Chapter 62
The nurse is providing discharge instructions to a client receiving spironolactone (Aldactone) therapy. Which comment by the client indicates a need for further teaching?
"I will eat a banana every day." Spironolactone increases potassium levels, so potassium supplements and foods rich in potassium, such as bananas, need to be avoided to prevent hyperkalemia.While taking spironolactone, symptoms of hyponatremia such as drowsiness and lethargy must be reported. Sodium intake is not typically increased while taking a diuretic; this would exacerbate underlying problems for which the diuretic was prescribed. The client may need increased dietary sodium. Spironolactone will not have an effect on the client's heart rate.
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?
"The disease can sometimes affect emotional responses." The nurse's best response is that the disease can affect emotional responses. The client may have inappropriate or psychotic behavior or difficulty concentrating 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. Because the diagnosis of Cushing's disease and hypercortisolism 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 current behavior. This is the perfect opportunity for the nurse to educate the family about the disease.
The nurse and nursing student are caring for a client with pheochromocytoma who is admitted for surgery. Which of these statements by the student requires immediate intervention by the nurse?
"When performing the gastrointestinal assessment, I need to palpate the client's abdomen." The abdomen must not be palpated in a client with pheochromocytoma because this action could cause a sudden release of catecholamines and trigger severe hypertension.Reviewing the chest x-ray for pulmonary edema is not necessary. 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, but providing a roommate for distraction will not reduce the client's anxiety.
A client with syndrome of inappropriate antidiuretic hormone (SIADH) is admitted with a serum sodium level of 105 mEq/L (105 mmol/L). Which request by the health care provider does the nurse carry out first?
Administer infusion of 150 mL of 3% NaCl over 3 hours. The first intervention the nurse performs is to administer an infusion of 150 mL of 3% NaCl over 3 hours. When the serum sodium level is below 115 mEq/L (115 mmol/L), the client is at increased risk for seizures and coma.Drawing blood for an H&H, inserting an indwelling catheter for urine monitoring, and weighing the newly admitted client are not top priority interventions.
A client presents to the emergency department with a history of adrenal insufficiency. The following laboratory values are obtained: Na+ 130 mEq/L (130 mmol/L), K+ 6.6 mEq/L (6.6 mmol/L), and glucose 72 mg/dL (4 mmol/L). Which prescription will the nurse implement first?
Administer insulin with dextrose in normal saline. The nurse would first administer insulin (20 to 50 units) with dextrose (20 to 50 mg) in normal saline to correct hyperkalemia. Insulin shifts potassium into cells to prevent or treat dysrhythmias.Spironolactone is a potassium-sparing diuretic that helps the body retain potassium and not eliminate it. Although H2 blocker therapy with ranitidine would be appropriate for this client, it is not the first priority. Arterial blood gases are not used to assess cardiac dysrhythmias and peaked T waves associated with hyperkalemia. An electrocardiogram needs to be obtained instead.
A client with iatrogenic Cushing's disease is a resident in a long-term care facility. Which nursing action included in the plan of care is most appropriate to delegate to unlicensed assistive personnel (UAP)?
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 the UAP's scope of practice to develop a plan of care, although they will play a very important role in following the plan of care as delegated by a professional nurse. Client teaching requires professional knowledge and education and would not be delegated to UAP. Monitoring for signs and symptoms of fluid retention is part of client assessment, and is not within the UAP's skill set. This monitoring requires a higher level of education and clinical judgment possessed by a professional nurse.
The nurse is assessing a client who had a transsphenoidal hypophysectomy yesterday. Which finding requires immediate notification to the primary health care provider?
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. The finding requires the nurse to immediately notify the primary health care provider.Dry lips and mouth are not unusual after surgery. The client was NPO and received anesthesia. Frequent oral rinses and the use of dental floss would be encouraged because the client cannot brush the teeth until the surgeon gives permission. Any nasal drainage is expected to 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.
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 with Cushing's syndrome who requires frequent glucose monitoring and administration of insulin The best client to assign to the RN who was floated to the medical-surgical unit from the pediatric unit is the client with Cushing's syndrome. An RN who works with pediatric clients would be familiar with glucose monitoring and insulin administration related to this client.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 hypertonic saline and correction of hyponatremia. Teaching and orientation to the unit that is best provided by a nurse more familiar with that area. Discharge teaching specific to adrenalectomy would be provided by the RN who is regularly assigned to the medical-surgical floor and is more familiar with care of postoperative adult clients with endocrine disorders.
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 (2.0 mmol/L) The nurse first attends to the client with adrenal insufficiency who has a blood glucose level of 36 mg/dL (2.0 mmol/L). The client's condition is considered a medical emergency and must be assessed and treated immediately.Although it is important to maintain medications on schedule, the client requiring a dose of desmopressin cannot take priority over treatment of severe hypoglycemia. A serum potassium of 3.4 mEq/L (3.4 mmol/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.
The nurse is teaching a client about the expected outcome for treatment of syndrome of inappropriate antidiuretic hormone (SIADH). What does the nurse tell the client to look for?
Decrease in difficulty in breathing The nurse tells the client to look for a decrease in difficulty in breathing. The syndrome of inappropriate antidiuretic hormone (SIADH) is a disease where vasopressin (antidiuretic hormone [ADH]) is secreted even when plasma osmolarity is low or normal. Symptoms of fluid overload including dyspnea will resolve with treatment as the fluid retention decreases.Dry mucous membranes are a sign of fluid volume deficit or; fluid excess should resolve during treatment of SIADH, but not to the point of dehydration, 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, typically found in SIADH, and are an indication that hyponatremia is still present. Untreated hyponatremia can lead to seizures and coma.
