CH 40-42: Endocrine Disorders
Which safety measure is most important for the nurse to institute for a patient who has Cushing's (hypercortisolism) disease? A. Padding the siderails of the patient's bed B. Assisting the patient to change positions slowly C. Using a lift sheet to change the patient's position D. Keeping suctioning equipment at the patient's bedside
Answer: C Rationale: Thinning of skin, along with increased friability of skin, accompanied by fluid retention increase the chances of skin injury due to pressure or friction. Using a lift sheet to reposition a patient decreases sheer forces to the skin.
Which patient statement indicates a need for further clarification regarding medications after a bilateral adrenalectomy? A. "I will take my cortisol replacement with food." B. "I will avoid aspirin and aspirin-containing products." C. "If I have any kind of stress, I will need my cortisol dose increased." D. "If I have nausea or vomiting, I will skip the medication until is it resolved."
Answer: D Rationale: Patients who undergo bilateral adrenalectomy are dependent upon daily doses of exogenous glucocorticoids. Missing doses of these medications may lead to acute adrenal crisis.
In assessing a patient with an alteration in thyroid function, the nurse must understand that TRH release is from which structure? A. Hypothalamus B. Anterior pituitary gland C. Posterior pituitary gland D. Thyroid gland
Answer: A Rationale: Thyroid function is controlled through the coordinated activities of the hypothalamus that secretes TRH what in turn acts on the anterior pituitary.
The nurse questions which intervention in the patient diagnosed with hypercortisolism? A. Limit salt intake B. Limit foods containing potassium C. Increase weight-bearing exercises D. Avoid use of skin tape
Answer: B Rationale: Hypokalemia develops in the patient with hypercortisolism as cortisol leads to loss of potassium and sodium retention. There would be no rationale in limiting potassium in this patient at risk for hypokalemia.
Which clinical manifestation observed in Ms. Johnson does the nurse correlate to elevated levels of thyroid hormone? A. Lethargy B. Insomnia C. Dry skin D. Constipation
Answer: B Rationale: Ms. Johnson has an acceleration of metabolism, which can lead to hyperexcitability and insomnia. Lethargy, dry skin, and constipation are associated with hypothyroidism secondary to decreased metabolic rate.
Which thyroid hormone value does the nurse correlate to primary hyperthyroidism? A. Elevated TRH B. Elevated TSH C. Elevated T3 D. Elevated thyrocalcitonin
Answer: C Rationale: Because primary hyperthyroidism is an excess secretion of thyroid hormones, both T3 and T4 levels are elevated. In primary hyperthyroidism, both TRH and TSH are decreased due to elevated thyroid hormones. Thyrocalcitonin secretion is based upon serum calcium levels.
The nurse monitors for which therapeutic effect as a result of the administration of Pitressin? A. Decreased urine output B. Decreased blood pressure C. Decreased serum glucose D. Decreased thirst
Answer: A Rationale: Pitressin (form of antidiuretic hormone) works by increasing reabsorption of water in the kidneys, and is manifested by a decrease in urine output. Other therapeutic effects include normalizing blood pressure (which may be decreased with DI). Pitressin has no effect of serum glucose level. Thirst may decrease as fluid balance is reestablished.
Which serum electrolyte value alerts the nurse to the possibility of hyperaldosteronism? A. Serum sodium, 150 mmol/L; serum potassium, 2.5 mmol/L B. Serum sodium, 140 mmol/L; serum potassium, 5.0 mmol/L C. Serum sodium, 130 mmol/L; serum potassium, 2.5 mmol/L D. Serum sodium, 130 mmol/L; serum potassium, 7.5 mmol/L
Answer: A Rationale: Because the primary actions of aldosterone are sodium and water reabsorption and potassium excretion, patients with hyperaldosteronism develop hypertension and hypokalemia. The action of aldosterone leads to sodium retention and potassium excretion. The sodium may or may not be above normal levels as the patient will also retain water due to retained sodium.
Which statement by a patient diagnosed with a primary thyroid disorder indicates the need for further teaching? A. "Having a brain tumor is so scary." B. "My thyroid gland is not working." C. "Now I understand why the nurse keeps measuring my neck." D. "My energy level may be affected by this disorder."
