Patho PrepU Chapter 32
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." Explanation: 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. Page 788
Congenital adrenal hyperplasia is a congenital disorder in which a deficiency exists in any of the enzymes necessary for the synthesis of cortisol. Infants of both sexes are affected, although boys are not diagnosed at birth unless of enlarged genitalia. Female infants often have ambiguous genitalia because of the oversecretion of adrenal androgens. What are the manifestations of the ambiguous genitalia caused by congenital adrenal hyperplasia?
Enlarged clitoris, fused labia, and urogenital sinus Explanation: In female infants, an increase in androgens is responsible for creating the virilization syndrome of ambiguous genitalia with an enlarged clitoris, fused labia, and urogenital sinus. The other answers are incorrect. Page 786
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 Explanation: 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. Page 778
A client with Graves' disease has had radioiodine treatment with worsening of ophthalmopathy. What medication does the nurse prepare to administer that the client will use for several weeks to decrease these symptoms?
Glucocorticoids Explanation: Some physicians prescribe glucocorticoids for several weeks surrounding the radioiodine treatment if the person had signs of ophthalhmopathy. Page 783
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. Explanation: 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. Page 780
Following destruction of the pituitary gland, ACTH stimulation stops. Without ACTH to stimulate the adrenal glands, the adrenals' production of cortisol drops. This is an example of which type of endocrine disorder?
Secondary Explanation: In secondary disorders of endocrine function, the target gland is essentially normal, but defective levels of stimulating hormones or releasing factors from the pituitary system alter its function. Page 786
A nurse on a medical unit is providing care for a 37-year-old female patient who has a diagnosis of Graves' disease. Which of the following treatments would the nurse most likely anticipate providing for the client?
β-adrenergic-blocking medications to reduce sympathetic nervous stimulation Explanation: The hyperthyroidism that constitutes Graves' disease can often be mitigated by the administration of β-adrenergic-blocking medications. Levothyroxine would be used to address hypothyroidism and calcium channel blockers are not an identified treatment modality for Graves' disease. Somatostatin analogs are used to treat GH excess. Page 782
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." Explanation: 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. Page 772
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." Explanation: 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. Page 782
A female patient presented to her primary care physician with classic signs/symptoms of Cushing syndrome. Upon testing, it was discovered that the patient had vaginal small cell carcinoma. How can the healthcare providers explain her Cushing syndrome signs/symptoms to this patient?
"Your tumor in your vagina is secreting a hormone called adenocorticotropic hormone (ACTH) which is responsible for these signs/symptoms." Explanation: Hyperfunction is usually associated with excessive hormone production. This can result from excessive stimulation and hyperplasia of the endocrine gland or from a hormone-producing tumor. A clinical example of this phenomenon is evidenced by the case of a woman with vaginal small cell carcinoma who also presented with Cushing syndrome. After testing, it was determined that the tumor was secreting ACTH. In this situation, the cause was not related to a pituitary problem. There is a connection between Cushing syndrome and the carcinoma. The thyroid gland is not responsible for Cushing syndrome. Page 788
The nurse is preparing a client for testing to determine if the client has Cushing syndrome. What tests are included in the screening process? Select all that apply.
-24-hour urine secretion of cortisol -Dexamethasone suppression test -Plasma levels of ACTH Explanation: The determination of 24-hour excretion of cortisol in urine provides a reliable and practical index of cortisol secretions. One of the prominent features of Cushing syndrome is loss of the diurnal pattern of cortisol secretion. The overnight 1 mg dexamethasone suppression test is also used as a screening tool for Cushing syndrome. Other tests include measurement of plasma levels of ACTH. Page 789
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.
-Intolerance to cold -Decreased sweating -Coarse and dry skin and hair Explanation: 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. Page 778
The nurse is educating a client with hyperthyroidism who has recovered from thyrotoxicosis (thyroid storm) and is preparing for discharge. What can the nurse inform the client that this hypermetabolic state can be caused by in order to decrease exacerbation? Select all that apply.
-Stress -Physical or emotional trauma -Manipulation of the thyroid gland Explanation: Thyroid storm is often precipitated by stress, such as an infection, by physical or emotional trauma, or by manipulation of a hyperactive thyroid gland during thyroidectomy. Page 783
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 -Delirium -Very high fever Explanation: 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. Very low fever and bradycardia are not manifestations of a thyroid storm. Page 783
Which statements are true regarding hypothyroidism? Select all that apply.
-Weight gain -Anorexia -Onset of symptoms is gradual Explanation: The hypometabolic state associated with hypothyroidism is characterized by a gradual onset of weakness and fatigue, a tendency to gain weight despite a loss of appetite, and cold intolerance. As the condition progresses, the skin becomes dry and rough and the hair becomes coarse and brittle. Gastrointestinal motility is decreased, producing constipation, flatulence, and abdominal distention. Page 780
The nurse is caring for a client diagnosed with hyperthyroidism. Which of the following signs and symptoms are most likely to be seen in this client? Select all that apply.
