CHAPTER 62: CARE OF PATIENTS WITH PITUITARY AND ADRENAL GLAND PROBLEMS, Ch. 61 Endocrine Med-Surg

Hormones of the Testes

testosterone

A nurse is preparing to receive a client from the PACU who is post-op thyroidectomy. The nurse should ensure that which of the following equipment is available? (Select all that apply) (a) Suction (b) Humidified O2 (c) Flashlight (d) Tracheostomy tray (e) Chest tube tray

A,B,D

Hormones of Posterior Pituitary

ADH (antidiuretic hormone) oxytocin

Hormones of the Hypothalamus

(1) GHRH (Growth Hormone Releasing Hormone) (2) GHIH (Growth Hormone Inhibiting Hormone) (3) TRH (Thyrotropin Releasing Hormone) (4) CRH (Corticotropin Releasing Hormone) (5) GnRH (Gonadotropin Releasing Hormone) (6) MIH (Melanocyte Inhibiting Hormone) (7) PIH (Prolactin Inhibiting Hormone)

Hormones of the Anterior Pituitary

(1) TSH (Thyroid Stimulating Hormone) (2) ACTH (Adrenocorticotropic hormone) (3) LH (Leutinizing hormone) (4) FSH (Follicle Stimulating Hormone) (5) GH (Growth hormone) (6) PRL (Prolactin)

Hormones of the Pancreas

insulin and glucagon

Endocrine system controls

metabolism Nutrition Elimination Temperature Fluid & Electrolyte Balance Growth Reproduction

T4 target range

4-12 mcg/dL

T3 target range

70-205 ng/dL

What does ADH do?

Facilitates reabsorption of water in nephron of kidney

A nurse is planning care for a pt with Cushing's disease. The nurse should recognize that this client is at increased risk for which of the following? (Select all that apply) (a) Infection (b) Gastric ulcers (c) Renal calculi (d) Bone fractures (e) Dysphagia

A,B,D

A nurse is caring for a client who has SIADH. Which of the following findings should the nurse expect? (Select all that apply) (a) Decreased serum sodium (b) Urine specific gravity of 1.001 (c) Serum osmolarity of 230 (d) Polyuria (e) Increased thirst

A, C

A nurse is reviewing a health record of a client who has SIADH. Which of the following lab findings should the nurse expect? (Select all that apply) (a) Low sodium (b) High potassium (c) Increased urine osmolarity (d) High urine sodium (e) Increased urine specific gravity

A, C, D, E

A nurse in an ICU is planning care for a client who has myxedema coma. Which of the following actions should the nurse include? (Select all that apply) (a) Observe cardia monitor for dysrhythmias (b) Observe for UTI (c) Initiate IV with 0.9% NS (d) Administer IV bolus of levothyroxine (e) Provide warmth using a heating pad

A,B,C,D

A nurse is reviewing lab results on a client who has Addison's disease. Which of the following lab results should the nurse expect? (Select all that apply) (a) Sodium 130 (b) Potassium 6.1 (c) Calcium 11.6 (d) BUN 28 (e) Fasting blood glucose 148

A,B,C,D

A nurse is reviewing the lab finding of a client with Cushing's disease. Which of the following findings should the nurse expect? (Select all that apply) (a) Sodium 150 (b) Potassium 3.3 (c) Calcium 8 (d) Lymphocytes 35% (e) Fasting glucose 145

A,B,C,E

A nurse in a providers office is planning care for a client who has Graves' disease and a new prescription for methimazole. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) (a) Monitor CBC (b) Monitor T3 (triiodothyronine) (c) Instruct the client to increase consumption of shellfish (d) Advise the client to take the meds at the same time each day (e) Inform the client that an adverse effect of this med is iodine toxicity

A,B,D

25. A client is brought to the emergency department via rescue squad in acute adrenal crisis. Which action by the nurse is the priority? a. Start an IV line if the client does not already have one. b. Administer hydrocortisone sodium succinate (Solu-Cortef). c. Instruct the nursing assistant to check the client's blood glucose. d. Administer 20 units of insulin and 20 mg of dextrose in normal saline.