Answer: A Rationale: A primary disorder of thyroid function is caused by a malfunction of the thyroid glands. Secondary thyroid disorders are related to malfunction of the anterior pituitary gland, and tertiary disorders are related to hypothalamic malfunction. Patients with brain tumors may have tumor growth in the hypothalamus (tertiary) or pituitary gland (secondary).
The nurse monitors for which complication in Ms. Davis secondary to her hypercortisolism? A. Osteoporosis B. Hypoglycemia C. Muscle loss D. Hyperkalemia
Answer: A Rationale: Osteoporosis may develop relative to the effects of cortisol on bone density and can increase the risk of pathologic fractures. Patients with hypercortisolism have hyperglycemia, not hypoglycemia, and hypokalemia. Muscle loss is more associated with adrenal insufficiency, not excessive cortisol.
The nurse correlates which assessment findings to the patient diagnosed with hyperaldosteronism? (Select all that apply.) A. Blood pressure, 160/90 mm Hg B. Heart rate, 60 bpm C. Potassium, 3.0 mEq/L D. Glucose, 250 mg/dL E. Sodium, 130 mEq/L
Answer: A and C Rationale: Aldosterone actions include sodium retention and potassium excretion, so patients with hyperaldosteronism manifest elevated blood pressure due to sodium and fluid retention and hypokalemia. These is no effect on glucose as there is with hypercortisolism.
The nurse assesses for which clinical manifestations in the patient admitted with primary hypercortisolism? (Select all that apply.) A. Elevated serum glucose B. Elevated serum potassium C. Elevated urine specific gravity D. Elevated blood pressure E. Elevated temperature
Answer: A and D Rationale: The clinical manifestations of hypercortisolism are directly related to hypersecretion of cortisol and include hyperglycemia, fluid retention, hypokalemia, abnormal fat distribution, and decreased muscle mass. The maldistribution of fats and changes in muscle are related to the effects that glucocorticoids have on fat and protein metabolism.
In caring for a patient with elevated secretion of triiodothyronine and thyroxine, the nurse assesses for which findings? (Select all that apply.) A. Increased heart rate B. Increased gastric motility C. Increased cholesterol D. Increased urine output E. Increased respiratory rate
Answer: A, B, and E Rationale: Actions of thyroid hormones (triiodothyronine and thyroxine) lead to increased heart rate, increased gastric motility, increased respiratory rate, as well as overall increase in metabolic activity. These hormones also decrease production of cholesterol and phospholipids. Urinary output is more related to release of antidiuretic hormone.
Upon review of Ms. Andrews' admission clinical presentation, which clinical manifestations are most related to excessive growth hormone? A. Headache B. Enlarged hands C. Visual changes D. Nausea
Answer: B Rationale: An excess of growth hormone in adults does not affect bone length because of closure of the epiphyses but does affect bone density, and acromegaly (thickening of bones, particularly of the hands, feet, and facial bones) may develop.
The nurse incorporates the nursing diagnosis "Fluid volume deficit related to excessive secretion of vasopressin" in the plan of care for the patient with which disorder? A. Acromegaly B. Diabetes insipidus C. Hypopituitarism D. SIADH
Answer: B Rationale: Diabetes insipidus (DI) leads to fluid volume deficit secondary to losses of large amounts of water through the kidneys. Acromegaly is associated with overgrowth of bones secondary to excessive growth hormone secretion. Hypopituitarism is associated with multiple disorders based upon target deficiencies. SIADH is an excess of ADH leading to water retention and fluid volume overload.
In evaluating the therapeutic effects of vasopressin, the nurse monitors for which finding? A. Urine specific gravity of 1.050 B. Urine output of 30 to 50 mL/hr C. Serum sodium of 148 mEq/L D. Serum osmolality of 310 mOsm/kg
Answer: B Rationale: Vasopressin is used to treat Diabetes Insipidus (DI) and works like antidiuretic hormone to increase water reabsorption in the kidneys. The therapeutic effect of this medication leads to decreased urine output. Both the serum sodium and osmolality are increased with DI.
