Chapter 50: Nursing Management: Endocrine Problems Nursing School Test Banks

Chapter 50: Nursing Management: Endocrine Problems

Test Bank

MULTIPLE CHOICE

1. A 45-year-old male patient with suspected acromegaly is seen at the clinic. To assist in making the diagnosis, which question should the nurse ask?

a.

Have you had a recent head injury?

b.

Do you have to wear larger shoes now?

c.

Is there a family history of acromegaly?

d.

Are you experiencing tremors or anxiety?

ANS: B

Acromegaly causes an enlargement of the hands and feet. Head injury and family history are not risk factors for acromegaly. Tremors and anxiety are not clinical manifestations of acromegaly.

DIF: Cognitive Level: Apply (application) REF: 1190

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. A 42-year-old female patient is scheduled for transsphenoidal hypophysectomy to treat a pituitary adenoma. During preoperative teaching, the nurse instructs the patient about the need to

a.

cough and deep breathe every 2 hours postoperatively.

b.

remain on bed rest for the first 48 hours after the surgery.

c.

avoid brushing teeth for at least 10 days after the surgery.

d.

be positioned flat with sandbags at the head postoperatively.

ANS: C

To avoid disruption of the suture line, the patient should avoid brushing the teeth for 10 days after surgery. It is not necessary to remain on bed rest after this surgery. Coughing is discouraged because it may cause leakage of cerebrospinal fluid (CSF) from the suture line. The head of the bed should be elevated 30 degrees to reduce pressure on the sella turcica and decrease the risk for headaches.

DIF: Cognitive Level: Apply (application) REF: 1191

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

3. The nurse is planning postoperative care for a patient who is being admitted to the surgical unit form the recovery room after transsphenoidal resection of a pituitary tumor. Which nursing action should be included?

a.

Palpate extremities for edema.

b.

Measure urine volume every hour.

c.

Check hematocrit every 2 hours for 8 hours.

d.

Monitor continuous pulse oximetry for 24 hours.

ANS: B

After pituitary surgery, the patient is at risk for diabetes insipidus caused by cerebral edema. Monitoring of urine output and urine specific gravity is essential. Hemorrhage is not a common problem. There is no need to check the hematocrit hourly. The patient is at risk for dehydration, not volume overload. The patient is not at high risk for problems with oxygenation, and continuous pulse oximetry is not needed.

DIF: Cognitive Level: Apply (application) REF: 1191

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

4. The nurse is assessing a 41-year-old African American male patient diagnosed with a pituitary tumor causing panhypopituitarism. Assessment findings consistent with panhypopituitarism include

a.

high blood pressure.

b.

decreased facial hair.

c.

elevated blood glucose.

d.

tachycardia and cardiac palpitations.

ANS: B

Changes in male secondary sex characteristics such as decreased facial hair, testicular atrophy, diminished spermatogenesis, loss of libido, impotence, and decreased muscle mass are associated with decreases in follicle stimulating hormone (FSH) and luteinizing hormone (LH). Fasting hypoglycemia and hypotension occur in panhypopituitarism as a result of decreases in adrenocorticotropic hormone (ACTH) and cortisol. Bradycardia is likely due to the decrease in thyroid stimulating hormone (TSH) and thyroid hormones associated with panhypopituitarism.

DIF: Cognitive Level: Apply (application) REF: 1192

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

5. Which information will the nurse include when teaching a 50-year-old male patient about somatropin (Genotropin)?

a.

The medication will be needed for 3 to 6 months.

b.

Inject the medication subcutaneously every day.

c.

Blood glucose levels may decrease when taking the medication.

d.

Stop taking the medication if swelling of the hands or feet occurs.

ANS: B

Somatropin is injected subcutaneously on a daily basis, preferably in the evening. The patient will need to continue on somatropin for life. If swelling or other common adverse effects occur, the health care provider should be notified. Growth hormone will increase blood glucose levels.

DIF: Cognitive Level: Apply (application) REF: 1192

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

6. The nurse determines that demeclocycline (Declomycin) is effective for a patient with syndrome of inappropriate antidiuretic hormone (SIADH) based on finding that the patients

a.

weight has increased.

b.

urinary output is increased.

c.

peripheral edema is decreased.

d.

urine specific gravity is increased.

