Lacharity: Chapter 14: Endocrine

12. You are providing care for a patient who underwent thyroidectomy 2 days ago. Which laboratory value requires close monitoring by a nurse? 1. Calcium level 2. Sodium level 3. Potassium level 4. White blood cell count

Ans: 1 Calcium level The parathyroid glands are located on the back of the thyroid gland. The parathyroids are important in maintaining calcium and phosphorus balance. The nurse should be attentive to all patient laboratory values, but calcium and phosphorus levels are important to monitor after thyroidectomy because abnormal values could be the result of removal of the parathyroid glands during the procedure. Focus: Prioritization

15. When providing care for a patient with Addison disease, you should be alert for which laboratory value change? 1. Decreased hematocrit 2. Increased sodium level 3. Decreased potassium level 4. Decreased calcium level

Ans: 1 Decreased hematocrit A patient with Addison disease is at risk for anemia. The nurse should expect this patient's sodium level to decrease, and potassium and calcium levels to increase. Focus: Prioritization

9. A patient with adrenal insufficiency is to be discharged and will take prednisone (Deltasone) 10 mg orally each day. Which instruction would you be sure to teach the patient? 1. Excessive weight gain or swelling should be reported to the physician. 2. Changing positions rapidly may cause hypotension. 3. A diet with foods low in sodium may be beneficial. 4. Signs of hypoglycemia may occur while taking this drug.

Ans: 1 Excessive weight gain or swelling should be reported to the physician. Rapid weight gain and edema are signs of excessive drug therapy, and the dosage of the drug would need to be adjusted. Hypertension, hyponatremia, hyperkalemia, and hyperglycemia are common in patients with adrenal hypofunction. Focus: Prioritization

16. A female patient is admitted with a diagnosis of primary hypofunction of the adrenal glands. Which assessment finding supports this diagnosis? 1. Patchy areas of pigment loss over the face 2. Decreased muscle strength 3. Greatly increased urine output 4. Scalp alopecia

Ans: 1 Patchy areas of pigment loss over the face Vitiligo, or patchy areas of pigment loss with increased pigmentation at the edges, is seen with primary hypofunction of the adrenal glands and is caused by autoimmune destruction of melanocytes in the skin. The other findings are signs of pituitary hypofunction. Focus: Prioritization

10. You are caring for a patient who has just undergone hypophysectomy for hyperpituitarism. Which postoperative finding requires immediate intervention? 1. Presence of glucose in the nasal drainage 2. Presence of nasal packing in the nares 3. Urine output of 40 to 50 mL/hr 4. Patient reports of thirst

Ans: 1 Presence of glucose in the nasal drainage The presence of glucose in nasal drainage indicates that the fluid is cerebrospinal fluid (CSF) and suggests a CSF leak. Packing is normally inserted in the nares after the surgical incision is closed. Urine output of 40 to 50 mL/hr is adequate, and patients may experience thirst postoperatively. When patients are thirsty, nursing staff should encourage fluid intake. Focus: Prioritization

2. Which change in vital signs would you instruct the UAP to report immediately for a patient with hyperthyroidism? 1. Rapid heart rate 2. Decreased systolic blood pressure 3. Increased respiratory rate 4. Decreased oral temperature

Ans: 1 Rapid heart rate The cardiac problems associated with hyperthyroidism include tachycardia, increased systolic blood pressure, and decreased diastolic blood pressure. Patients with hyperthyroidism also may have increased body temperature related to increased metabolic rate. Respiratory changes are usually not symptomatic of this condition. Focus: Delegation, supervision

5. A patient is hospitalized with adrenocortical insufficiency. Which nursing activity should you delegate to a UAP? 1. Reminding the patient to change positions slowly 2. Assessing the patient for muscle weakness 3. Teaching the patient how to collect a 24-hour urine sample 4. Revising the patient's nursing plan of care

Ans: 1 Reminding the patient to change positions slowly Patients with hypofunction of the adrenal gland often have hypotension and should be instructed to change positions slowly. Once a patient has been so instructed, it is appropriate for the UAP to remind the patient of those instructions. Assessing, teaching, and planning nursing care require more education and should be done by licensed nurses. Focus: Delegation, supervision