The nurse notes that which disorder places the patient at greatest risk for hypertensive crisis? A. Hypothyroidism B. Pheochromocytoma C. Diabetes insipidus D. Adrenal insufficiency
Answer: B Rationale: Pheochromocytomas are catecholamine secreting tumors of the adrenal medulla. Because of excessive catecholamine secretion, pheochromocytomas may precipitate life-threatening hypertension or cardiac arrhythmias. Hypothyroidism results in sluggish metabolism. Diabetes insipidus may lead to hypovolemia and hypotension secondary to large losses of dilute urine. Patients with adrenal insufficiency are at risk for hypovolemia secondary to sodium and water losses due to lack of glucocorticoids and mineralocorticoids.
The nurse recognizes that the negative feedback system causes which change secondary to increased T3 and T4? A. Increased TRH B. Decreased TSH C. Increased parathormone D. Decreased thyrocalcitonin
Answer: B Rationale: With elevated circulating levels of thyroid hormones (T3 and T4), the hypothalamus decreases the secretion of thyroid releasing hormone (TRH) and the anterior pituitary gland decreases secretion of thyroid stimulating hormone (TSH). Parathormone is secreted by the parathyroid gland when serum calcium levels are low. Thyrocalcitonin secretion from the thyroid gland increases or decreases based upon serum calcium levels.
The nurse correlates which effects to the stimulation of alpha receptors? (Select all that apply.) A. Increased heart rate B. Vasoconstriction C. Bronchiole relaxation D. Pupil dilation E. Increased gastrointestinal motility
Answer: B and D Rationale: Alpha receptors lead to vasoconstriction, pupil dilation, increased sphincter tome, increased sweating, and increased gluconeogenesis. Stimulation of Beta1 increases heart rate, and stimulation of Beta2 leads to bronchial dilation. Gastric motility is influenced by beta receptors.
The nurse recognizes that which hormones are produced by the posterior pituitary gland? (Select all that apply.) A. ACTH B. Vasopressin C. Thyroid stimulating hormone D. Oxytocin E. Growth hormone
Answer: B and D Rationale: Vasopressin (antidiuretic hormone) and oxytocin are secreted by the posterior pituitary gland. ACTH, TSH, and growth hormone are released from the anterior pituitary gland.
In providing care to Ms. Andrews after she undergoes a transsphenoidal hypophysectomy, the nurse prioritizes which intervention? A. Maintaining the patient in a flat, supine position B. Instructing the patient to cough and deep breathe C. Monitoring for clear fluid drainage from the nose D. Limiting exposure to bright lights
Answer: C Rationale: Clear fluid drainage from the nose in the patient after transsphenoidal hypophysectomy may indicate a cerebrospinal fluid (CSF) leak that can lead to meningitis. The patient is usually placed with the head of bed elevated 45°, and coughing is minimized to avoid pressure on the operative site. Bright lights may be limited to decrease environmental stimuli, but this is not as high of a priority as monitoring for a CSF leak.
The nurse correlates primary hypercortisolism to dysfunction of which gland? A. Hypothalamus B. Anterior pituitary gland C. Adrenal cortex D. Adrenal medulla
Answer: C Rationale: Cortisol is the primary glucocorticoid released from the adrenal cortex. Primary endocrine disorders are associated with the endocrine gland, and in this example, the adrenal cortex. Secondary endocrine disorders are related to anterior pituitary gland dysfunction, and tertiary disorders are related to hypothalamic dysfunction. The adrenal medulla secretes epinephrine and norepinephrine.
Ms. Andrews is ordered to receive bromocriptine mesylate (Parlodel) for the treatment of her tumor. The nurse correlates which rationale for this medication? A. Decreases serum glucose levels B. Decreases water reabsorption in the kidneys C. Decreases secretion of growth hormone D. Decreases secretion of ADH
Answer: C Rationale: Dopamine agonists (bromocriptine mesylate [Parlodel]) inhibit the release of anterior pituitary hormones. Medications that inhibit release of growth hormone include somatostatin analogs and growth hormone receptor blockers.
The patient just diagnosed with acromegaly is scheduled for a transsphenoidal hypophysectomy. Which statement made by the patient indicates a need for clarification regarding this treatment? A. "I will get to drink fluids once I am awake after surgery." B. "I'm glad there will be no visible incision from this surgery." C. "I hope I can go back to wearing size 8 shoes instead of size 12." D. "I will wear slip-on shoes after surgery so I don't have to bend over."
