Chapter 62 - Pituitary and Adrenal Gland issues
A client with pheochromocytoma is admitted for surgery. What does the nurse do for the admitting assessment? Avoids palpating the abdomen Monitors for pulmonary edema with a chest x-ray Obtains a 24-hour urine specimen on admission Places the client in a room with a roommate for distraction
Avoids palpating the abdomen The abdomen must not be palpated in a client with pheochromocytoma because this action could cause a sudden release of catecholamines and severe hypertension. The tumor on the adrenal gland causes sympathetic hyperactivity, increasing blood pressure and heart rate, not pulmonary edema. A 24-hour urine collection will already have been completed to determine the diagnosis of pheochromocytoma. A client diagnosed with a pheochromocytoma may feel anxious as part of the disease process; providing a roommate for distraction will not reduce the client's anxiety.
Which urine properties indicate to the nurse that the client with syndrome of inappropriate (SIADH) antidiuretic hormone is responding to interventions? A. Urine output volume increased; urine specific gravity increased B. Urine output volume increased; urine specific gravity decreased C. Urine output volume decreased; urine specific gravity increased D. Urine output volume decreased; urine specific gravity decreased
Answer: B Rationale: SIADH involves excessive secretion of vasopressin (ADH) when it is not needed. Water is reabsorbed, causing an increase in blood volume and a decrease in urine volume. Blood concentration is diluted, and urine concentration, as measured by specific gravity, is highly increased. When interventions to counter act SIADH are effective, the person slows water reabsorption so that urine output volume increases at the same time that urine concentration decreases, seen as a decreased urine specific gravity.
. A client with iatrogenic Cushing's syndrome is a resident in a long-term care facility. Which nursing action included in the client's care would be best to delegate to unlicensed assistive personnel (UAP)? Assist with personal hygiene and skin care. Develop a plan of care to minimize risk for infection. Instruct the client on the reasons to avoid overeating. Monitor for signs and symptoms of fluid retention.
Assist with personal hygiene and skin care. Assisting a client with bathing and skin care is included in UAP scope of practice. It is not within their scope of practice to develop a plan of care, although they will play a very important role in following the plan of care. Client teaching requires a broad education and should not be delegated to UAP. Monitoring for signs and symptoms of fluid retention is part of client assessment, which requires a higher level of education and clinical judgment.
After receiving change-of-shift report about these four clients, which client does the nurse attend to first? Client with acute adrenal insufficiency who has a blood glucose of 36 mg/dL Client with diabetes insipidus who has a dose of desmopressin (DDAVP) due Client with hyperaldosteronism who has a serum potassium of 3.4 mEq/L Client with pituitary adenoma who is reporting a severe headache
Client with acute adrenal insufficiency who has a blood glucose of 36 mg/dL .A glucose level of 36 mg/dL is considered an emergency; this client must be assessed and treated immediately. Although it is important to maintain medications on schedule, the client requiring a dose of desmopressin is not the first client who needs to be seen. A serum potassium of 3.4 mEq/L in the client with hyperaldosteronism may be considered normal (or slightly hypokalemic), based on specific hospital levels. The client reporting a severe headache needs to be evaluated as soon as possible after the client with acute adrenal insufficiency. As an initial measure, the RN could delegate obtaining vital signs to unlicensed assistive personnel.
Which client does the nurse identify as being at highest risk for acute adrenal insufficiency resulting from corticosteroid use? Client with hematemesis, upper epigastric pain for the past 3 days not relieved with food, and melena Client with right upper quadrant pain unrelieved for the past 2 days, dark-brown urine, and clay-colored stools Client with shortness of breath and chest tightness, nasal flaring, audible wheezing, and oxygen saturation of 85% for the second time this week Client with three emergency department visits in the past month for edema, shortness of breath, weight gain, and jugular venous distention
Client with shortness of breath and chest tightness, nasal flaring, audible wheezing, and oxygen saturation of 85% for the second time this week Corticosteroids may be used to treat signs and symptoms of asthma, such as shortness of breath and chest tightness, nasal flaring, audible wheezing, and oxygen saturation of 85%. This places the client at risk for adrenal insufficiency. Corticosteroids are not used to treat signs and symptoms of GI bleeding or peptic ulcer disease (hematemesis, upper epigastric pain for the past 3 days not relieved with food, and melena), gallbladder disease (right upper quadrant pain unrelieved for the past 2 days, dark brown urine, and clay-colored stools), or congestive heart failure (edema, shortness of breath, weight gain, and jugular venous distention).