The nurse is planning to administer medications to a client with diabetes insipidus (DI) who has dry lips and mucous membranes and poor skin turgor. Which intervention will the nurse provide first?
Encourage oral fluid intake The nurse first needs to encourage fluid intake. Dry lips and mucous membranes and poor skin turgor are indications of dehydration, which can occur with DI due to diuresis. This is a serious condition that requires ongoing fluid replacement to maintain perfusion until treatment is effective. 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 dehydration. Desmopressin acetate is a synthetic form of antidiuretic hormone that is given to reduce urine production. It is the anticipated treatment for DI and would not be withheld.
When caring for a client with hypercortisolism the nurse notices that the phlebotomist, who plans to draw blood from the client, displays symptoms of a cold. What would the nurse do?
Ensure the phlebotomist wears a facemask. The nurse needs to make sure the phlebotomist wears a facemask. A client with hypercortisolism will be immunosuppressed. Anyone with a suspected upper respiratory infection who must enter the client's room needs to wear a mask to prevent the spread of infection. Asking for another phlebotomist might be an option in some facilities, but it is not necessary. The phlebotomist, not the client, is exhibiting cold-like symptoms, so monitoring the client for these symptoms is not appropriate. Refusing to allow the phlebotomist to enter the room will delay treatment.
The client is taking fludrocortisone (Florinef) for adrenal hypofunction. The nurse instructs the client to report which symptom while taking this drug?
Headache A side effect of fludrocortisone is hypertension, likely related to hyponatremia and fluid retention. New onset of headache must be reported, and the client's blood pressure would be monitored.Anxiety is not a side effect of fludrocortisone and is not associated with adrenal hypofunction. Nausea is associated with adrenal hypofunction, but not a side effect of fludrocortisone. Sodium-related fluid retention and weight gain, not loss, are possible with fludrocortisone therapy
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH) admitted with change in mental status. To determine whether fluid restrictions have been effective, for which of these outcomes will the nurse monitor?
Increased serum sodium Increased serum sodium due to fluid restriction indicates effective therapy.Restricting fluid would result in increasing hematocrit levels as the fluid volume excess resolves. Plasma osmolality is decreased as a result of SIADH, so treatment would result in this level rising to near normal. Urine specific gravity is increased with SIADH and would decrease to near normal with treatment.
A client has undergone a transsphenoidal hypophysectomy. Which intervention does the nurse implement to avoid increasing intracranial pressure (ICP) in the client?
Instruct the client not to strain during a bowel movement. Straining during a bowel movement increases ICP and must be avoided. Laxatives or stool softeners may be given and fluid intake be encouraged to prevent straining.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 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?
Providing isotonic fluids Acute adrenal insufficiency (Addisonian crisis) is a life-threatening condition in which the need for cortisol and aldosterone is greater than the body's supply. Providing isotonic fluid is the highest priority nursing intervention because hypotension and tachycardia indicate volume loss that is caused by acute adrenal insufficiency. Isotonic fluids will help to correct hyponatremia which typically accompanies adrenal insufficiency. IV access is also needed to administer IV medications such as hydrocortisone.Furosemide is a loop diuretic to increase fluid loss. This client is already experiencing fluid volume depletion related to insufficient cortisol and aldosterone. Potassium is normally increased in acute adrenal insufficiency, so replacing potassium is not needed. Sodium levels are already low, so restricting sodium is inappropriate. GI problems, such as nausea, vomiting, and diarrhea, often occur, increasing the effect of fluid loss.
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?
Remind the client to not order coffee with meals The most appropriate nursing action for the charge nurse to delegate to the nursing assistant is to remind the client to not order coffee with meals. Drinking caffeinated beverages and changing position suddenly are not safe for a client with a potential adrenal gland tumor because the effects of catecholamines that stimulate blood pressure changes. The nursing assistant's scope of practice includes assisting clients with ordering meals, and reminding clients about previous nursing instructions.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?
Test any nasal drainage for the presence of glucose. Home health aides can perform testing for nasal drainage for the presence of glucose after education and validation of the skill. After delegating this task, the nurse would follow up on the result to determine if the primary health care provider needs to be contacted. 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 primary health care provider.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 has been admitted to the medical intensive care unit with a diagnosis of diabetes insipidus (DI) secondary to lithium overdose. The client has a prescription for Desmopressin (DDAVP). Which outcome indicates a positive response to treatment?
Urine output of 60-80 mL/hour Lithium may cause drug-related diabetes insipidus causing the kidneys to be unable to respond to ADHl, causing profound diuresis. Desmopressin acetate (DDAVP), a synthetic form of vasopressin (ADH), is the drug of choice to stop fluid loss.A blood glucose result of 110 mg/dL (6.1 mmol/L) is within the range of normal blood glucose levels. The ability to sit quietly and read a magazine is not an expected outcome after the administration of desmopressin; this is potentially and outcome for clients receiving lithium therapy for bipolar disorder. Hypokalemia may result from the ongoing diuresis of DI, but this does not evaluate the outcome of treatment.
A client with Cushing's disease says that she has lost 1 pound (0.5 kg) What does the nurse do next?
Weigh the client. The nurse would next weigh the client. Fluid retention with weight gain is more of a problem than weight loss in clients with Cushing's disease.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. Increases in blood pressure will correlate with excess water and sodium reabsorption causing fluid retention and weight gain in the client with Cushing's disease.
