Iggy Chapter 61: Assessment of the Endocrine System

A nurse evaluates laboratory results for a male client who reports fluid secretion from his breasts. Which hormone value should the nurse assess first?

Anterior pituitary hormones (Breast fluid and milk production are induced by the presence of prolactin, secreted from the anterior pituitary gland. The other hormones would not cause fluid secretion from the clients breast.)

A nurse cares for a client who is prescribed a 24-hour urine collection. The unlicensed assistive personnel (UAP) reports that, while pouring urine into the collection container, some urine splashed his hand. Which action should the nurse take next?

Ask the UAP if he washed his hands afterward. (For safety, the nurse should find out if the UAP washed his or her hands. The UAP should do this for two reasons. First, it is part of Standard Precautions to wash hands after client care. Second, if the container did have preservative in it, this would wash it away. The preservative may be caustic to the skin. The nurse can call the laboratory while the UAP is washing hands, if needed. The UAP would then need to fill out an incident or exposure report and may or may not need to go to Employee Health. The UAP also needs further education on Standard Precautions, which include wearing gloves.)

A nurse cares for a client who is prescribed a drug that blocks a hormones receptor site. Which therapeutic effect should the nurse expect?

Decreased hormone activity (Hormones cause activity in the target tissues by binding with their specific cellular receptor sites, thereby changing the activity of the cell. When receptor sites are occupied by other substances that block hormone binding, the cells response is the same as when the level of the hormone is decreased.)

A nurse assesses clients who have endocrine disorders. Which assessment findings are paired correctly with the endocrine disorder? (Select all that apply.)

Excessive thyroid-stimulating hormone Increased bone formation. Excessive melanocyte-stimulating hormone Darkening of the skin (Thyroid-stimulating hormone targets thyroid tissue and stimulates the formation of bone. Melanocyte- stimulating hormone stimulates melanocytes and promotes pigmentation or the darkening of the skin. Parathyroid hormone stimulates bone resorption. Antidiuretic hormone targets the kidney and promotes water reabsorption, causing a decrease in urinary output. Adrenocorticotropic hormone targets the adrenal cortex and stimulates the synthesis and release of corticosteroids.)

A nurse cares for clients with hormone disorders. Which are common key features of hormones? (Select all that apply.)

Hormones may travel long distances to get to their target tissues. Continued hormone activity requires continued production and secretion. Control of hormone activity is caused by negative feedback mechanisms. (Hormones are secreted by endocrine glands and travel through the body to reach their target tissues. Hormone activity can increase or decrease according to the bodys needs, and continued hormone activity requires continued production and secretion. Control is maintained via negative feedback. Hormones are not stored for later use, and they do not alter genetic activity.)

A nurse assesses a female client who presents with hirsutism. Which question should the nurse ask when assessing this client?

How do you feel about yourself? (Hirsutism, or excessive hair growth on the face and body, can result from endocrine disorders. This may cause a disruption in body image, especially for female clients. The nurse should inquire into the clients body image and self-perception. Asking about the clients financial status or current medications does not address the clients immediate problem. The client is not doing anything to herself to cause the problem, nor can the client prevent it from happening.)

A nurse assesses a client diagnosed with adrenal hypofunction. Which client statement should the nurse correlate with this diagnosis?

I have a terrible craving for potato chips. (The nurse correlates a clients salt craving with adrenal hypofunction. Excessive thirst is related to diabetes insipidus or diabetes mellitus. Clients who have hypothyroidism often have a decrease in appetite. Excessive hunger is associated with diabetes mellitus.)

A nurse cares for a client who has excessive catecholamine release. Which assessment finding should the nurse correlate with this condition?

Increased pulse. (Catecholamines are responsible for the fight-or-flight stress response. Activation of the sympathetic nervous system can be correlated with tachycardia. Catecholamines do not decrease blood pressure or respiratory rate, nor do they increase urine output.)

A nurse prepares to palpate a clients thyroid gland. Which action should the nurse take when performing this assessment?

Place the client in a sitting position with the chin tucked down. (The client should be in a sitting position with the chin tucked down as the examiner stands behind the client. The nurse feels for the thyroid isthmus while the client swallows and turns the head to the right, and the nurse palpates the right lobe with the right hand. The technique is repeated in the opposite fashion for the left lobe.)

A nurse cares for a client who is prescribed a serum catecholamine test. Which action should the nurse take when obtaining the sample?

