CH 56 med surg

A nurse collaborates with assistive personnel (AP) to provide care for a client who is prescribed a 24-hour urine specimen collection. Which statement would the nurse include when teaching the AP about this activity? a. "Note the time of the client's first void and collect urine for 24 hours." b. "Add the preservative to to the container at the end of the test." c. "Start the collection by saving the first urine of the morning." d. "It is okay if one urine sample during the 24 hours is not collected."

A The collection of a 24-hour urine specimen is often delegated to AP. The nurse must ensure that the AP understands the proper process for collecting the urine. The 24-hour urine collection specimen is started after the client's 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 client's 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 abirb.com/test 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.

A client is scheduled to have a glycosylated hemoglobin (A1C) drawn and asks the nurse why she has to have it. How would the nurse respond? a. "It measures your average blood glucose level for the past 3 months." b. "It determines what type of anemia you may have." c. "It measures the amount of liver glycogen you have." d. "It determines you have some type of leukemia or other blood cancer."

ANS: A A1C measures the average blood glucose level to determine if the client is a diabetic or how controlled a diabetic client is.

A nurse assesses a client who is prescribed a medication that stimulates beta1 receptors. Which assessment finding would indicate that the medication is effective? a. Heart rate of 92 beats/min b. Respiratory rate of 18 breaths/min c. Oxygenation saturation of 92% d. Blood pressure of 144/69 mm Hg

ANS: A 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 other vital signs are within normal limits and do not indicate any response to the medication.

Which assessment finding in an older adult client does the nurse identify that may indicate an age-related decrease in antidiuretic hormone (ADH)? a. Diluted urine and dehydration b. Yeast infection and polydipsia c. Higher than normal body weight d. Constipation, lethargy, and dry skin

ANS: A These are symptoms that result from an age-related decrease in antidiuretic hormone. The other symptoms listed are not related to age.

Which client assessment finding alerts the nurse to perform a detailed endocrine system assessment? Select all that apply. a. Fatigue b. Weight gain c. Reports being cold all the time d. Decrease in peripheral pulses e. Changes in hair texture and distribution

ANS: A, B, C, E •Changes in physical appearance can reflect an endocrine problem. Obvious changes identified during the physical assessment include hair texture and distribution, facial contours and eye protrusion, voice quality, body proportions, and secondary sexual characteristics. Changes in weight and fatigue may also be associated with endocrine disorders as well as other conditions. Poor peripheral pulses are more likely associated with cardiovascular diseases.

A nurse assesses clients who have endocrine disorders. Which assessment findings are paired correctly with the endocrine disorder? (Select all that apply.) a. Excessive thyroid-stimulating hormone—increased bone formation b. Excessive melanocyte-stimulating hormone—darkening of the skin c. Excessive parathyroid hormone—synthesis and release of corticosteroids d. Excessive antidiuretic hormone—increased urinary output e. Excessive adrenocorticotropic hormone—increased bone resorption

ANS: A,B 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.) a. Hormones may travel long distances to get to their target tissues. b. Continued hormone activity requires continued production and secretion. c. Control of hormone activity is caused by negative feedback mechanisms. d. Most hormones are stored in the target tissues for use later. e. Most hormones cause target tissues to change activities by changing gene activity.

ANS: A,B,C 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 body's 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.

2. A nurse cares for a client with a hypofunctioning anterior pituitary gland. Which hormones would the nurse expect to be decreased as a result? (Select all that apply.) a. Thyroid-stimulating hormone b. Vasopressin c. Follicle-stimulating hormone d. Calcitonin e. Growth hormone

ANS: A,C,E 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.