ANS: A All actions are appropriate for the client with adrenal crisis. However, therapy is given IV, so the priority is to establish IV access. Solu-Cortef is the drug of choice. Blood glucose is monitored hourly and treatment is provided as needed. Insulin and dextrose are used to treat any hyperkalemia.

5. When performing personal care on a middle-aged woman, the nurse observes that the client has very little pubic and axillary hair. Which is the nurse's best action? a. Ask the client if she has less pubic hair now than 5 years ago. b. Ask the client the date of her last menstrual period. c. Examine the client's scalp hair for texture and thickness. d. Draw blood for hormonal immune assays.

ANS: A Although pubic hair thickness varies from person to person, loss of pubic hair is associated with gonadotropin deficiency. The nurse needs to determine whether this manifestation is normal for this client. A middle-aged woman may be postmenopausal, which would not give the nurse helpful information. Examining the client's scalp also would not yield helpful information. Diagnostic studies should not be undertaken without further assessment.

21. The client has chronic hypercortisolism. Which intervention is the highest priority for the nurse? a. Wash the hands when entering the room. b. Keep the client in protective isolation. c. Observe the client for increased white blood cell counts. d. Assess the daily chest x-ray.

ANS: A Excess cortisol reduces the number of circulating lymphocytes, inhibits maturation of macrophages, reduces antibody synthesis, and inhibits production of cytokines and inflammatory chemicals. As a result, these clients are at greater risk of infection and may not have the expected inflammatory manifestations when an infection is present. The nurse needs to take precautions to decrease the client's risk. It is not necessary to keep the client in isolation. The client does not need a daily chest x-ray.

26. A female client has a decrease in all pituitary hormones. Which assessment question by the nurse elicits the best information? a. "Do you have any biological children?" b. "Do you have a decreased sex drive?" c. "Have you noticed increased facial hair?" d. "Are you more intolerant of heat?"

ANS: A Hypofunction of all anterior pituitary hormones is often caused by postpartum hemorrhage of the anterior pituitary gland. This usually occurs immediately after delivery but may be delayed for several years. Asking the client if she has children of her own would let the nurse know of this possibility. The other questions are assessments for specific hormone dysfunction.

20. The new nurse is assessing a client with suspected pheochromocytoma. Which action by the nurse requires the precepting nurse to intervene? a. Auscultating, palpating, and percussing the client's abdomen b. Taking the client's blood pressure for reports of chest pain c. Assessing the client's diet for red wine and aged cheeses d. Limiting visitors while the client is sleeping

ANS: A Pheochromocytomas are found on the adrenal glands or in the abdomen. Palpation of a pheochromocytoma can cause intense release of catecholamines and can precipitate a hypertensive crisis. The experienced nurse should intervene if the new nurse attempts this. The other actions would be appropriate.

19. A client with hyperaldosteronism is being treated with spironolactone (Aldactone) before surgery. Which precautions does the nurse teach this client? a. "Read the label before using salt substitutes." b. "Do not add salt to your food when you eat." c. "Avoid exposure to sunlight." d. "Take Tylenol instead of aspirin for pain."

ANS: A Spironolactone is a potassium-sparing diuretic used to control potassium levels. Its use can lead to hyperkalemia. Although the goal is to increase the client's potassium, unknowingly adding potassium can cause complications. Some salt substitutes are composed of potassium chloride and should be avoided by clients on spironolactone therapy. Depending on the client, he or she may benefit from a low-sodium diet before surgery, but this may not be necessary. Avoiding sunlight and Tylenol is not necessary.

2. Which conditions may cause hypopituitarism? (Select all that apply.) a. Benign pituitary tumors b. Diplopia c. Anorexia nervosa d. Hypotension e. Shock f. Weight gain

ANS: A, C, D, E These four conditions can cause hypopituitarism. The other options are not causes of hypopituitarism.

1. Which physical characteristics are indicative of anterior pituitary hyperfunction? (Select all that apply.) a. Protrusion of the lower jaw b. High-pitched voice c. Enlarged hands and feet d. Kyphosis e. Barrel-shaped chest f. Excessive sweating

ANS: A, C, D, E, F Anterior pituitary hyperfunction typically will cause protrusion of the lower jaw, deepening of the voice, enlarged hands and feet, kyphosis, barrel-shaped chest, and excessive sweating.