ANS: B

Demeclocycline blocks the action of antidiuretic hormone (ADH) on the renal tubules and increases urine output. An increase in weight or an increase in urine specific gravity indicates that the SIADH is not corrected. Peripheral edema does not occur with SIADH. A sudden weight gain without edema is a common clinical manifestation of this disorder.

DIF: Cognitive Level: Apply (application) REF: 1193-1194

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

7. The nurse determines that additional instruction is needed for a 60-year-old patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH) when the patient says which of the following?

a.

I need to shop for foods low in sodium and avoid adding salt to food.

b.

I should weigh myself daily and report any sudden weight loss or gain.

c.

I need to limit my fluid intake to no more than 1 quart of liquids a day.

d.

I will eat foods high in potassium because diuretics cause potassium loss.

ANS: A

Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be prescribed. The other patient statements are correct and indicate successful teaching has occurred.

DIF: Cognitive Level: Apply (application) REF: 1194

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

8. A 56-year-old patient who is disoriented and reports a headache and muscle cramps is hospitalized with possible syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would expect the initial laboratory results to include a(n)

a.

elevated hematocrit.

b.

decreased serum sodium.

c.

low urine specific gravity.

d.

increased serum chloride.

ANS: B

When water is retained, the serum sodium level will drop below normal, causing the clinical manifestations reported by the patient. The hematocrit will decrease because of the dilution caused by water retention. Urine will be more concentrated with a higher specific gravity. The serum chloride level will usually decrease along with the sodium level.

DIF: Cognitive Level: Understand (comprehension) REF: 1193

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

9. An expected nursing diagnosis for a 30-year-old patient admitted to the hospital with symptoms of diabetes insipidus is

a.

excess fluid volume related to intake greater than output.

b.

impaired gas exchange related to fluid retention in lungs.

c.

sleep pattern disturbance related to frequent waking to void.

d.

risk for impaired skin integrity related to generalized edema.

ANS: C

Nocturia occurs as a result of the polyuria caused by diabetes insipidus. Edema, excess fluid volume, and fluid retention are not expected.

DIF: Cognitive Level: Apply (application) REF: 1194

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

10. Which information will the nurse teach a 48-year-old patient who has been newly diagnosed with Graves disease?

a.

Exercise is contraindicated to avoid increasing metabolic rate.

b.

Restriction of iodine intake is needed to reduce thyroid activity.

c.

Antithyroid medications may take several months for full effect.

d.

Surgery will eventually be required to remove the thyroid gland.

ANS: C

Medications used to block the synthesis of thyroid hormones may take 2 to 3 months before the full effect is seen. Large doses of iodine are used to inhibit the synthesis of thyroid hormones. Exercise using large muscle groups is encouraged to decrease the irritability and hyperactivity associated with high levels of thyroid hormones. Radioactive iodine is the most common treatment for Graves disease although surgery may be used.

DIF: Cognitive Level: Apply (application) REF: 1199

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

11. A patient who had a subtotal thyroidectomy earlier today develops laryngeal stridor and a cramp in the right hand upon returning to the surgical nursing unit. Which collaborative action will the nurse anticipate next?

a.

Suction the patients airway.

b.

Administer IV calcium gluconate.

c.

Plan for emergency tracheostomy.

d.

Prepare for endotracheal intubation.

ANS: B

The patients clinical manifestations of stridor and cramping are consistent with tetany caused by hypocalcemia resulting from damage to the parathyroid glands during surgery. Endotracheal intubation or tracheostomy may be needed if the calcium does not resolve the stridor. Suctioning will not correct the stridor.

DIF: Cognitive Level: Apply (application) REF: 1201

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

12. Which nursing action will be included in the plan of care for a 55-year-old patient with Graves disease who has exophthalmos?

a.

Place cold packs on the eyes to relieve pain and swelling.

b.

Elevate the head of the patients bed to reduce periorbital fluid.

c.

Apply alternating eye patches to protect the corneas from irritation.

d.

Teach the patient to blink every few seconds to lubricate the corneas.