Answer: C Rationale: Changes to bone thickness are permanent, and the hands and feet sizes will not decrease after treatment of the hypersecreting tumor. Patients are allowed oral intake once awake, alert with an intact gag and swallow. There will not be a visible scar as the surgical approach is transsphenoidal. The patient is discouraged from bending at the waist as this can increase intracranial pressure and place pressure on the graft site at the surgical site.
The nurse assesses for which of the following in the patient with hypersecretion of parathyroid hormone (PTH)? A. Increased serum sodium B. Increased serum glucose C. Increased serum calcium D. Increased serum potassium
Answer: C Rationale: Parathyroid hormone increases serum calcium by increasing bone resorption, reabsorption of calcium in the kidneys, and activation of vitamin D, which increases intestinal reabsorption of calcium.
In reviewing admission orders for a patient admitted with SIADH, the nurse should question which order? A. IV 3% NS at 10 mL/hr B. Seizure precautions C. Sodium-restricted diet D. Fluid restriction of 1000 mL/day
Answer: C Rationale: The patient with SIADH has dilutional hyponatremia secondary to increased water reabsorption in the kidneys secondary to excessive ADH. Elevating the serum sodium is important to decrease the risk of seizures and other complications, so there is no need to restrict sodium in the diet. The patient is usually placed on a fluid restriction. A 3% normal saline is a very hypertonic solution that should be administered via a central line and delivered by an infusion pump.
Which of the following patients is at greatest risk for primary hypercortisolism? A. A 65-year-old male B. A 56-year-old female C. A 44-year-old male D. A 28-year-old female
Answer: D Rationale: Females are five times more likely to develop primary hypercortisolism, and the peak incidence of hypersecreting tumors of the adrenal and pituitary glands is in the 25- to 40-year age range.
In a patient with a secondary disorder of the thyroid gland, the nurse assesses for changes in function in which structure? A. Thyroid gland B. Hypothalamus C. Posterior pituitary gland D. Anterior pituitary gland
Answer: D Rationale: Primary endocrine disorders involve the endocrine gland (thyroid glands in this example). Secondary disorders result from malfunction of the anterior pituitary gland, and tertiary disorders result from malfunction of the hypothalamus. The posterior pituitary gland secretes antidiuretic hormone (vasopressin) and oxytocin.
Which laboratory result does the nurse correlate with a diagnosis of diabetes insipidus (DI)? A. Serum osmolality, 285 mOsm/kg B. Serum sodium, 132 mEq/L C. Hematocrit 32% D. Urine specific gravity, 1.001
Answer: D Rationale: The clinical presentation of the patient with DI is dependent upon the significance of water loss. Due to the lack of ADH, the patient excretes large volumes of dilute urine with a low specific gravity. Serum sodium and osmolality levels are increased in DI secondary to hemoconcentration.
The nurse correlates an increase in the secretion of cortisol to an increase in the release of which of the following hormones? A. Growth hormone B. Epinephrine C. Corticotropin-releasing hormone D. Adrenocorticotropic hormone
Answer: D Rationale: Adrenocorticotropic hormone (ACTH) increases secretion of glucocorticoids and mineralocorticoids, and cortisol is the primary glucocorticoid. Growth hormone is controlled by secretion of growth hormone-releasing hormone (GHRH) and growth hormone-inhibiting hormone (somatostatin; GHIH) from the anterior pituitary gland. Epinephrine is released from the adrenal medulla. Corticotropin-releasing hormone secretion from the hypothalamus increases release of ACTH from the anterior pituitary gland.
Case Study #1 (CH 40)
Case Study: Episode 1 Follow this patient throughout the chapter. Greta Johnson is a 27-year-old female who has been experiencing insomnia, restlessness, and irritability the past several months. Because these symptoms are interfering with her ability to complete her work as a graduate research assistant at a local community college, she presents today to her nurse practitioner for a complete physical. During the initial interview, Greta describes that sometimes she feels as if her "heart is racing" and has noticed palpitations. She has also noted an 8-pound weight loss over the last month despite an increased appetite and food intake. Case Study: Episode 2 The nurse practitioner completes a detailed history and physical examination of Greta Johnson. Because of her symptoms of restlessness, irritability, and anxiety along with tachycardia and palpitations, an evaluation of thyroid function is started. The nurse assesses Greta's vital signs and finds her heart rate to be 134 bpm and her blood pressure 130/80 mm Hg. The nurse practitioner arranges for blood to be drawn for T3, T4, and TSH. Case Study: Wrap-up The nurse practitioner begins a work-up for thyroid dysfunction for Greta Johnson. On the basis of her clinical presentation, hyperthyroidism is suspected. The laboratory results reveal increased levels of T3 and T4 with decreased levels of TSH. A tentative diagnosis of primary hyperthyroidism is made, and Greta is referred for further evaluation and treatment.