24. You are caring for a patient with hyperthyroidism who had a partial thyroidectomy yesterday. Which change in assessment would you report to the health care provider immediately? 1. Temperature elevation to 100.2° F 2. Heart rate increase from 64 beats/min to 76 beats/min 3. Respiratory rate decrease from 26 breaths/min to 16 breaths/min 4. Pulse oximetry reading of 92%

Ans: 1 Temperature elevation to 100.2° F When caring for a patient with hyperthyroidism, even after a partial thyroidectomy, a temperature elevation of 1° must be reported immediately because it may indicate an impending thyroid crisis. The other changes should be monitored, but none is urgent. Focus: Prioritization

20. Which health care provider orders for the patient with Addison disease should you delegate to the experienced UAP? (Select all that apply.) 1. Weigh the patient every morning. 2. Obtain fingerstick glucose before each meal and at bedtime. 3. Check vital signs every 2 hours. 4. Monitor for cardiac dysrhythmias. 5. Administer oral prednisone 10 mg every morning. 6. Record intake and output.

Ans: 1, 2, 3, 6 1. Weigh the patient every morning. 2. Obtain fingerstick glucose before each meal and at bedtime. 3. Check vital signs every 2 hours. 6. Record intake and output. Weighing patients, recording intake and output, and checking vital signs are all within the scope of practice for a UAP. An experienced UAP would have been trained to perform fingerstick glucose monitoring also. Administering medications and monitoring for cardiac dysrhythmias are within the scope of practice of licensed nurses. Focus: Delegation

14. You are preparing a care plan for a patient with Cushing disease. Which nursing diagnoses would you be sure to include? (Select all that apply.) 1. Risk for Injury related to the potential for bruising 2. Disturbed Body Image 3. Imbalanced Nutrition: Less than Body Requirements 4. Risk for Injury related to the potential for hypertension 5. Risk for Infection

Ans: 1, 2, 4, 5 1. Risk for Injury related to the potential for bruising 2. Disturbed Body Image 4. Risk for Injury related to the potential for hypertension 5. Risk for Infection A patient with Cushing disease experiences body changes affecting body image and is at risk for bruising, infection, and hypertension. Such a patient usually gains weight. Focus: Prioritization

23. Which actions should you delegate to the LPN/LVN for the care of a patient with hypothyroidism? (Select all that apply.) 1. Assessing and recording the rate and depth of respirations 2. Auscultating lung sounds every 4 hours 3. Creating an individualized nursing care plan for the patient 4. Administering sedation medications every 6 hours 5. Checking blood pressure, heart rate, and respirations every 4 hours 6. Reminding the patient to report any episodes of chest pain or discomfort

Ans: 1, 2, 6 1. Assessing and recording the rate and depth of respirations 2. Auscultating lung sounds every 4 hours 6. Reminding the patient to report any episodes of chest pain or discomfort Assessment, auscultation, and reminding patients about information that has been taught to them are within the scope of practice of the LPN/LVN. Certainly the LPN/LVN could check the patient's vital signs, but this would be more appropriately delegated to the UAP. Creating nursing care plans falls within the scope of practice of the RN. The use of sedation is discouraged for patients with hypothyroidism because it may make respiratory problems more difficult. If sedation is used, dosage is reduced and it is not given around the clock. Focus: Delegation, supervision

21. The LPN/LVN asks you why the patient with Cushing disease has bruising and petechiae across her abdomen. What is your best response? 1. "Patients with Cushing disease often have bleeding disorders." 2. "Patients with Cushing disease have very fragile capillaries." 3. "Please ask the patient if she slipped or fell during the night." 4. "Thin and delicate skin can result in development of bruising."

Ans: 2 "Patients with Cushing disease have very fragile capillaries." A key cardiovascular feature seen in patients with Cushing disease is capillary fragility, which results in bruising and petechiae. Bleeding disorders are not a sign of Cushing disease, and although these patients have delicate skin, this is not the cause of the bruising. You may want to investigate whether the patient fell, but these patients have bruising and petechiae despite falls. Focus: Supervision, prioritization

11. Which patients should you, as the charge nurse, assign to the care of an LPN/LVN, under the supervision of the RN team leader? 1. 51-year-old who has just undergone bilateral adrenalectomy 2. 83-year-old with type 2 diabetes and chronic obstructive pulmonary disease 3. 38-year-old with myocardial infarction preparing for discharge 4. 72-year-old with mental status changes admitted from a long-term care facility