ANS: B

The patient should sit upright as much as possible to promote fluid drainage from the periorbital area. With exophthalmos, the patient is unable to close the eyes completely to blink. Lubrication of the eyes, rather than eye patches, will protect the eyes from developing corneal scarring. The swelling of the eye is not caused by excessive blood flow to the eye, so cold packs will not be helpful.

DIF: Cognitive Level: Apply (application) REF: 1200

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

13. A 62-year-old patient with hyperthyroidism is to be treated with radioactive iodine (RAI). The nurse instructs the patient

a.

about radioactive precautions to take with all body secretions.

b.

that symptoms of hyperthyroidism should be relieved in about a week.

c.

that symptoms of hypothyroidism may occur as the RAI therapy takes effect.

d.

to discontinue the antithyroid medications taken before the radioactive therapy.

ANS: C

There is a high incidence of postradiation hypothyroidism after RAI, and the patient should be monitored for symptoms of hypothyroidism. RAI has a delayed response, with the maximum effect not seen for 2 to 3 months, and the patient will continue to take antithyroid medications during this time. The therapeutic dose of radioactive iodine is low enough that no radiation safety precautions are needed.

DIF: Cognitive Level: Understand (comprehension) REF: 1199

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

14. Which nursing assessment of a 69-year-old patient is most important to make during initiation of thyroid replacement with levothyroxine (Synthroid)?

a.

Fluid balance

b.

Apical pulse rate

c.

Nutritional intake

d.

Orientation and alertness

ANS: B

In older patients, initiation of levothyroxine therapy can increase myocardial oxygen demand and cause angina or dysrhythmias. The medication also is expected to improve mental status and fluid balance and will increase metabolic rate and nutritional needs, but these changes will not result in potentially life-threatening complications.

DIF: Cognitive Level: Apply (application) REF: 1203

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

15. An 82-year-old patient in a long-term care facility has several medications prescribed. After the patient is newly diagnosed with hypothyroidism, the nurse will need to consult with the health care provider before administering

a.

docusate (Colace).

b.

ibuprofen (Motrin).

c.

diazepam (Valium).

d.

cefoxitin (Mefoxin).

ANS: C

Worsening of mental status and myxedema coma can be precipitated by the use of sedatives, especially in older adults. The nurse should discuss the use of diazepam with the health care provider before administration. The other medications may be given safely to the patient.

DIF: Cognitive Level: Apply (application) REF: 1203

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

16. A patient who was admitted with myxedema coma and diagnosed with hypothyroidism is improving and expected to be discharged in 2 days. Which teaching strategy will be best for the nurse to use?

a.

Provide written reminders of self-care information.

b.

Offer multiple options for management of therapies.

c.

Ensure privacy for teaching by asking visitors to leave.

d.

Delay teaching until patient discharge date is confirmed.

ANS: A

Written instructions will be helpful to the patient because initially the hypothyroid patient may be unable to remember to take medications and other aspects of self-care. Because the treatment regimen is somewhat complex, teaching should be initiated well before discharge. Family members or friends should be included in teaching because the hypothyroid patient is likely to forget some aspects of the treatment plan. A simpler regimen will be easier to understand until the patient is euthyroid.

DIF: Cognitive Level: Apply (application) REF: 1203

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

17. A 63-year-old patient with primary hyperparathyroidism has a serum phosphorus level of 1.7 mg/dL (0.55 mmol/L) and calcium of 14 mg/dL (3.5 mmol/L). Which nursing action should be included in the plan of care?

a.

Restrict the patient to bed rest.

b.

Encourage 4000 mL of fluids daily.

c.

Institute routine seizure precautions.

d.

Assess for positive Chvosteks sign.

ANS: B

The patient with hypercalcemia is at risk for kidney stones, which may be prevented by a high fluid intake. Seizure precautions and monitoring for Chvosteks or Trousseaus sign are appropriate for hypocalcemic patients. The patient should engage in weight-bearing exercise to decrease calcium loss from bone.

DIF: Cognitive Level: Apply (application) REF: 1206

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

18. A patient develops carpopedal spasms and tingling of the lips following a parathyroidectomy. Which action should the nurse take first?

a.

Administer the ordered muscle relaxant.

b.

Give the ordered oral calcium supplement.

c.

Have the patient rebreathe from a paper bag.

d.

Start the PRN oxygen at 2 L/min per cannula.

