NCLEX. ADULT HEALTH. ENDOCRINE
The nurse assesses a female client with a diagnosis of primary adrenal insufficiency (Addison disease). The nurse recognizes which finding associated with the disease? 1) bronze pigmentation of the skin 2) increased body or facial hair 3) purple or red striae on the abdomen 4) supraclavicular fat pad
1) Addison disease, or primary adrenocortical insufficiency, is also described as hypofunction of the adrenal cortex. The adrenal gland is responsible for secretion of glucocorticoids, androgens, and mineralocorticoids. Bronze hyperpigmentation of the skin in sun-exposed areas is caused by an increase in adrenocorticotropic hormone (ACTH) by the pituitary in response to low cortisol (ie, glucocorticoid) levels (Option 1). Clients with Addison disease may also have vitiligo, or patchy/blotchy skin, which is usually present when the etiology of the disease is an autoimmune problem. The immune cells are thought to destroy melanocytes which produce melanin (or brown pigment), resulting in a patchy appearance. Other common manifestations of Addison disease include the following: Slow, progressive onset of weakness and fatigue Anorexia and weight loss Orthostatic hypotension Hyponatremia and hyperkalemia Salt cravings Nausea and vomiting Depression and irritability (Options 2, 3, and 4) Purple striae, hirsutism (increased facial and body hair), and a supraclavicular fat pad (ie, buffalo hump) are characteristics of Cushing syndrome, a condition associated with excess corticosteroid production. In contrast, Addison disease is a condition of hyposecretion of glucocorticoids. Educational objective: Hyperpigmentation of the skin is a common characteristic of Addison disease, or primary adrenocortical insufficiency, which can also cause hypotension, hyponatremia, hyperkalemia, and vitiligo.
The nurse educates a 30-year-old female client who is being evaluated for hyperthyroidism with a radioactive iodine uptake (RAIU) test. Which instruction(s) should the nurse include in the teaching plan? Select all that apply. 1) A pregnancy test must be obtained prior to RAIU test administration 2) All jewelry or metal around the neck area should be removed before the RAIU test 3) Antithyroid meds should be held for 5-7 days before the RAIU test 4) Conscious sedation will be used to help with relaxation during the RAIU test 5) It is important to refrain from eating or drinking for at least 12 hours before the RAIU test
1, 2, 3 A RAIU test involves administering a low dose of radioactive iodine, in contrast to radioactive iodine treatment for some types of thyroid cancer, which uses a high dose to destroy all thyroid tissue. The thyroid gland is the only tissue that uses iodine, which is a key component of thyroid hormones. A scan is performed at 2, 6, and 24 hours to assess the areas actively absorbing iodine, which can narrow the diagnosis to hyperfunctioning thyroid disorders (eg, Graves' disease). Important nursing considerations: Notify the primary health care provider (PHCP) if computerized tomography scan or other recent x-ray using iodine contrast has been performed; the iodine may alter the test results. Antithyroid or thyroid hormone medication should be held for 5-7 days before undergoing a RAIU test as these can also alter results. All premenopausal women must take a pregnancy test before the procedure, as radioactive iodine could adversely affect the development of the fetal thyroid gland. Important aspects of client education: Maintain nothing by mouth (NPO) status for 2-4 hours prior to the procedure (Option 5). Eating may resume 1-2 hours after swallowing the iodine; a normal diet can be restarted when the test ends. Remove dentures and jewelry/metal around the neck to allow clear visualization during the scan. Drink plenty of fluids after the procedure to clear RAI from the system. Notify the PHCP if you are allergic to any medications (eg, iodine). However, a RAIU test is generally safe (even in the presence of an iodine allergy) due to the diminutive amount of iodine used. You will be awake during the procedure but there should be no discomfort (Option 4). Do not breastfeed immediately after this procedure, and ask your PHCP when breastfeeding may resume. Educational objective: RAIU measures the metabolic activity in the thyroid gland in order to differentiate between the many types of thyroid disorders. For an accurate measurement, medications affecting the thyroid should be held 7 days prior to the test date and clients are NPO for 4 hours prior to iodine administration. Premenopausal women must take a pregnancy test. Dentures, metal, and jewelry should be removed.