A client with syndrome of inappropriate antidiuretic hormone is admitted with a serum sodium level of 105 mEq/L. Which request by the health care provider does the nurse address first? Administer infusion of 150 mL of 3% NaCl over 3 hours. Draw blood for hemoglobin and hematocrit. Insert retention catheter and monitor urine output. Weigh the client on admission and daily thereafter.
Administer infusion of 150 mL of 3% NaCl over 3 hours. The client with a sodium level of 105 mEq/L is at high risk for seizures and coma. The priority intervention is to increase the sodium level to a more normal range. Ideally, 3% NaCl should be infused through a central line or with a small needle through a large vein to prevent irritation. Monitoring laboratory values for fluid balance and monitoring urine output are important, but are not the top priority. Monitoring client weight will help in the assessment of fluid balance; however, this is also not the top priority.
The client who is about to have a unilateral adrenalectomy for an adenoma that is causing hypercortisolism asks the nurse if she will have to continue the severe sodium restriction after surgery. What is the nurse's best response? A. "No, once the tumor has been removed and your cortisol levels have normalized, you will not retain excess sodium anymore." B. "No, after surgery you will have to take oral cortisol, which can easily be controlled so that your sodium levels do not rise." C. Yes, the fact that you are retaining sodium and have high blood pressure is related to your age and lifestyle, not the tumor." D. "Yes, sodium is very bad for people and everyone needs to eliminate sodium completely from their diets for the rest of their lives."
Answer: A Rationale: A tumor secreting excessive amounts of cortisol is this patient's reason for needing to severely restrict her sodium. After the tumor is removed, she will not have hypercortisolism but may have to take oral cortisol until the remaining adrenal gland begins to secrete sufficient cortisol. She will no longer experience severe sodium retention. Although people in North America tend to have high-sodium diets and many could stand to reduce their sodium intake, sodium is an essential element and cannot be eliminated from the diet.
These data are obtained by the RN who is assessing a client who had a transsphenoidal hypophysectomy yesterday. What information has the most immediate implications for the client's care? Dry lips and oral mucosa on examination Nasal drainage that tests negative for glucose Client report of a headache and stiff neck Urine specific gravity of 1.016
Client report of a headache and stiff neck Headache and stiff neck (nuchal rigidity) are symptoms of meningitis that have immediate implications for the client's care. Dry lips and mouth are not unusual after surgery. Frequent oral rinses and the use of dental floss should be encouraged because the client cannot brush the teeth. Any nasal drainage should test negative for glucose; nasal drainage that tests positive for glucose indicates the presence of a cerebrospinal fluid leak. A urine specific gravity of 1.016 is within normal limits.
A client with diabetes insipidus (DI) has dry lips and mucous membranes and poor skin turgor. Which intervention does the nurse provide first? Force fluids Offer lip balm Perform a 24-hour urine test withold desmopressin acetate (DDAVP)
Force fluids Dry lips and mucous membranes and poor skin turgor are indications of dehydration, which can occur with DI. This is a serious condition that must be treated rapidly. Encouraging fluids is the initial step, provided the client is able to tolerate oral intake. Lip balm may make the client more comfortable, but does not address the problem of dehydration. A 24-hour urine test will identify loss of electrolytes and adrenal androgen metabolites, but will not correct the dehydration that this client is experiencing. Desmopressin acetate is a synthetic form of antidiuretic hormone that is given to reduce urine production; it improves DI and should not be withheld.
Which laboratory result indicates that fluid restrictions have been effective in treating syndrome of inappropriate antidiuretic hormone (SIADH)? Decreased hematocrit Decreased serum osmolality Increased serum sodium Increased urine specific gravity
Increased serum sodium Increased serum sodium due to fluid restriction indicates effective therapy. Hemoconcentration is a result of hypovolemic hyponatremia caused by SIADH and diabetes insipidus. Plasma osmolality is decreased as a result of SIADH. Urine specific gravity is decreased with diabetes insipidus and is increased with SIADH.
A client diagnosed with hyperpituitarism resulting from a prolactin-secreting tumor has been prescribed bromocriptine mesylate (Parlodel). As a dopamine agonist, what effect does this drug have by stimulating dopamine receptors in the brain? Decreases the risk for cerebrovascular disease Increases the risk for depression Inhibits the release of some pituitary hormones Stimulates the release of some pituitary hormones
Inhibits the release of some pituitary hormones Bromocriptine mesylate inhibits the release of both prolactin and growth hormone. It does not decrease the risk for cerebrovascular disease leading to stroke. Increased risk for depression is not associated with the use of bromocriptine mesylate; however, hallucinations have been reported as a side effect. Bromocriptine mesylate does not stimulate the release of any hormones.