When caring for an older client who has hypothyroidism, what assessment findings will the nurse expect? (Select all that apply.) a. Lethargy b. Diarrhea c. Low body temperature d. Tachycardia e. Slowed speech f. Weight gain

ANS: A,C,E,F A client who has an underactive thyroid gland has a decreased metabolic rate, resulting in lethargy and lack of energy, weight gain, slowed speech, and decreased vital signs like a lowered body temperature. The client also typically has constipation (instead of diarrhea) due to slower peristalsis and bradycardia (instead of tachycardia)

A nurse teaches an older woman who has a decreased production of estrogen. Which statement would the nurse include in this client's teaching to decrease injury? a. "Drink at least 2 quarts (2 L) of fluids each day." b. "Walk around the neighborhood for daily exercise." c. "Bathe your perineal area twice a day." d. "You should check your blood glucose before meals."

ANS: B An older female with decreased production of estrogen is at risk for decreased bone density and fractures. The nurse would encourage the client to participate in weight-bearing exercises such as walking. Drinking fluids and performing perineal care will decrease vaginal drying but not injury. Older adults often have a decreased glucose tolerance, but this is not related to a decrease in estrogen.

A nurse is caring for a patient who has excessive catecholamine release. Which assessment finding would the nurse correlate with this condition? a. Decreased blood pressure b. Increased pulse c. Decreased respiratory rate d. Increased urine output

ANS: B 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.

The nurse is teaching assistive personnel (AP) about hormones that are produced by the adrenal glands. Which hormone has the primary responsibility of maintaining fluid volume and electrolyte composition? a. Sodium b. Magnesium c. Aldosterone d. Renin

ANS: C Aldosterone is a hormone secreted by the adrenal cortex that causes water and sodium absorption to maintain body fluid volume. Renin is secreted by the kidney to trigger angiotensinogen converting angiotensin I to angiotensin II to help control blood pressure. Magnesium and sodium are electrolytes and not hormones.

The nurse assesses an older client. What age-related physiologic changes would the nurse expect? a. Heat intolerance b. Rheumatoid arthritis c. Dehydration d. Increased appetite

ANS: C As people age, the many of the endocrine glands decrease hormone production, including a decrease in antidiuretic hormone production. This change, in addition to less body fluid being present as one ages, can cause dehydration. Older adults usually have cold intolerance and a decrease in appetite. Rheumatoid arthritis is not an age-related change; osteoarthritis causes primarily by aging.

Which is the priority nursing assessment for a client with primary adrenal cortex dysfunction? a. Vital signs b. Daily weights. c. Fluid intake and output. d. Physiologic response to stress.

ANS: D •The adrenal cortex makes up about 90% of the adrenal gland. Hormones secreted from the adrenal cortex are responsible for fluid and electrolyte balance, stress response, metabolism of nutrients, and emotional and sex hormone responses. Priority nursing interventions with adrenal cortex dysfunction focus on the negative feedback mechanisms of aldosterone and cortisol. Assessing the physiologic responses to stress is appropriate, as cortisol affects the body's stress response. All other assessments can then be completed.

The nurse assesses a client who is scheduled to have a laboratory test to determine if the client's adrenal glands are hypoactive. What type of testing would the client likely have? a. Catecholamine testing b. Suppression testing c. Bone marrow testing d. Provocative testing

ANS: D Provocative testing is done to determine if an endocrine gland is capable of producing its normal level of hormone(s), especially when a client is suspected of having a hypoactive endocrine gland.

A nurse assesses a female client who presents with hirsutism. Which question would the nurse ask when assessing this client? a. "How do you plan to pay for your treatments?" b. "How do you feel about yourself?" c. "What medications are you prescribed?" d. "What are you doing to prevent this from happening?"

B 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 would inquire into the client's body image and self-perception. Asking about the client's financial status or current medications does not address the client's immediate problem. The client is not doing anything to herself to cause the problem, nor can the client prevent it from happening.

The nurse reviews the function of thyroid gland hormones. What is the primary function of calcitonin? a. Sodium and potassium balance b. Magnesium balance c. Norepinephrine balance d. Calcium and phosphorus balance

D Calcitonin is the primary body hormone that is secreted from the thyroid gland and is responsible for maintaining calcium and phosphorus balance.