ACTH. Which medication will the nurse administer in conjunction for this test?

-Dexamethasone -Administration of dexamethasone, a synthetic glucocorticoid drug, provides a mean of measuring negative feedback suppression of ACTH. Adrenal tumors and ectopic ACTH-producing tumors are usually unresponsive to ACTH suppression by dexamethasone

Which of the following pathophysiologic phenomena may result in a diagnosis of Cushing disease?

-Excess ACTH production by a pituitary tumor -Three important forms of Cushing syndrome result from excess glucocorticoid production by the body. One is a pituitary form, which results from excessive production of ACTH by a tumor of the pituitary gland. Hypopituitarism and destruction of the adrenal cortex are associated with Addison disease. Disruption of the HPA system is not implicated in the etiology of Cushing disease.

A client is seeking treatment for infertility. What decrease in hormone secretion from the anterior lobe of the pituitary gland that regulates fertility would the nurse recognize may cause this issue?

-Follicle stimulating hormone (FSH) -ACTH controls the release of cortisol from the adrenal gland. TSH controls the secretion of thyroid hormone from the thyroid gland. LH regulates sex hormones. FSH regulates fertility

The nurse is teaching a client diagnosed with Addison disease about the importance of lifetime oral replacement therapy. Which pharmacologic agent would be the drug of choice and included in this teaching plan?

-Hydrocortisone -The daily regulation of the chronic phase of Addison disease is usually accomplished by oral replacement therapy, with higher doses being given during periods of stress. Hydrocortisone is usually the drug of choice in treating Addison disease. In mild cases, hydrocortisone alone may be adequate. Ketoconazole causes excessive breakdown of glucocorticoids and can also result in adrenal insufficiency.

The newborn-nursery nurse is preparing to perform a required neonatal screening for congenital hypothyroidism. What should the nurse do to obtain the necessary sample?

-Perform a heel stick to obtain a drop of blood for a T4 and TSH. -Screening is usually done in the hospital nursery. In this test, a drop of blood is taken from the infant's heel and analyzed for T4 and TSH.

A parent arrives in the endocrinology clinic with her 8-year-old son, concerned about his rapid development and tall stature. What significant assessment finding does the nurse recognize is important to report to the physician related to the development of precocious puberty?

-Significant genital enlargement -Diagnosis of precocious puberty is based on physical findings of early thelarche, adrenarche, and menarche. The most common sign in boys is early genital enlargement. Radiologic findings may indicate advanced bone age. People with precocious puberty are unusually tall for their age as children but short as adults because of the early closure of the epiphyses.

The nurse is assessing a female client with a diagnosis of primary adrenal cortical insufficiency. Which manifestation should the nurse anticipate?

-Sparse axillary and pubic hair -A common finding would be sparse axillary and pubic hair. Other signs/symptoms would include dehydration, weakness, fatigue, anorexia, nausea, and weight loss. Skin would have increased pigmentation. Weight gain and fluid retention may be the result of Cushing syndrome.

A parent brings his child to the clinic, concerned about her short stature and asking the nurse if there is a problem with her height. What indication is the nurse aware of when performing the assessment that determines whether this child has short stature?

-The child's height is well below the third percentile on several clinic visits. -Short stature is a condition in which the attained height is well below the third percentile, or linear growth is below normal for age and sex. Diagnosis of short stature is not made on a single measurement, but is based on sequential height measurements and on velocity of growth and parental height.

The nurse is providing discharge instructions for a client with Graves' disease who has ophthalmopathy. What should the nurse be sure to include in the instructions to decrease exacerbation of this clinical manifestation?

-The client should be strongly urged not to smoke. -The client should be strongly urged not to smoke.

The nurse is providing education for a client diagnosed with hypothyroidism. What information about diet should the nurse be sure to include in this information?

-The client should maintain a low cholesterol diet. -Blood levels of cholesterol are decreased in hyperthyroidism and increased in hypothyroidism. The client may be placed on an antihyperlipidemic medication in addition to decreasing the cholesterol heavy foods in the diet.

The nurse is educating a parent of a child with short stature caused by growth hormone (GH) deficiency about the administration of GH. What should the nurse include when educating the parents about administration?

-The medication will be given daily during the period of active growth and can be continued into adulthood. -GH is administered by daily subcutaneous injection during the period of active growth, and can be continued into adulthood.

A client who has just undergone a thyroidectomy is experiencing high fever, tachycardia, and extreme restlessness. The nurse would interpret these findings as manifestations of which complication?

-Thyroid storm -The symptoms this client is experiencing are related to thyroid storm and must be treated immediately to prevent death. Myxedematous coma is related to hypothyroidism but typically does not occur after a thyroidectomy. Addisonian crisis is related to hypoadrenalism.