A client has undergone a transsphenoidal hypophysectomy. Which intervention does the nurse implement to avoid increasing intracranial pressure (ICP) in the client? Encourages the client to cough and deep-breathe Instructs the client not to strain during a bowel movement Instructs the client to blow the nose for postnasal drip Places the client in the Trendelenburg position
Instructs the client not to strain during a bowel movement. Straining during a bowel movement increases ICP and must be avoided. Laxatives may be given and fluid intake encouraged to help with this. Although deep breathing is encouraged, the client must avoid coughing early after surgery because this increases pressure in the incision area and may lead to a cerebrospinal fluid (CSF) leak. If the client has postnasal drip, he or she must inform the nurse and not blow the nose; postnasal drip may indicate leakage of CSF. The head of the bed must be elevated after surgery.
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? Assess skin turgor and mucous membranes for hydration status. Discuss the dietary restrictions needed for 24-hour urine testing. Plan ways to control the environment that will avoid stimulating the client. Remind the client to avoid drinking coffee and changing position suddenly.
Remind the client to avoid drinking coffee and changing position suddenly. . Drinking caffeinated beverages and changing position suddenly are not safe for a client with a potential adrenal gland tumor because of the effects of catecholamines. Reminding the client about previous instructions is an appropriate role for a nursing assistant who may observe the client doing potentially risky activities. Client assessment, client teaching, and environment planning are higher-level skills that require the experience and responsibility of the RN, and are not within the scope of practice of the nursing assistant.
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? Document symptoms of incisional infection or meningitis. Give over-the-counter laxatives if the client is constipated. Set up medications as prescribed for the day. Test any nasal drainage for the presence of glucose.
Test any nasal drainage for the presence of glucose. Cerebrospinal fluid (CSF) will test positive using a glucose "dipstick." Nasal drainage that is positive for glucose after a transsphenoidal hypophysectomy would indicate a CSF leak that would require immediate notification of the health care provider. Home health aides can be taught the correct technique to perform this procedure. Assessing for symptoms of infection and documenting them in the record, medication administration, and setting up medication are not within the scope of practice of the home health aide.
A client with Cushing's disease says that she has lost 1 pound. What does the nurse do next? Auscultates the lungs for crackles Checks urine for specific gravity Forces fluids Weighs the client
Weighs the client Fluid retention with weight gain is more of a problem than weight loss in clients with Cushing's disease. Weighing the client with Cushing's disease is part of the nurse's assessment. Crackles in the lungs indicate possible fluid retention, which would cause weight gain, not weight loss. Urine specific gravity will help assess hydration status, but this would not be the next step in the client's assessment. Forcing fluids is not appropriate because usually excess water and sodium reabsorption cause fluid retention in the client with Cushing's disease.
The client is taking fludrocortisone (Florinef) for adrenal hypofunction. The nurse instructs the client to report which symptom while taking this drug? Anxiety Headache Nausea Weight loss
eadache A side effect of fludrocortisone is hypertension. New onset of headache should be reported, and the client's blood pressure should be monitored. Anxiety is not a side effect of fludrocortisone and is not associated with adrenal hypofunction. Nausea is associated with adrenal hypofunction; it is not a side effect of fludrocortisone. Sodium-related fluid retention and weight gain, not loss, are possible with fludrocortisone therapy.
The nurse is providing discharge instructions to a client on spironolactone (Aldactone) therapy. Which comment by the client indicates a need for further teaching? "I must call the provider if I am more tired than usual." "I need to increase my salt intake." "I should eat a banana every day." "This drug will not control my heart rate."
"I should eat a banana every day." Spironolactone increases potassium levels, so potassium supplements and foods rich in potassium, such as bananas, should be avoided to prevent hyperkalemia. While taking spironolactone, symptoms of hyponatremia such as drowsiness and lethargy must be reported; the client may need increased dietary sodium. Spironolactone will not have an effect on the client's heart rate.