The nurse teaches disease management to a group of clients with type I diabetes mellitus. Which of the following should the nurse teach as signs or symptoms associated with hypoglycemia? Select all that apply. 1) Diaphoresis 2) Flusing 3) Pallor 4) Polyuria 5) Trembling
1, 3, 5 Hypoglycemia (low blood glucose <70 mg/dL [3.9 mmol/L]) is an acute and potentially serious complication that occurs when levels of insulin exceed the proportion of glucose. Epinephrine is one of the major hormones released during a hypoglycemic reaction and may cause early symptoms such as trembling, palpitations, anxiety/arousal, and restlessness. Diaphoresis and pallor are present on examination. When the brain is deprived of glucose due to prolonged and severe hypoglycemia, neuroglycopenic symptoms (confusion, seizures, coma) develop. (Option 2) Flushing (red skin) is commonly seen with fever, carcinoid syndrome, polycythemia vera, and sexual intercourse. Flushing is not seen with hypoglycemia. (Option 4) Polyuria and weight loss are usually associated with hyperglycemia, not hypoglycemia. Educational objective: Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) is an acute and potentially serious complication. Signs and symptoms include shakiness, palpitations, anxiety/arousal, restlessness, diaphoresis, and pallor.
A client with type 1 diabetes mellitus is on intensive insulin therapy. The client is of the Islamic faith and insists on fasting during Ramadan. What is the most important nursing action? 1) Advise the client of risks of fasting when diabetic 2) Assess the client's clinical stability and glycemic control 3) Refer the client to the HCP for adjustment of the insulin therapy 4) Refer the client to the registered dietitian for meal planning
2) Diabetic clients whose religious practices require them to change their current diet (eg, fasting) and glycemic management regimen should be assessed for clinical stability (eg, comorbidities) and glycemic control, including: History of hyperglycemia, hypoglycemia, and ketoacidosis Dosage and timing of medications Knowledge of meal planning Ability to perform blood glucose monitoring during the fast Fasting during Ramadan is one of the Five Pillars of Islam. Observance of Ramadan and daytime fasting occurs throughout the ninth month of the lunar calendar. During this time, Muslim clients are required to refrain from food and drink from dawn to sunset. Clients who are sick, children, pregnant women, and the elderly are exempt from fasting; however, some clients who fall into these categories may insist on fasting, creating challenges for their health care team. (Option 1) Clients with diabetes who are at lower risk for adverse events while fasting based on risk assessment need to receive instruction on adjusting their meal planning, physical exercise, and insulin therapy. Those at high risk for complications should be discouraged from fasting. (Options 3 and 4) These are appropriate nursing actions after the client has been assessed for risk of diabetic complications from fasting. Educational objective: Clients with diabetes who insist on fasting for religious reasons need to be assessed for risk of adverse events. Key assessment areas include clinical stability and glycemic control (eg, history of hyper-/hypoglycemic episodes, medication regimen, and the ability to self-monitor blood glucose during the fast).
The nurse teaches proper foot care to a client with diabetes mellitus. Which statement by the client indicates that further teaching is needed? 1) I will apply lanolin to my feet to prevent dry skin 2) I will make sure my flip flops are made of leather 3) I will not apply a heating pad directly to my feet 4) I will test the water with a thermometer before bathing
2) Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet due to the chronic complication of peripheral neuropathy. Peripheral neuropathy results from damage to the nerves in the extremities. Clients may be unable to feel injuries if they occur and must take extra measures in caring for their feet. Clients should be taught to wear closed-toed, leather-based shoes to prevent injury. Careful, daily attention to foot care can prevent long-term complications. The following instructions can be used in teaching diabetic foot care: Proper footwear - Wear shoes that are comfortable, supportive, and well-fitting (preferably leather). Avoid high-heeled, open-heeled, and open-toed shoes. Wear clean, absorbent (eg, cotton) socks. Daily hygiene and inspection - Use a mild soap and warm water; dry feet thoroughly, especially between toes. Apply lanolin lotion to prevent drying (but not between toes) (Option 1). Inspect for any break in skin integrity using a mirror or a second person to visualize the bottom of the feet. Trim toenails straight across; file edges along contour of the toes. Injury avoidance - Do not walk barefoot, use hot water or heating pads, wear restrictive shoes or clothing, or cross the legs for extended periods (Options 3 and 4). Report problems - Do not self-treat corns, calluses, or ingrown toenails. Cleanse cuts or abrasions with mild soap and water; report non-healing or infected injuries to the health care provider immediately. Educational objective: Careful, daily attention to foot care can prevent long-term complications. Clients with diabetes should be taught to wear closed-toed, leather-based shoes to prevent injury. Clients should also receive instruction regarding daily hygiene and inspection, injury avoidance, and prompt reporting of problems.