3. Which serum laboratory values alert the nurse to the possibility of hyperaldosteronism? (Select all that apply.) a. Sodium, 150 mEq/L b. Sodium, 130 mEq/L c. Potassium, 2.5 mEq/L d. Potassium, 5.0 mEq/L e. pH, 7.28 f. pH, 7.50

ANS: A, C, E Aldosterone increases reabsorption of sodium and excretion of potassium. Hyperaldosteronism causes hypernatremia, hypokalemia, and metabolic alkalosis. The other values are not indicative of hyperaldosteronism.

10. A client is going home after an endoscopic transnasal hypophysectomy. Which statement by the client indicates an adequate understanding of discharge instructions? a. "I will wear dark glasses whenever I am outdoors." b. "I will keep food on upper shelves so I do not have to bend over." c. "I will wash the incision line every day with peroxide and redress it immediately." d. "I will remember to cough and deep breathe every 2 hours while I am awake."

ANS: B After this surgery, the client must take care to avoid activities that can increase intracranial pressure. The client should avoid bending from the waist and should not bear down, cough, or lie flat. With this approach, there is no incision to clean and dress.

22. A female client is beginning treatment with bromocriptine (Parlodel). The nurse has initiated teaching sessions about potential side effects. Which is the most important point of instruction? a. "Take and record your temperature daily." b. "Be sure to eat 20 to 30 grams of fiber daily." c. "Plan to take the medication on an empty stomach." d. "I will need to teach you how to give the injection."

ANS: B Constipation is an expected side effect of treatment with bromocriptine, so the client should be taught ways to prevent and/or manage it. Eating plenty of fiber and drinking fluids is a good plan. Taking the client's temperature daily is not necessary. The medication, which is given orally, should be taken with food to reduce side effects.

2. An adult client has been diagnosed with a deficiency of gonadotropin and growth hormone. Which fact reported in the client's history could have contributed to this problem? a. Mother with adult-onset diabetes mellitus b. Experienced head trauma 5 years ago c. Severe allergy to shellfish and iodine d. Has used oral contraceptives for 5 years

ANS: B Gonadotropin and growth hormone are anterior pituitary hormones. Head trauma is a common cause of anterior pituitary hypofunction. The other factors do not increase the risk of this condition.

17. The client with adrenal hyperfunction screams at her husband, bursts into tears, and throws her water pitcher against the wall. She then tells the nurse, "I feel like I am going crazy." Which is the nurse's best response? a. "I will ask your doctor to order a psychiatric consult for you." b. "You feel this way because of your hormone levels." c. "Can I bring you information about support groups?" d. "I will close the door to your room and restrict visitors."

ANS: B Hypercortisolism can cause the client to show neurotic or psychotic behavior. The client needs to know that these behavior changes do not reflect a true psychiatric disorder and will resolve when therapy results in lower and steadier blood cortisol levels. The client needs to understand this effect and does not need a psychiatrist, support groups, or restricted visitors at this time.

14. A client who has been taking high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition, which has now resolved, asks the nurse why she needs to continue taking corticosteroids. Which is the nurse's best response? a. "It is possible for the inflammation to recur if you stop the drugs." b. "Once you start corticosteroids, you have to be weaned off them." c. "You must decrease the dose slowly so your hormones will begin to work again." d. "The drug suppresses your immune system, which needs to be built back up."

ANS: B One of the most common causes of adrenal insufficiency, a life-threatening problem, is the sudden cessation of long-term, high-dose corticosteroid therapy. This therapy suppresses the hypothalamic-pituitary-adrenal axis and must be withdrawn gradually to allow for pituitary production of adrenocorticotropic hormone (ACTH) and adrenal production of cortisol.

24. A client has cortisol deficiency and is being treated with prednisone (Deltasone). Which instruction by the nurse is most appropriate? a. "You will need to learn how to rotate the injection sites." b. "If you work outside when it's hot, you may need another drug." c. "Be sure to stay on your salt restriction even though it's difficult." d. "Take one tablet in the morning and two tablets at night to start."

ANS: B Steroid dosage adjustment may be needed and might be difficult, especially in hot weather, when the client is sweating a great deal more than normal. Clients take prednisone orally, have no need for a salt restriction, and usually start the regimen with two tablets in the morning and one at night.