The patient is a 32-year-old woman admitted to your unit after surgery for fractures of the left arm and leg resulting from a car crash. She is awake and able to verify her medical history of rheumatoid arthritis and her usual daily medications. These are 10 mg of prednisone, naproxen 800 mg twice daily, oral contraceptives, calcium 600 mg, and one multiple vitamin tablet. All of these are prescribed for her to receive during her hospitalization. She is concerned about pain management and how long the recovery will be for the fractures. She is friendly, somewhat anxious, asks many questions, and wants to do "her part" to ensure good recovery. Over the next 4 days, she has become quieter, mumbles that her head and stomach hurt, and now does not recognize the assistant who has been providing her daily care. When she receives her medications, she has difficulty picking them up. The nursing assistant remarks that taking her pulse is difficult because it is so slow and irregular. When you assess her, she is so weak that she is unable to lift her arm for a blood pressure check. Her blood pressure is 92/50, which is down from the 128/84 reading on admission. You also verify that her heart beat is slow and irregular. 1. What other assessment data should you obtain immediately and why? 2. What is the most likely cause of the changes in this patient's physical and mental status? 3. How could this problem been avoided? 4. What specifically would be the nurse's role in preventing this problem? 5. What could be done to prevent this problem from happening again?
1. What other assessment data should you obtain immediately and why? Listen to her apical pulse to assess the true heart rate. With some dysrhythmias, especially if she is having premature contraction, the radial pulse can be very different from the apical pulse. Assess her oxygen saturation to determine whether cardiac function is adequate for the moment or whether the rapid response team is needed now. (Cardiac arrest is possible because of hyperkalemia.) Perform a finger stick blood glucose analysis immediately to determine whether she is hypoglycemic. 2. What is the most likely cause of the changes in this patient's physical and mental status? The most likely cause is acute adrenal insufficiency as a result of increased cortisol needs related to the stress of surgery and injury. Because she has been on prednisone long term, she has some degree of adrenal suppression and cannot increase the extra cortisol needed during the additional stress. Although she is receiving 10 mg of prednisone daily, it is not enough for her current needs. 3. How could this problem been avoided? Daily assessment of her salivary or serum cortisol levels could have indicated a need for a higher dose. Also, because she was receiving prednisone, daily blood glucose levels should have been performed. Examining these parameters would provide data to determine the adequacy of her therapy, as well as its potential side effects. 4. What specifically would be the nurse's role in preventing this problem? This type of adrenal insufficiency develops over a period of days. Monitoring trends for level of consciousness, blood pressure, and heart rate and rhythm should be something all nurses do on every patient. It is very likely that changes were present earlier and not recognized. 5. What could be done to prevent this problem from happening again? Any patient who routinely takes a corticosteroid should be automatically evaluated on a daily basis for manifestations of adrenal insufficiency. Ideally, the person would receive additional corticosteroid therapy in advance of changes to prevent adrenal insufficiency. At the very least, assessing for early manifestations could have identified this problem earlier and prevented a near tragedy.
A client presents to the emergency department with a history of adrenal insufficiency. The following laboratory values are obtained: Na+ 130 mEq/L, K+ 5.6 mEq/L, and glucose 72 mg/dL. Which is the first request that the nurse anticipates? Administer insulin and dextrose in normal saline to shift potassium into cells. Give spironolactone (Aldactone) 100 mg orally. Initiate histamine2 (H2) blocker therapy with ranitidine for ulcer prophylaxis. Obtain arterial blood gases to assess for peaked T waves.
Administer insulin and dextrose in normal saline to shift potassium into cells. This client is hyperkalemic. The nurse should anticipate a request to administer 20 to 50 units of insulin with 20 to 50 mg of dextrose in normal saline as an IV infusion to shift potassium into the cells. Spironolactone is a potassium-sparing diuretic that helps the body keep potassium, which the client does not need. Although H2 blocker therapy would be appropriate for this client, it is not the first priority. Arterial blood gases are not used to assess for peaked T waves associated with hyperkalemia; an electrocardiogram needs to be obtained instead.
For which client does the nurse question the prescription of androgen replacement therapy? A. 35-year-old man who has had a vasectomy B. 48-year old man who takes prednisone for severe asthma C. 62-year-old man who has a history of prostate cancer D. 70-year-old man who has hypertension and type 2 diabetes
Answer: C Rationale: Prostate cancer tends to increase its growth rate in the presence of any type of androgen. Thus, the man who has a history of prostate cancer should avoid exogenous androgen because it could enhance the growth if the previously treated cancer returns. None of the other conditions are contraindicated for androgen replacement therapy.
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? Client in Addisonian crisis who is receiving IV hydrocortisone Client admitted with syndrome of inappropriate antidiuretic hormone (SIADH) secondary to lung cancer Client being discharged after a unilateral adrenalectomy to remove an adrenal tumor Client with Cushing's syndrome who has elevated blood glucose and requires frequent administration of insulin
Client with Cushing's syndrome who has elevated blood glucose and requires frequent administration of insulin RN who works with pediatric clients would be familiar with glucose monitoring and insulin administration. A client in Addisonian crisis would best be monitored by an RN from the medical-surgical floor. Although the float RN could complete the admission history, the client with SIADH secondary to lung cancer might require teaching and orientation to the unit that a nurse more familiar with that area would be better able to provide. Discharge teaching specific to adrenalectomy should be provided by the RN who is regularly assigned to the medical-surgical floor and is more familiar with taking care of postoperative adult clients with endocrine disorders.