The nurse cares for a client with type 1 diabetes mellitus. Which laboratory result is most important to report to the primary health care provider? 1) Fasting blood glucose 99 mg/dL 2) Serum creatinine 2.0 mg/dL 3) Serum potassium 3.9 mEq/L 4) Serum sodium 140 mEq/L
2) The normal serum creatinine for an adult is 0.6-1.3 mg/dL (53-115 µmol/L). It provides an estimation of the glomerular filtration rate and is an indicator of kidney function. A level of 2 mg/dL (177 µmol/L) is clearly abnormal. The client with diabetes mellitus is at risk for diabetic nephropathy, a complication associated with microvascular blood vessel damage in the kidney. Early treatment and tight control of blood glucose levels are indicated to prevent progressive renal injury in a client with diabetic nephropathy. (Option 1) Normal serum fasting blood glucose is 70-99 mg/dL (3.9-5.5 mmol/L). (Option 3) Normal serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). (Option 4) Normal serum sodium is 135-145 mEq/L (135-145 mmol/L). Educational objective: The normal serum creatinine for an adult is 0.6-1.3 mg/dL (53-115 µmol/L). Serum creatinine provides an estimation of the glomerular filtration rate and is an indicator of kidney function.
The nurse is caring for an adolescent client diagnosed with type 1 diabetes. The client exhibits hot, dry skin and a glucose level of 350 mg/dL (19.4 mmol/L). Arterial blood gases show a pH of 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? 1) Administer IV regular insulin 2) Administer NS infusion 3) Obtain urine for urinalysis 4) Request prescription for potassium infusion
2) 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. Educational objective: Clients with diabetic ketoacidosis and hyperosmolar hyperglycemic state require IV normal saline as a priority due to severe dehydration. Once fluids are given as a bolus, insulin is initiated. The serum potassium levels can be elevated in the initial stages despite a low total body potassium. Potassium repletion is started once the serum potassium levels are normalized or trending low (from elevated levels).
The nurse practicing in an out-patient clinic cares for a client recently diagnosed with hyperthyroidism. Which diet-related teaching should the nurse add to the client's plan of care? Select all that apply. 1) Emphasize the importance of a low-carb diet 2) Encourage the client to increase high-fiber foods in the diet 3) Include meals and snacks high in protein content 4) Teach avoidance of caffeine containing liquids 5) Teach the client about consumption of a high-calorie diet of 4,000-5,000 calories/day
3, 4, 5 Hyperthyroidism refers to sustained hyperfunctioning of the thyroid gland due to excessive secretion thyroid hormones (T3, T4); this leads to an increased metabolic rate. In clients with hyperthyroidism, teaching and learning objectives to satisfy hunger and prevent weight loss and tissue wasting include: Adherence to a high calorie diet (4000-5000 calories per day). Consumption of approximately 6 full meals and snacks per day. These should be packed with protein (1-2 g/kg of ideal body weight), carbohydrates, and be full of vitamins and minerals (Option 1). Avoidance of high-fiber foods due to the constant hyperstimulation of the gastrointestinal (GI) tract. High-fiber foods may increase GI symptoms (eg, diarrhea) (Option 2). However, high-fiber diets are recommended if the client with hyperthyroidism has constipation. Avoidance of stimulating substances (eg, caffeinated drinks: coffee, tea, soft drinks). Avoidance of spicy foods as these can also increase GI stimulation. Educational objective: Hyperthyroidism leads to a high metabolic rate. It is important for the nurse to teach the client nutritional measures, including consumption of a diet high in calories (high in protein, carbohydrates, vitamins, and minerals) to satisfy hunger and prevent weight loss and tissue wasting.