4. The male client with hypopituitarism asks the nurse how long he will have to take testosterone hormone replacement therapy. Which is the nurse's best answer? a. "When your blood levels of testosterone are normal, the therapy is no longer needed." b. "When your beard thickens and your voice deepens, the dose is decreased, but treatment will continue forever." c. "When your sperm count is high enough to demonstrate fertility, you will no longer need this therapy." d. "When you start to have undesirable side effects, the dose is decreased to the lowest possible level, and treatment is continued until you are 50 years old."

ANS: B Testosterone therapy is initiated with high-dose testosterone derivatives and is continued until virilization is achieved. The dose is then decreased, but therapy continues throughout life.

13. Which dietary alterations does the nurse make for a client with Cushing's disease? a. High carbohydrate, low potassium b. Low carbohydrate, low sodium c. Low protein, low calcium d. High carbohydrate, low potassium

ANS: B The client with Cushing's disease has weight gain, muscle loss, hyperglycemia, and sodium retention. Dietary modifications need to include reduction of total calories and carbohydrates to prevent or reduce the degree of hyperglycemia. Sodium retention causes water retention and hypertension. Clients are encouraged to restrict their sodium intake moderately. Clients often have bone density loss and need more calcium.

11. A client with suspected syndrome of inappropriate antidiuretic hormone (SIADH) has a serum sodium of 114 mEq/L. Which action by the nurse is best? a. Consult with the registered dietitian about increased dietary sodium. b. Restrict the client's fluid intake to 900 mL/24 hr. c. Handle the client gently by using turn sheets for repositioning. d. Instruct the nursing assistants to measure intake and output.

ANS: B With SIADH, clients often have dilutional hyponatremia. The client needs a fluid restriction, sometimes to as little as 500 to 600 mL/24 hr. The client should be on intake and output (I&O); however, this will monitor only the client's intake, so it is not the best answer. Reducing intake will help increase the client's sodium. Adding sodium to the client's diet will not help if he or she is retaining fluid and diluting the sodium. The client is not at increased risk for fracture, so gentle handling is not an issue.

1. A client has a hormone deficiency. Which deficiency is the highest priority? a. Growth hormone b. Luteinizing hormone c. Thyroid-stimulating hormone d. Follicle-stimulating hormone

ANS: C A deficiency of thyroid-stimulating hormone (TSH) is the most life-threatening deficiency of the hormones listed in this question. TSH is needed to ensure proper synthesis and secretion of the thyroid hormones, whose functions are essential for life.

23. The nurse is caring for a client who has undergone a hypophysectomy. Which is the nurse's priority postoperative intervention? a. Keep the head of the bed flat and the client supine. b. Instruct the client to cough, turn, and deep breathe hourly. c. Report clear or yellow drainage from the nose or incision site. d. Apply petroleum jelly to the client's lips to avoid mouth dryness.

ANS: C A light yellow drainage or a halo effect on the dressing is indicative of a cerebrospinal leak. The client should have the head of the bed elevated after surgery. Although deep breathing is important postoperatively, coughing should be avoided to prevent cerebrospinal leakage. Although application of petroleum jelly to the lips will help with mouth dryness, this instruction is not as important as reporting the yellowish drainage.

8. A client just diagnosed with acromegaly is scheduled for a hypophysectomy. Which statement made by the client indicates a need for clarification regarding this treatment? a. "I will drink whenever I feel thirsty after surgery." b. "I'm glad no visible incision will result 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."

ANS: C Although removal of the tissue that is oversecreting hormones can relieve many symptoms of hyperpituitarism, skeletal changes and organ enlargement are not reversible. It will be appropriate for the client to drink as needed postoperatively and avoid bending over, reassured that the incision will not be visible.

7. A client has documented acromegaly. During a physical assessment before surgery for a knee replacement, the nurse discovers that she has a moderately enlarged liver. Which is the nurse's best action? a. Counsel the client on the health risks of alcoholism. b. Assess for jaundice of the skin and eyes. c. Document the finding and monitor the client. d. Draw blood for liver function studies.

ANS: C Clients with acromegaly or gigantism commonly have organomegaly of the heart and liver. Other than documenting the finding and monitoring the client, these actions would be inappropriate because the finding is commonly associated with acromegaly.