Place the sample on ice and send to the laboratory immediately. (A blood sample for catecholamine must be placed on ice and taken to the laboratory immediately. This sample is not urine, and therefore the first sample should not be discarded nor should preservatives be added to the sample. The nurse should use the appropriate tube and obtain the sample based on which drugs are administered, not dietary schedules.)

A nurse teaches a client who has been prescribed a 24-hour urine collection to measure excreted hormones. The client asks, Why do I need to collect urine for 24 hours instead of providing a random specimen? How should the nurse respond?

This test will assess for a hormone secreted on a circadian rhythm. (Some hormones are secreted in a pulsatile, or circadian, cycle. When testing for these substances, a collection that occurs over 24 hours will most accurately reflect hormone secretion. Dilution of hormones in urine, secretion of hormone amounts, and ability to collect the correct hormone are not reasons to complete a 24-hour urine test.)

A nurse teaches an older adult with a decreased production of estrogen. Which statement should the nurse include in this clients teaching to decrease injury?

Walk around the neighborhood for daily exercise. (An older adult client with decreased production of estrogen is at risk for decreased bone density and fractures. The nurse should encourage the client to participate in weight-bearing exercises such as walking. Drinking fluids and performing perineal care will decrease vaginal drying but not decrease injury. Older adults often have a decreased glucose tolerance, but this is not related to a decrease in estrogen.)

A nurse cares for a client with excessive production of thyrocalcitonin (calcitonin). For which electrolyte imbalance should the nurse assess?

Calcium (Parafollicular cells produce thyrocalcitonin (calcitonin), which regulates serum calcium levels. Calcitonin has no impact on potassium, sodium, or magnesium balances.)

A nurse plans care for an older adult who is admitted to the hospital for pneumonia. The client has no known drug allergies and no significant health history. Which action should the nurse include in this clients plan of care?

Offer fluids every hour or two (A normal age-related endocrine change is decreased antidiuretic hormone (ADH) production. This results in a more diluted urine output, which can lead to dehydration. If no contraindications are known, the nurse should offer (or delegate) the client something to drink at least every 2 hours. A client with simple pneumonia would not require Airborne Precautions. Indwelling urinary catheterization is not necessary for this client and would increase the clients risk for infection. The nurse should plan a toileting schedule and assist the client to the bathroom if needed. Palpating the clients thyroid gland is a part of a comprehensive examination but is not specifically related to this client.)

A nurse cares for a client with a hypofunctioning anterior pituitary gland. Which hormones should the nurse expect to be affected by this condition? (Select all that apply.)

Thyroid-stimulating hormone Follicle-stimulating hormone Growth hormone (Thyroid-stimulating hormone, follicle-stimulating hormone, and growth hormone all are secreted by the anterior pituitary gland. Vasopressin is secreted from the posterior pituitary gland. Calcitonin is secreted from the thyroid gland.)

4. A nurse assesses a client who is prescribed a medication that stimulates beta1 receptors. Which assessment finding should alert the nurse to urgently contact the health care provider?

Heart rate of 50 beats/min (Stimulation of beta1 receptor sites in the heart has positive chronotropic and inotropic actions. The nurse expects an increase in heart rate and increased cardiac output. The client with a heart rate of 50 beats/min would be cause for concern because this would indicate that the client was not responding to the medication. The other vital signs are within normal limits and do not indicate a negative response to the medication.)

A nurse cares for a client with a deficiency of aldosterone. Which assessment finding should the nurse correlate with this deficiency?

Increased urine output (Aldosterone, the major mineralocorticoid, maintains extracellular fluid volume. It promotes sodium and water reabsorption and potassium excretion in the kidney tubules. A client with an aldosterone deficiency will have increased urine output. Vasoconstriction is not related. These sodium and glucose levels are normal; in aldosterone deficiency, the client would have hyponatremia and hyperkalemia.)

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is prescribed a 24-hour urine specimen collection. Which statement should the nurse include when delegating this activity to the UAP?

Note the time of the clients first void and collect urine for 24 hours. (The collection of a 24-hour urine specimen is often delegated to a UAP. The nurse must ensure that the UAP understands the proper process for collecting the urine. The 24-hour urine collection specimen is started after the clients first urination. The first urine specimen is discarded because there is no way to know how long it has been in the bladder, but the time of the clients first void is noted. The client adds all urine voided after that first discarded specimen during the next 24 hours. When the 24-hour mark is reached, the client voids one last time and adds this specimen to the collection. The preservative, if used, must be added to the container at the beginning of the collection. All urine samples need to be collected for the test results to be accurate.)