The nurse is performing an initial assessment on a client diagnosed with Addison's disease. Which assessment findings should the nurse anticipate? Select all that apply. 1) acanthosis nigricans 2) hirsutism 3) hyperpigmented skin 4) truncal obesity 5) weight loss
3, 5 Addison's disease, or chronic adrenal insufficiency, occurs when the adrenal glands do not produce adequate amounts of steroid hormones (mineralocorticoids, glucocorticoids, androgens). Symptoms include weight loss, muscle weakness, low blood pressure, hypoglycemia, and hyperpigmented skin (skin folds, buccal area, palmar crease). Hyperpigmented skin is a characteristic universal finding; this results from increased adrenocorticotropic hormone which is due to a decrease in cortisol negative feedback. Treatment consists of replacement therapy with oral mineralocorticoids and corticosteroids (Options 3 and 5). (Option 1) Acanthosis nigricans is a skin condition that occurs with obesity and diabetes and appears as velvet-like patches of darkened, thick skin. These areas typically occur around the back of the neck and in the groin and armpits. (Option 2) Hirsutism is a condition in women that consists of male-pattern hair growth on the face, lower abdomen, chest, and back. Common causes are polycystic ovary syndrome and Cushing's syndrome. Loss of libido and decreased axillary and pubic hair are common in Addison's disease due to lower levels of androgens. (Option 4) Clients with Cushing's syndrome, an overproduction of steroid hormones, have truncal obesity or large deposits of abdominal fat. Educational objective: Addison's disease (chronic adrenal insufficiency) leads to hyperpigmented skin, low blood pressure, weight loss, and muscle weakness.
The nurse is caring for a 72-year-old client with hypothyroidism admitted to the emergency department for altered mental status. The client lives alone but has not taken medications or seen a health care provider for several months. Which action is the priority? Click on the exhibit button for additional information. Vital signs Temperature 95 F (35 C) Blood pressure 90/50 mm Hg Heart rate 50/min Respirations 10/min SaO2 83% 1) Administer IV levothyroxine 2) Check serum TSH, triiodothyronine, and thyroxine 3) Place a warming blanket on the client 4) Prepare for endotracheal intubation
4) Myxedema coma refers to a state of severe hypothyroidism causing decreased level of consciousness (eg, lethargy, stupor) that may progress to a comatose state. Myxedema coma is characterized by hypothermia, bradycardia, hypotension, and hypoventilation. Hypoventilation may occur as a result of respiratory muscle fatigue and mechanical obstruction by an edematous tongue. Clients with signs of respiratory failure (eg, slow or shallow breathing, low oxygen saturation) require emergency endotracheal intubation and mechanical ventilation. The nurse should provide respiratory support (eg, ventilation with a bag-valve-mask) and prepare to assist with intubation (Option 4). (Option 1) Clients with myxedema coma require thyroid hormone replacement with IV levothyroxine to correct the hypothyroid state but only after respiratory status is secured. Improvement in clinical status may not occur for up to a week after initiation of hormone replacement. (Option 2) A serum thyroid panel (eg, TSH, triiodothyronine, thyroxine) is required to confirm hypothyroidism, and these measurements should be monitored during treatment; however, the nurse should ensure that the client is stable before reviewing laboratory values. (Option 3) A warming blanket should be placed on the client to treat hypothermia; however, respiratory support is the priority. Educational objective: Myxedema coma is a state of severe hypothyroidism and decreased level of consciousness that may progress to coma and respiratory failure. The nurse should provide respiratory support (eg, ventilation with a bag-valve-mask) and prepare to assist with intubation.