-Weight loss -Hypertension -Tremor -Diarrhea Explanation: The signs and symptoms of hyperthyroidism relate to the increased metabolic rate associated with this condition. Hypertension, diarrhea, weight loss, and tremor are all signs and symptoms of hyperthyroidism, while the other choices reflect signs and symptoms of hypothyroidism. Page 781
After receiving change-of-shift report about the following four patients, which patient should the nurse assess first?
70-year-old returning from PACU following partial thyroidectomy who is extremely agitated, has an irregular pulse rate of 134, and an elevated temperature of 103.20 F Explanation: Manipulation of a hyperactive thyroid gland during thyroidectomy can cause thyroid storm. It is manifested by very high fever, extreme cardiovascular effects (tachycardia, HF, angina), and severe CNS effects (agitation, restlessness, and delirium). The 22-year-old has normal sodium levels. The 31-year old has a high blood glucose level but not at a critical level. The medication schedule for the 53-year-old is lower priority. It is always preferred to give medications in timely manner; however, thyroid storms are the priority for this group of patients. Page 783
Which client does the nurse recognize is at the most risk for the development of subacute thyroiditis?
A 32-year-old postpartum client Explanation: 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. Page 780
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 Explanation: 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. Page 781
The mother of 6-year-old male and female fraternal twins has brought her son to see a pediatrician because he is nearly 4 inches shorter than his sister. Which of the following phenomena would the physician most likely suspect as contributing factor to the boy's short stature?
A shortage of hypothalamic GHRH production Explanation: Inadequate levels of hypothalamic GHRH will result in adequate production but inadequate release of GH by the pituitary. Genetic short stature is less likely given the disparity between his height and his twin's, and a shortage of IGF receptors is not a noted pathology. While poorly controlled diabetes can contribute to short stature, excess insulin production is not a likely factor. Page 772
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. Explanation: 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. Page 784
The nurse is caring for a 42-year-old male client who is admitted for treatment of heart failure. He has abnormally large hands and feet and a broad face with a protruding jaw. Based on these signs and symptoms, the nurse identifies which of the following endocrine disturbances as the most likely cause for these physical changes?
Acromegaly Explanation: Enlargement of the small bones of the hands and feet and of the membranous bones of the face and skull results in a pronounced enlargement of the hands and feet, a broad and bulbous nose, a protruding jaw, and a slanting forehead. 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. Enlargement of the heart and accelerated atherosclerosis may lead to an early death. Hyperthyroidism results from excess thyroid hormone. Myxedema and Cushing syndrome are the result of adrenal abnormalities and do not cause these bone changes. Page 773
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 Explanation: Chronic suppression causes atrophy of the adrenal gland, and the abrupt withdrawal of drugs can cause acute adrenal insufficiency. The other answers are incorrect. Page 786
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 Explanation: 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." Page 789
Which classification of medication does the nurse prepare to administer to the client with hyperthyroidism that will block the effects of the hyperthyroid state on sympathetic nervous system function?
Beta-adrenergic blocking agent Explanation: The beta-adrenergic blocking drugs (propranolol, metoprolol, atenolol, and nadolol are preferred) are administered to block the effects of the hyperthyroid state on sympathetic nervous system function. They are given in conjunction with antithyroid drugs such as propylthiouracil and methimazole. Page 782
The health care provider is teaching a client about the metabolic effect of cortisol. The most appropriate information to provide would be:
Breakdown of proteins and fats Explanation: The best-known metabolic effect of cortisol and other glucocorticoids is their ability to stimulate gluconeogenesis (glucose production) by the liver. Metabolic effects of cortisol involve the metabolism of proteins, carbohydrates, and fats. Behavior and emotion regulation is a psychological effect of cortisol. The other two options are immunologic and inflammatory effects of cortisol. Page 784
A client with acromegaly comes to the clinic and informs the nurse that she is having a productive cough and a low grade fever. This is the client's fourth visit in one year for the same problem. What condition does the nurse understand results from this client's enlarged cartilaginous structures?
Bronchitis Explanation: The cartilaginous structures in the larynx and respiratory tract become enlarged, resulting in a deepening of the voice and tendency to develop bronchitis. Page 774
Which complication of acromegaly can be life threatening?
Cardiac structures increase in size Explanation: 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. Page 774
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 Explanation: 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. Page 773
An adult client with growth-hormone deficiency related to hypopituitarism has been taking replacement therapy for several months. The client informs the nurse that she is having pain in the hand and wrist almost constantly. What does the nurse understand is a common side effect of this therapy that seems to have affected this client?