12. Which safety measure is most important for the nurse to institute for a client who has Cushing's disease? a. Pad the siderails of the client's bed. b. Assist the client to change positions slowly. c. Use a lift sheet to change the client's position. d. Keep suctioning equipment at the client's bedside.

ANS: C Cushing's syndrome or disease greatly increases the serum levels of cortisol, which contributes to excessive bone demineralization and increases the risk for pathologic bone fracture. The client should not require suctioning. Padding the siderails and assisting the client to change position may be effective, but these measures will not protect him or her as much as using a lift sheet.

15. A client has received vasopressin (DDAVP) for diabetes insipidus. Which assessment finding indicates a therapeutic response to this therapy? a. Urine output is increased; specific gravity is increased. b. Urine output is increased; specific gravity is decreased. c. Urine output is decreased; specific gravity is increased. d. Urine output is decreased; specific gravity is decreased.

ANS: C Diabetes insipidus causes urine output to be greatly increased, with a low urine osmolarity, as evidenced by a low specific gravity. Effective treatment results in decreased urine output that is more concentrated, as evidenced by an increased specific gravity.

3. Which safety measure does the nurse use for the adult client who has growth hormone deficiency? a. Avoid intramuscular medications. b. Place the client in protective isolation. c. Use a lift sheet to reposition the client. d. Assist the client to change positions slowly.

ANS: C In adults, growth hormone is necessary to maintain bone density and strength. Adults with growth hormone deficiency have thin, fragile bones. Avoiding IM medications, using protective isolation, and assisting the client as he or she moves from sitting to standing will not serve as safety measures when the client is deficient in growth hormone.

9. A client who had a trans-sphenoidal hypophysectomy 2 days ago now has nuchal rigidity. Which is the nurse's priority action? a. Have the client do active range-of-motion exercises for the neck. b. Document the finding and monitor the client. c. Take the client's temperature and other vital signs. d. Assess using a pain scale and administer pain medication.

ANS: C Nuchal rigidity is a major manifestation of meningitis, a potential postoperative complication associated with this surgery. Meningitis is an infection; usually the client will also have a fever and tachycardia. Range-of-motion exercises are inappropriate because meningitis is a possibility. Although pain medication may be a palliative measure, it is not the most appropriate initial action. Documentation should be done after all assessments are completed and should not be the only action.

18. A client on medication after a bilateral adrenalectomy calls the clinic asking to be seen for "stomach flu" with nausea and vomiting. Which response by the nurse is best? a. "I will call in a prescription for an antiemetic medication for you." b. "Try to drink extra fluids until you can come in for an appointment." c. "You need to go to the nearest emergency department today." d. "Double the dose of your medication today and tomorrow."

ANS: C The client with bilateral adrenalectomy is on lifelong cortisol replacement therapy. The client cannot skip any doses of his or her medication. If the client has nausea and vomiting for longer than 24 hours and cannot give himself or herself an injection of hydrocortisone, the client must go to the nearest emergency department to get it. The other answers are inappropriate.

16. A client with hypercortisolism has an irregular pulse. Which is the nurse's priority intervention? a. Documenting the finding and reassessing in 1 hour b. Assessing blood pressure in both arms c. Administering atropine sulfate d. Assessing the telemetry reading

ANS: D Hypercortisolism causes potassium imbalances, which can lead to fatal dysrhythmias. With an irregular pulse, the nurse should assess the client's cardiac rhythm. The finding should be documented, but the nurse cannot wait an hour to take further action. Assessing bilateral blood pressures will not provide useful information. No indications for atropine are known.

6. A client thought to have a problem with the pituitary gland is given a stimulation test using insulin. A short time later, blood analysis reveals elevated levels of growth hormone (GH) and adrenocorticotropic hormone (ACTH). Which is the nurse's interpretation of this finding? a. Pituitary hypofunction b. Pituitary hyperfunction c. Pituitary-induced diabetes mellitus d. A normal pituitary response to insulin

ANS: D Some tests for pituitary function involve administering agents that are known to stimulate the secretion of specific pituitary hormones and then measuring the response. Such tests are termed stimulation tests. For example, the presence of insulin in those with normal pituitary function causes increased release of GH and ACTH. The stimulation test for GH or ACTH assessment involves injecting the client with regular insulin (0.05 to 1 U/kg of body weight) and checking circulating levels of GH and ACTH.