The nurse is teaching a client about how to monitor therapy effectiveness for syndrome of inappropriate antidiuretic hormone. What does the nurse tell the client to look for? Daily weight gain of less than 2 pounds Dry mucous membranes Increasing heart rate Muscle spasms
Daily weight gain of less than 2 pounds The client must monitor daily weights because this assesses the degree of fluid restriction needed. A weight gain of 2 pounds or more daily or a gradual increase over several days is cause for concern. Dry mucous membranes are a sign of dehydration and an indication that therapy is not effective. An increased heart rate indicates increased fluid retention or dehydration and hypovolemia, and either condition is an indication that therapy is not effective. Muscle spasms are associated with hyponatremia and are an indication of a change in the client's neurologic status. Untreated hyponatremia can lead to seizures and coma.
A client has been admitted to the medical intensive care unit with a diagnosis of diabetes insipidus (DI) secondary to lithium overdose. Which medication is used to treat the DI? Desmopressin (DDAVP) Dopamine hydrochloride (Intropin) Prednisone Tolvaptan (Samsca)
Desmopressin (DDAVP) Desmopressin is the drug of choice for treatment of severe DI. It may be administered orally, nasally, or by intramuscular or intravenous routes. Dopamine hydrochloride is a naturally occurring catecholamine and inotropic vasopressor; it would not be used to treat DI. Prednisone would not be used to treat DI. Tolvaptan is a selective competitive arginine vasopressin receptor 2 antagonist and is not used with DI.
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? Administering furosemide (Lasix) Providing isotonic fluids Replacing potassium losses Restricting sodium
Providing isotonic fluids Restricting sodium Providing isotonic fluid is the priority intervention because this client's vital signs indicate volume loss that may be caused by nausea and vomiting and may accompany acute adrenal insufficiency. Isotonic fluids will be needed to administer IV medications such as hydrocortisone. Furosemide is a loop diuretic, which this client does not need. Potassium is normally increased in acute adrenal insufficiency, but potassium may have been lost if the client has had diarrhea; laboratory work will have to be obtained. Any restrictions, including sodium, should not be started without obtaining laboratory values to establish the client's baseline.
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? "Don't mind this. The disease is causing this." "I need to check the client's cortisol level." "The disease can sometimes affect emotional responses." "Medication is available to help with this."
The disease can sometimes affect emotional responses." The client may have neurotic or psychotic behavior as a result of high blood cortisol levels. Being honest with the family helps them to understand what is happening. Telling the family not to mind the laughter and that the disease is causing it is vague and minimizes the family's concern. This is the perfect opportunity for the nurse to educate the family about the disease. Cushing's disease is the hypersecretion of cortisol, which is abnormally elevated in this disease and, because the diagnosis has already been made, blood levels do not need to be redrawn. Telling the family that medication is available to help with inappropriate laughing does not assist them in understanding the cause of or the reason for the client's behavior.
The nurse is caring for a client with hypercortisolism. The nurse begins to feel the onset of a cold but still has 4 hours left in the shift. What does the nurse do? Asks another nurse to care for the client Monitors the client for cold-like symptoms Refuses to care for the client Wears a facemask when caring for the client
Wears a facemask when caring for the client A client with hypercortisolism will be immune-suppressed. Anyone with a suspected upper respiratory infection who must enter the client's room must wear a mask to prevent the spread of infection. Although asking another nurse to care for the client might be an option in some facilities, it is not generally realistic or practical. The nurse, not the client, feels the onset of the cold, so monitoring the client for cold-like symptoms is part of good client care for a client with hypercortisolism. Refusing to care for the client after starting care would be considered abandonment.
How does the drug desmopressin (DDAVP) decrease urine output in a client with diabetes insipidus (DI)? Blocks reabsorption of sodium Increases blood pressure Increases cardiac output Works as an antidiuretic hormone (ADH) in the kidneys
Works as an antidiuretic hormone (ADH) in the kidneys Correct Desmopressin is a synthetic form of ADH that binds to kidney receptors and enhances reabsorption of water, thus reducing urine output. Desmopressin does not have any effect on sodium reabsorption. It may cause a slight increase or a transient decrease in blood pressure, but this does not affect urine output. Desmopressin does not increase cardiac output.