ANS: C

The patients symptoms suggest mild hypocalcemia. The symptoms of hypocalcemia will be temporarily reduced by having the patient breathe into a paper bag, which will raise the PaCO2 and create a more acidic pH. The muscle relaxant will have no impact on the ionized calcium level. Although severe hypocalcemia can cause laryngeal stridor, there is no indication that this patient is experiencing laryngeal stridor or needs oxygen. Calcium supplements will be given to normalize calcium levels quickly, but oral supplements will take time to be absorbed.

DIF: Cognitive Level: Apply (application) REF: 1207

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

19. A patient who had radical neck surgery to remove a malignant tumor developed hypoparathyroidism. The nurse should plan to teach the patient about

a.

bisphosphonates to reduce bone demineralization.

b.

calcium supplements to normalize serum calcium levels.

c.

increasing fluid intake to decrease risk for nephrolithiasis.

d.

including whole grains in the diet to prevent constipation.

ANS: B

Oral calcium supplements are used to maintain the serum calcium in normal range and prevent the complications of hypocalcemia. Whole grain foods decrease calcium absorption and will not be recommended. Bisphosphonates will lower serum calcium levels further by preventing calcium from being reabsorbed from bone. Kidney stones are not a complication of hypoparathyroidism and low calcium levels.

DIF: Cognitive Level: Apply (application) REF: 1207

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

20. Which finding for a patient who has hypothyroidism and hypertension indicates that the nurse should contact the health care provider before administering levothyroxine (Synthroid)?

a.

Increased thyroxine (T4) level

b.

Blood pressure 112/62 mm Hg

c.

Distant and difficult to hear heart sounds

d.

Elevated thyroid stimulating hormone level

ANS: A

An increased thyroxine level indicates the levothyroxine dose needs to be decreased. The other data are consistent with hypothyroidism and the nurse should administer the levothyroxine.

DIF: Cognitive Level: Apply (application) REF: 1203

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

21. A 37-year-old patient is being admitted with a diagnosis of Cushing syndrome. Which findings will the nurse expect during the assessment?

a.

Chronically low blood pressure

b.

Bronzed appearance of the skin

c.

Purplish streaks on the abdomen

d.

Decreased axillary and pubic hair

ANS: C

Purplish-red striae on the abdomen are a common clinical manifestation of Cushing syndrome. Hypotension and bronzed-appearing skin are manifestations of Addisons disease. Decreased axillary and pubic hair occur with androgen deficiency.

DIF: Cognitive Level: Understand (comprehension) REF: 1208

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

22. A 44-year-old female patient with Cushing syndrome is admitted for adrenalectomy. Which intervention by the nurse will be most helpful for a nursing diagnosis of disturbed body image related to changes in appearance?

a.

Reassure the patient that the physical changes are very common in patients with Cushing syndrome.

b.

Discuss the use of diet and exercise in controlling the weight gain associated with Cushing syndrome.

c.

Teach the patient that the metabolic impact of Cushing syndrome is of more importance than appearance.

d.

Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery.

ANS: D

The most reassuring communication to the patient is that the physical and emotional changes caused by the Cushing syndrome will resolve after hormone levels return to normal postoperatively. Reassurance that the physical changes are expected or that there are more serious physiologic problems associated with Cushing syndrome are not therapeutic responses. The patients physiological changes are caused by the high hormone levels, not by the patients diet or exercise choices.

DIF: Cognitive Level: Apply (application) REF: 1210

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

23. Which finding indicates to the nurse that the current therapies are effective for a patient with acute adrenal insufficiency?

a.

Increasing serum sodium levels

b.

Decreasing blood glucose levels

c.

Decreasing serum chloride levels

d.

Increasing serum potassium levels

ANS: A

Clinical manifestations of Addisons disease include hyponatremia and an increase in sodium level indicates improvement. The other values indicate that treatment has not been effective.

DIF: Cognitive Level: Apply (application) REF: 1208

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

24. A 38-year-old male patient is admitted to the hospital in Addisonian crisis. Which patient statement supports a nursing diagnosis of ineffective self-health management related to lack of knowledge about management of Addisons disease?

a.

I frequently eat at restaurants, and my food has a lot of added salt.

b.