Case Study #2 (CH 41)
Case Study: Episode 1 Follow this patient throughout the chapter. Carol Andrews makes an appointment with her primary healthcare provider because of a persistent headache, changes in vision, and occasional episodes of nausea. She also complains of enlargement of her hands and feet, requiring her to remove her rings and purchase larger shoes. Her primary healthcare provider orders a series of laboratory studies including serum chemistries and hematology studies. Magnetic resonance imaging (MRI) of the head is also ordered.. Case Study: Episode 2 The result of Carol Andrews' MRI is positive for a pituitary adenoma, and she is scheduled for a transsphenoidal hypophysectomy for removal of the tumor. The operative procedure is uneventful, and she is admitted to the neurosurgical intensive care unit. Postoperative orders include vital signs with neurological assessments every hour, hourly intake and output measurements, head of bed at 45 degrees, oxygen at 35% with humidification via a face tent, a nasal drainage pad to be maintained under the nose and monitored for drainage, and an IV of lactated Ringer's (LR) solution at 80 mL per hour. She has an indwelling urinary catheter and is placed on continuous electrocardiogram monitoring. Laboratory orders include hourly measurements of urine specific gravity and serum and urine electrolytes every 6 hours.. Case Study: Episode 3 Approximately 8 hours after Ms. Andrews arrives in the neurosurgical intensive care unit after undergoing transsphenoidal hypophysectomy, the nurse notes that the patient has had 200 to 300 mL/hr urine output for the last 3 hours. Urine specific gravity is 1.002, and serum electrolyte results include a sodium level of 148 mEq/L and an osmolality of 292 mOsm/kg. The patient's blood pressure is 92/56 mm Hg with a heart rate of 110 bpm. The neurosurgeon is notified, and the patient is started on a Pitressin (vasopressin) IV infusion.. Case Study: Wrap-up Ms. Andrews responds favorably to the IV Pitressin, and after 24 hours she is started on DDAVP intranasally. Her blood pressure is 110/68 mm Hg with a heart rate of 88 bpm. Urine output has decreased to an average of 50 mL/hr, and IV fluids are discontinued because she is taking oral fluids. Discharge planning is initiated, and she is scheduled to be discharged on the fourth postoperative day. She is discharged on DDAVP. The nurse incorporates teaching about activity restrictions related to transsphenoidal hypophysectomy.
Case Study #3 (CH 42)
Case Study: Episode 1 Follow this patient throughout the chapter. Melinda Davis, a 32-year-old female, makes an appointment with her adult nurse practitioner because of changes in her menstrual cycle and concerns about difficulty getting pregnant. Ms. Davis is employed in a daycare center, and she and her spouse have been trying to conceive for about 10 months.. Case Study: Episode 2 Ms. Davis is seen by her nurse practitioner about her complaints of inability to conceive and changes in menstrual cycles. During the history, she reports increased swelling of her hands and feet and is unable to wear her wedding ring. Additionally, she has gained about 8 pounds in the last month. She complains of increasing fatigue and has noticed that she seems to bruise "just by bumping into things." Her blood pressure is higher than previous measurements. On the basis of these findings, the nurse practitioner orders a complete metabolic panel, abdominal x-rays, cortisol levels, and a dexamethasone suppression test.. Case Study: Wrap-up Ms. Davis returns to the nurse practitioner the following week to review the results of her diagnostic evaluation. Her serum glucose level is 154 mg/dL, and her potassium level is 3.0 mEq/L. Her blood pressure remains elevated, and she has gained another pound in the last week. The abdominal x-rays are suggestive of a mass on the right adrenal gland, and a follow-up CT scan of the abdomen demonstrates a mass on the right adrenal gland. On the basis of this finding and the abnormal results of the dexamethasone suppression test, Ms. Davis is diagnosed with primary hypercortisolism secondary to a hypersecreting tumor and undergoes a right adrenalectomy.