Hormones of the Adrenal Cortex

Aldosterone (mineralcorticoids) Cortisol (glucocorticoids) sex hormones

Which problems does the nurse expect in an older adult as a result of age-related changes in endocrine function? (Select all that apply) (a) Increased BMR (basal metabolic rate) (b) Decreased core body temp (c) Dehydration (d) Diarrhea (e) Hyperglycemia (f) Polyuria

B, C, E, F

A nurse is providing med teaching for a client who has Addison's disease and is taking hydrocortisone. Which of the following instructions should the nurse include? (Select all that apply) (a) Take med on an empty stomach (b) Notify provider of any illness or stress (c) Report any weakness or dizziness (d) Do not discontinue medication suddenly (e) Eat a low sodium diet

B,C,D

A nurse is reinforcing teaching with a client who has a new prescription for levothyroxine to tx hypothyroidism. Which of the following information should the nurse include in the teaching? (Select all that apply) (a) Weight gain is expected with this drug (b) Med should not be discontinued w/o advice of provider (c) F/U serum TSH levels should be drawn (d) Take the med on an empty stomach (e) Use fiber laxatives for constipation

B,C,D

A nurse in an acute care facility is admitting a client who has acute adrenal insufficiency. Which of the following prescriptions should the nurse anticipate? (Select all that apply) (a) IV therapy with 0.45% sodium chloride (b) Regular insulin (c) Hydrocortisone sodium succinate (d) Sodium polystyrene sulfonate (e) Furosemide

B,C,D,E

A nurse is collecting an admissions history from a female client who has hypothyroidism. Which of the following findings should the nurse expect? (Select all that apply) (a) Diarrhea (b) Menorrhagia (c) Dry skin (d) Increased libido (e) Hoarseness

B,C,E

A nurse is reviewing manifestations of hyperthyroidism with a client. Which of the following findings should the nurse include? (Select all that apply) (a) Anorexia (b) Heat intolerance (c) Constipation (d) Palpitations (e) Weight loss (f) Bradycardia

B,D,E

Tests that identify SIADH

serum and/or urine electrolyte and osmolality (285-295 mOsm/kg) urine specific gravity (1.002-1.03)

A nurse is providing discharge teaching for a client who had a transsphenoidal hypophysectomy. Which of the following instructions should the nurse include? (Select all that apply) (a) Brush teeth after every meal/snack (b) Avoid bending at the knees (c) eat a high fiber diet (d) Notify provider of sweet-tasting drainage (e) Notify provider of diminished sense of smell

C,D

A nurse is assessing a client who is 12 hr post-op thyroidectomy. The nurse should identify which of the following findings as indicative of thyroid crisis? (Select all that apply) (a) Bradycardia (b) Hypothermia (c) Dyspnea (d) Abdominal pain (e) Mental confusion

C,D,E

Water Deprivation Test

For clients with diabetes insipidus, if kidneys are unable to concentrate urine- positive test

Major endocrine glands

Hypothalamus Pituitary Gland Adrenal Gland Thyroid Gland Islet cells of the pancreas Parathyroid Gland Gonads

Hormones of Parathyroid

PH (Parathyroid Hormone)

function of posterior pituitary

stores and releases ADH (vasopressin/antidiuretic hormone) and oxytocin

Why is Aspirin contraindicated for fever reduction during Thyroid storm/crisis?

Salicylates release thyroxine from protein-binding sites therefore increasing thyroxine levels even more

Best indicator for hyperthyroidism

T3 level elevated

Three cell types of the islets of the pancreas

alpha - secrete glucose beta - secrete insulin delta - secrete somatostatin

what happens if there is not enough ADH?

causes DI (diabetes insipidus) therefore drink a lot pee a lot diluted urine (low specific gravity = under 1.002) low BP (not enough vasopressin = vasodilation)

what happens if there is too much ADH?

causes SIADH (*S*yndrome of *I*nappropriate *ADH*) therefore fluid retention edema concentrated urine (high specific gravity = over 1.03) high BP (too much vasopressin = vasoconstriction)

Hormones of the Ovaries

estrogen and progesterone