Ans: 2 83-year-old with type 2 diabetes and chronic obstructive pulmonary disease The 83-year-old has no complicating factors at the moment. Providing care for patients in stable and uncomplicated condition falls within the LPN/LVN's educational preparation and scope of practice, with the care always being provided under the supervision and direction of an RN. The nurse should assess the patient who has just undergone surgery and the newly-admitted patient. The patient who is preparing for discharge after myocardial infarction may need some complex teaching. Focus: Delegation, supervision, assignment

18. Two UAPs are assisting a patient with Cushing disease to move up in bed. Which action by the UAPs requires your immediate intervention? 1. Positioning themselves on opposite sides of the patient's bed 2. Grasping under the patient's arms to pull him up in bed 3. Lowering the side rails of the patient's bed before moving him 4. Removing the pillow before moving the patient up in bed

Ans: 2 Grasping under the patient's arms to pull him up in bed The patient with Cushing disease usually has paper-thin skin that is easily injured. The UAPs should use a lift or a draw sheet to carefully move the patient and prevent injury to the skin. All of the other actions are appropriate to moving this patient up in bed. Focus: Delegation, supervision

25. You admit a patient whose assessment reveals prominent brow ridge, large hands and feet, and large lips and nose. Which pituitary hormone do you suspect is elevated? 1. Thyroid-stimulating hormone 2. Growth hormone 3. Adrenocorticotropic hormone 4. Vasopressin antidiuretic hormone

Ans: 2 Growth hormone These assessment findings are classic initial manifestations for growth hormone excess. Focus: Prioritization

3. For a patient with hyperthyroidism, which task will you delegate to an experienced UAP? 1. Instructing the patient to report any occurrence of palpitations, dyspnea, vertigo, or chest pain 2. Monitoring the apical pulse, blood pressure, and temperature every 4 hours 3. Drawing blood to measure levels of thyroid-stimulating hormone, triiodothyronine, and thyroxine 4. Teaching the patient about side effects of the drug propylthiouracil

Ans: 2 Monitoring the apical pulse, blood pressure, and temperature every 4 hours Monitoring vital signs and recording their values are within the education and scope of practice of UAPs. An experienced UAP should have been taught how to monitor the apical pulse. However, a nurse should observe the UAP to be sure that the UAP has mastered this skill. Instructing and teaching patients, as well as performing venipuncture to obtain laboratory samples, are more suited to the education and scope of practice of licensed nurses. In some facilities, an experienced UAP may perform venipuncture, but only after special training. Focus: Delegation, supervision, assignment

8. For the patient with pheochromocytoma, which physical assessment technique should you instruct an LPN/LVN to avoid? 1. Listening for abdominal bowel sounds in all four quadrants 2. Palpating the abdomen in all four quadrants 3. Checking the blood pressure every hour 4. Assessing the mucous membranes for hydration status

Ans: 2 Palpating the abdomen in all four quadrants Palpating the abdomen can cause the sudden release of catecholamines and severe hypertension. Focus: Delegation, supervision

22. The patient with hyperparathyroidism who is not a candidate for surgery asks you why she is receiving IV normal saline and IV furosemide. What is your best response? 1. "This therapy is to protect your kidney function." 2. "You are receiving these therapies to prevent edema formation." 3. "Diuretic and hydration therapies are used to reduce your serum calcium." 4. "These therapies may help to improve your candidacy for surgery."

Ans: 3 "Diuretic and hydration therapies are used to reduce your serum calcium." Diuretics and hydration help reduce serum calcium for patients who are not surgery candidates. Furosemide increases kidney excretion of calcium when combined with IV saline in large volumes. Focus: Prioritization

4. As the shift begins, you are assigned to care for the following patients. Which patient should you assess first? 1. 38-year-old with Graves disease and a heart rate of 94 beats/min 2. 63-year-old with type 2 diabetes and fingerstick glucose level of 137 mg/dL 3. 58-year-old with hypothyroidism and a heart rate of 48 beats/min 4. 49-year-old with Cushing disease and dependent edema rated as 1+