Carpal tunnel syndrome Explanation: The most common side effects of GH treatment in adults with hypopituitarism are peripheral edema, arthralgias, myalgias, carpal tunnel syndrome, paresthesias, and decreased glucose tolerance. Page 773
A patient is admitted to the hospital in Addisonian crisis one month after a diagnosis of Addison's disease. The nurse knows which of the following clinical manifestations would support this diagnosis?
Change in level of consciousness and profound hypotension Explanation: Acute adrenal crisis is a life-threatening situation. Exposure to even a minor illness or stress can cause a client with Addison's disease to develop nausea, vomiting, muscular weakness, hypotension, dehydration, and vascular collapse (which causes a change in LOC). Hemorrhage (low BP) can be caused by septicemia, adrenal trauma, anticoagulant therapy, adrenal vein thrombosis, or adrenal metastases. A hyperactive reflex may indicate disease of the pyramidal tract above the level of the reflex arc being tested. Generalized hyperactivity of DTRs may be caused by hyperthyroidism. Any tear or hole in the membrane that surrounds the brain and spinal cord (dura) can allow the fluid that surrounds those organs to leak. This fluid is called the cerebrospinal fluid (CSF). When it leaks out, the pressure around the brain and spinal cord drops. Causes of leakage through the dura include certain head, brain, or spinal surgeries; head injury; placement of tubes for epidural anesthesia or pain medications; or lumbar puncture. Irregular heart rates (arrhythmias) may be caused by many different factors, including coronary artery disease, electrolyte imbalances in the blood (such as sodium or potassium), changes in the heart muscle, or injury from a heart attack. Page 788
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. Explanation: 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. Page 770
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 Explanation: 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. The term does not apply to the normally developing infant in whom replacement thyroid hormones therapy was instituted shortly after birth. Page 780
Which disorder is a result of excess cortisol?
Cushing syndrome Explanation: 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. Page 788
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 Explanation: 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. Page 775
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 Explanation: 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. Page 782
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) Explanation: 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. Page 768
A 25-year-old female client exhibits exophthalmos of both eyes. The health care provider recognizes this as a manifestation of:
Graves disease Explanation: Graves disease is a state of hyperthyroidism in which opthalmopathies, such as exophthalmos, typically occur. The other conditions are states of hypothyroidism and are not associated with this abnormality. Page 781
When the assessment of thyroid autoantibodies is performed, what is the suspected diagnosis?
Hashimoto thyroiditis Explanation: The assessment of thyroid autoantibodies (e.g., antithyroid peroxidase antibodies in Hashimoto thyroiditis) is important in the diagnostic workup and consequent follow-up of thyroid clients. Page 778
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 Explanation: 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. Page 781
The nurse is teaching a client diagnosed with Addison disease about the importance of lifetime oral replacement therapy. Select the pharmacologic agent that would be prescribed.
Hydrocortisone Explanation: 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. Clients with Addison disease usually have elevated potassium levels, and insulin is not the treatment for Addison disease. Page 788
The nurse is caring for an infant in the neonatal intensive care unit who has growth hormone deficiency. What critical issues should the nurse carefully monitor for in this infant?
Hypoglycemia and seizures Explanation: In the neonate, GH deficiency can lead to hypoglycemia and seizures. If ACTH deficiency also is present, the hypoglycemia often is more severe. Page 772
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 Explanation: 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. Page 781
Following the identification of low blood levels of cortisol and low 24-hour urinary free cortisol, a 51-year-old female client has been diagnosed with a primary adrenal cortical insufficiency. Which of the following health consequences would be attributable to her low levels of cortisol?
Impaired immunological and inflammatory response Explanation: Cortisol plays a central role in the normal functioning of the immune response and inflammation. Exophthalmos is associated with Graves' disease and secondary sex characteristics are a function of adrenal androgens. Potassium and sodium are regulated by mineralocorticoids. Page 785
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 Explanation: 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. Page 781
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 Explanation: 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. Page 787
Following the identification of low levels of T3 and T4 coupled with the presence of a goiter, a 28-year-old female has been diagnosed with Hashimoto's thyroiditis. In light of this diagnosis, which of the following assessment results would constitute an unexpected finding?
Increased white cell count and audible crackles on chest auscultation. Explanation: An increased white cell count and the presence of adventitious fluid in the lungs are not classic findings associated with hypothyroidism. Myxedema, weight gain, lethargy, and dry skin and nails are commonly associated with low levels of thyroid hormones. Page 780
An overweight, 14-year-old boy feels tired all the time. He sleeps 12 to 14 hours a day and has a voracious appetite but no energy to burn off the calories. He has been diagnosed with hypothyroidism brought about by the accumulation of a nonpitting mucosus type of edema. For which life-threatening condition should his care team be prepared?