I had the stomach flu earlier this week, so I couldnt take the hydrocortisone.

c.

I always double my dose of hydrocortisone on the days that I go for a long run.

d.

I take twice as much hydrocortisone in the morning dose as I do in the afternoon.

ANS: B

The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given. The other patient statements indicate appropriate management of the Addisons disease.

DIF: Cognitive Level: Apply (application) REF: 1212

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

25. A 29-year-old woman with systemic lupus erythematosus has been prescribed 2 weeks of high-dose prednisone therapy. Which information about the prednisone is most important for the nurse to include?

a.

Weigh yourself daily to monitor for weight gain caused by increased appetite.

b.

A weight-bearing exercise program will help minimize the risk for osteoporosis.

c.

The prednisone dose should be decreased gradually rather than stopped suddenly.

d.

Call the health care provider if you experience mood alterations with the prednisone.

ANS: C

Acute adrenal insufficiency may occur if exogenous corticosteroids are suddenly stopped. Mood alterations and weight gain are possible adverse effects of corticosteroid use, but these are not life-threatening effects. Osteoporosis occurs when patients take corticosteroids for longer periods.

DIF: Cognitive Level: Apply (application) REF: 1214

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

26. A 56-year-old female patient has an adrenocortical adenoma, causing hyperaldosteronism. The nurse providing care should

a.

monitor the blood pressure every 4 hours.

b.

elevate the patients legs to relieve edema.

c.

monitor blood glucose level every 4 hours.

d.

order the patient a potassium-restricted diet.

ANS: A

Hypertension caused by sodium retention is a common complication of hyperaldosteronism. Hyperaldosteronism does not cause an elevation in blood glucose. The patient will be hypokalemic and require potassium supplementation before surgery. Edema does not usually occur with hyperaldosteronism.

DIF: Cognitive Level: Apply (application) REF: 1214

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

27. The nurse will plan to monitor a patient diagnosed with a pheochromocytoma for

a.

flushing.

b.

headache.

c.

bradycardia.

d.

hypoglycemia.

ANS: B

The classic clinical manifestations of pheochromocytoma are hypertension, tachycardia, severe headache, diaphoresis, and abdominal or chest pain. Elevated blood glucose may also occur because of sympathetic nervous system stimulation. Bradycardia and flushing would not be expected.

DIF: Cognitive Level: Apply (application) REF: 1215

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

28. After a 22-year-old female patient with a pituitary adenoma has had a hypophysectomy, the nurse will teach about the need for

a.

sodium restriction to prevent fluid retention.

b.

insulin to maintain normal blood glucose levels.

c.

oral corticosteroids to replace endogenous cortisol.

d.

chemotherapy to prevent malignant tumor recurrence.

ANS: C

Antidiuretic hormone (ADH), cortisol, and thyroid hormone replacement will be needed for life after hypophysectomy. Without the effects of adrenocorticotropic hormone (ACTH) and cortisol, the blood glucose and serum sodium will be low unless cortisol is replaced. An adenoma is a benign tumor, and chemotherapy will not be needed.

DIF: Cognitive Level: Apply (application) REF: 1191

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

29. Which intervention will the nurse include in the plan of care for a 52-year-old male patient with syndrome of inappropriate antidiuretic hormone (SIADH)?

a.

Monitor for peripheral edema.

b.

Offer patient hard candies to suck on.

c.

Encourage fluids to 2 to 3 liters per day.

d.

Keep head of bed elevated to 30 degrees.

ANS: B

Sucking on hard candies decreases thirst for a patient on fluid restriction. Patients with SIADH are on fluid restrictions of 800 to 1000 mL/day. Peripheral edema is not seen with SIADH. The head of the bed is elevated no more than 10 degrees to increase left atrial filling pressure and decrease antidiuretic hormone (ADH) release.

DIF: Cognitive Level: Apply (application) REF: 1194

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

30. A patient has just arrived on the unit after a thyroidectomy. Which action should the nurse take first?

a.

Observe the dressing for bleeding.

b.

Check the blood pressure and pulse.

c.

Assess the patients respiratory effort.

d.

Support the patients head with pillows.

ANS: C

Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany. The priority nursing action is to assess the airway. The other actions are also part of the standard nursing care postthyroidectomy but are not as high of a priority.