Ans: 3 58-year-old with hypothyroidism and a heart rate of 48 beats/min Although patients with hypothyroidism often have cardiac problems that include bradycardia, a heart rate of 48 beats/min may have significant implications for cardiac output and hemodynamic stability. Patients with Graves disease usually have a rapid heart rate, but 94 beats/min is within normal limits. The diabetic patient may need sliding-scale insulin dosing. This is important but not urgent. Patients with Cushing disease frequently have dependent edema. Focus: Prioritization

19. You are caring for the following patients with endocrine disorders. Which one must you assess first? 1. 21-year-old with diabetes insipidus whose urine output overnight was 2000 mL 2. 55-year-old with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who is demanding that the UAP refill his water pitcher 3. 65-year-old with Addison disease whose morning potassium level is 6.2 mEq/L 4. 48-year-old with Cushing disease with a weight gain of 1.5 lb over the past 4 days

Ans: 3 65-year-old with Addison disease whose morning potassium level is 6.2 mEq/L This patient's potassium level is very high, placing the patient at risk for cardiac dysrhythmias that could be life threatening. The other patients need to be seen also, but are not as urgent as this patient. Focus: Prioritization

1. A patient is admitted to the medical unit with possible Graves disease (hyperthyroidism). Which assessment finding supports this diagnosis? 1. Periorbital edema 2. Bradycardia 3. Exophthalmos 4. Hoarse voice

Ans: 3 Exophthalmos Exophthalmos (abnormal protrusion of the eyes) is characteristic of patients with hyperthyroidism due to Graves disease. Periorbital edema, bradycardia, and hoarse voice are all characteristics of patients with hypothyroidism. Focus: Prioritization

13. A 24-year-old patient with diabetes insipidus makes all of these statements when you are preparing the patient for discharge from the hospital. Which statement indicates to you that the patient needs additional teaching? 1. "I will drink fluids equal to the amount of my urine output." 2. "I will weigh myself every day using the same scale." 3. "I will wear my medical alert bracelet at all times." 4. "I will gradually wean myself off the vasopressin."

Ans: 4 "I will gradually wean myself off the vasopressin." A patient with permanent diabetes insipidus requires lifelong vasopressin therapy. All of the other statements are appropriate to the home care of this patient. Focus: Prioritization

17. You are instructing a senior nursing student on the techniques for palpation of the thyroid gland. What precaution would you be sure to include when instructing the student about thyroid palpation? 1. Always stand to the side of the patient. 2. Instruct the patient not to swallow. 3. Palpate using one hand and then the other. 4. Always palpate the thyroid gland gently.

Ans: 4 Always palpate the thyroid gland gently. The thyroid gland should always be palpated gently because vigorous palpation can stimulate a thyroid storm in a patient who may have hyperthyroidism. You should stand either behind or in front of the patient and use both hands to palpate the thyroid. Having the patient swallow can help with locating the thyroid gland. Focus: Supervision, delegation

6. Assessment findings for a patient with Cushing disease include all of the following. For which finding would you notify the physician immediately? 1. Purple striae present on the abdomen and thighs 2. Weight gain of 1 lb since the previous day 3. Dependent edema rated as 1+ in the ankles and calves 4. Crackles bilaterally in the lower lobes of the lungs

Ans: 4 Crackles bilaterally in the lower lobes of the lungs The presence of crackles in the patient's lungs indicate excess fluid volume due to excess water and sodium reabsorption and may be a symptom of pulmonary edema, which must be treated rapidly. Striae (stretch marks), weight gain, and dependent edema are common findings in patients with Cushing disease. These findings should be monitored but do not require urgent action. Focus: Prioritization

7. A patient with pheochromocytoma underwent surgery to remove his adrenal glands. Which nursing intervention should you delegate to a UAP? 1. Revising the nursing care plan to include strategies to provide a calm and restful environment postoperatively 2. Instructing the patient to avoid smoking and drinking caffeine-containing beverages 3. Assessing the patient's skin and mucous membranes for signs of adequate hydration 4. Monitoring lying and standing blood pressure every 4 hours with a cuff placed on the same arm

Ans: 4 Monitoring lying and standing blood pressure every 4 hours with a cuff placed on the same arm Monitoring vital signs is within the education and scope of practice for UAPs. The nurse should be sure to instruct the UAP that blood pressure measurements are to be taken with the cuff on the same arm each time. Revising the care plan and instructing and assessing patients are beyond the scope of UAPs and fall within the purview of licensed nurses. Focus: Assignment