Myxedematous coma Explanation: Myxedema implies the presence of a nonpitting mucous type of edema caused by an accumulation of a hydrophilic mucopolysaccharide substance in the connective tissues throughout the body. The hypothyroid state may be mild, with only a few signs and symptoms, or it may progress to a life-threatening condition called myxedematous coma. Phaeocytoma is a tumour of the adrenal gland, Thyroid storm is related to hyperthyroidism and paraneoplastic syndrome is a separate condition. Page 781
A newborn is found to have transient hypothyroidism following a cesarean birth. Which nursing intervention could have induced the transient hypothyroidism as the staff prepared the mother for the surgical procedure?
Performing a skin scrub with povidone-iodine solution on delivery site Explanation: Transient hypothyroidism may be caused by maternal or infant exposure to substances such as povidone-iodine used as a disinfectant. Antithyroid drugs can cross the placenta and block fetal thyroid function. Page 780
A 51-year-old woman has been diagnosed with Cushing syndrome after a diagnostic work-up that reveals cortisol hypersecretion. Which assessment findings would be inconsistent with her diagnosis?
Poor stress management and electrolyte imbalances Explanation: A low tolerance for stress and unstable electrolyte levels are associated with Addison disease and its consequent elevated levels of ACTH. High blood pressure, hypokalemia, a buffalo hump, and moon face are all characteristic of the elevated steroid levels that denote Cushing syndrome. Page 788
A 51 year-old woman has been diagnosed with Cushing syndrome after a diagnostic workup that reveals cortisol hypersecretion. The nurse knows which of the following assessment findings would be inconsistent with her diagnosis?
Poor stress management and hyperpigmentation Explanation: Hyperpigmentation and a low tolerance for stress are associated with Addison's disease and its consequent elevated levels of ACTH. High blood pressure, hypokalemia, and buffalo hump and moon face are all characteristic of the elevated steroid levels that denote Cushing syndrome. Page 788
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 Explanation: 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. Page 775
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 Explanation: 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. Page 781
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. Explanation: 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. Page 781
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. Explanation: 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. Page 771
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. Explanation: 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. Page 780
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. Explanation: Ophthalmopathy can also be aggravated by smoking, which should be strongly discouraged. It is not necessary for the client to avoid contact with others. Alcohol is not contraindicated but should be limited when taking any medication regimen. The client should not adjust the doses of medications without first consulting the physician. Page 783
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. Explanation: 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. Page 788
Diagnostic testing has revealed that a client has pituitary hypofunction, resulting in deficient production of ACTH. The nurse should recognize what implication of this finding?
The client will require exogenous supplements of cortisol. Explanation: Cortisol replacement is started when ACTH deficiency is present. ACTH does not affect thyroid hormone levels. Growth will not occur; the client will have less GH than normal. Cushing syndrome results from glucocorticoid excess, which is the opposite of what will occur. Page 770
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. Explanation: 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. Page 771
A newborn is screened for congenital hypothyroidism and is found to have the disorder. When educating the mother about the importance of the infant's taking thyroid hormone supplement, what should be included in the education?
The infant will have dosage levels adjusted as he grows. Explanation: Congenital hypothyroidism is treated by hormone replacement. Evidence indicates that it is important to normalize T4 levels as rapidly as possible because a delay is accompanied by poorer psychomotor and mental development. Dosage levels are adjusted as the child grows. When early and adequate treatment regimens are followed, the risk of intellectual disability in infants detected by screening programs is essentially nonexistent. Page 780
The nurse is caring for an older adult client who is being treated for primary hypothyroidism. The medication therapy includes a "go low and go slow" regimen. What is the importance of this medication regimen for this client?
There is a risk of inducing acute coronary syndromes in the older adult client if a more rapid correction of thyroid levels is used. Explanation: A "go low and go slow" approach to normalize thyroid levels should be considered in the treatment of older adult clients with hypothyroidism because of the risk of inducing acute coronary syndromes in the susceptible individual. Page 781
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. Explanation: The pathogenesis of sleep apnea syndrome is obstructive in the majority of people due to increased pharyngeal soft tissue accumulation. Page 774
The hallmark manifestations of Cushing syndrome are a moon face, a "buffalo hump" between the shoulder blades, and a protruding abdomen. What other manifestations of Cushing syndrome occur?
Thin extremities and muscle weakness Explanation: The major manifestations of Cushing syndrome represent an exaggeration of the many actions of cortisol (see Table 32-2). Altered fat metabolism causes a peculiar deposition of fat characterized by a protruding abdomen, subclavicular fat pads or "buffalo hump" on the back, and a round, plethoric "moon face." There is muscle weakness, and the extremities are thin because of protein breakdown and muscle wasting. The other answers are incorrect. Page 788-790
A client who has just undergone a thyroidectomy is experiencing high fever, tachycardia, and extreme restlessness. The nurse would interpret these manifestations as:
Thyroid crisis/storm Explanation: The symptoms this client is experiencing are related to thyroid crisis or 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. Page 781