DIF: Cognitive Level: Apply (application) REF: 1201

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

31. The nurse is caring for a patient following an adrenalectomy. The highest priority in the immediate postoperative period is to

a.

protect the patients skin.

b.

monitor for signs of infection.

c.

balance fluids and electrolytes.

d.

prevent emotional disturbances.

ANS: C

After adrenalectomy, the patient is at risk for circulatory instability caused by fluctuating hormone levels, and the focus of care is to assess and maintain fluid and electrolyte status through the use of IV fluids and corticosteroids. The other goals are also important for the patient but are not as immediately life threatening as the circulatory collapse that can occur with fluid and electrolyte disturbances.

DIF: Cognitive Level: Apply (application) REF: 1210-1211

OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

32. The nurse is caring for a patient admitted with diabetes insipidus (DI). Which information is most important to report to the health care provider?

a.

The patient is confused and lethargic.

b.

The patient reports a recent head injury.

c.

The patient has a urine output of 400 mL/hr.

d.

The patients urine specific gravity is 1.003.

ANS: A

The patients confusion and lethargy may indicate hypernatremia and should be addressed quickly. In addition, patients with DI compensate for fluid losses by drinking copious amounts of fluids, but a patient who is lethargic will be unable to drink enough fluids and will become hypovolemic. A high urine output, low urine specific gravity, and history of a recent head injury are consistent with diabetes insipidus, but they do not require immediate nursing action to avoid life-threatening complications.

DIF: Cognitive Level: Apply (application) REF: 1194-1195

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

33. Which prescribed medication should the nurse administer first to a 60-year-old patient admitted to the emergency department in thyroid storm?

a.

Propranolol (Inderal)

b.

Propylthiouracil (PTU)

c.

Methimazole (Tapazole)

d.

Iodine (Lugols solution)

ANS: A

b-Adrenergic blockers work rapidly to decrease the cardiovascular manifestations of thyroid storm. The other medications take days to weeks to have an impact on thyroid function.

DIF: Cognitive Level: Apply (application) REF: 1197-1199

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

34. Which assessment finding for a 33-year-old female patient admitted with Graves disease requires the most rapid intervention by the nurse?

a.

Bilateral exophthalmos

b.

Heart rate 136 beats/minute

c.

Temperature 103.8 F (40.4 C)

d.

Blood pressure 166/100 mm Hg

ANS: C

The patients temperature indicates that the patient may have thyrotoxic crisis and that interventions to lower the temperature are needed immediately. The other findings also require intervention but do not indicate potentially life-threatening complications.

DIF: Cognitive Level: Apply (application) REF: 1196 | 1198

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

35. A 37-year-old patient has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy. Which information is most important to communicate to the surgeon?

a.

The patient reports 7/10 incisional pain.

b.

The patient has increasing neck swelling.

c.

The patient is sleepy and difficult to arouse.

d.

The patients cardiac rate is 112 beats/minute.

ANS: B

The neck swelling may lead to respiratory difficulty, and rapid intervention is needed to prevent airway obstruction. The incisional pain should be treated but is not unusual after surgery. A heart rate of 112 is not unusual in a patient who has been hyperthyroid and has just arrived in the PACU from surgery. Sleepiness in the immediate postoperative period is expected.

DIF: Cognitive Level: Apply (application) REF: 1201

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

36. Which assessment finding of a 42-year-old patient who had a bilateral adrenalectomy requires the most rapid action by the nurse?

a.

The blood glucose is 176 mg/dL.

b.

The lungs have bibasilar crackles.

c.

The blood pressure (BP) is 88/50 mm Hg.

d.

The patient reports 5/10 incisional pain.

ANS: C

The decreased BP indicates possible adrenal insufficiency. The nurse should immediately notify the health care provider so that corticosteroid medications can be administered. The nurse should also address the elevated glucose, incisional pain, and crackles with appropriate collaborative or nursing actions, but prevention and treatment of acute adrenal insufficiency is the priority after adrenalectomy.

DIF: Cognitive Level: Apply (application) REF: 1201

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

37. A 23-year-old patient is admitted with diabetes insipidus. Which action will be most appropriate for the registered nurse (RN) to delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?

a.

Titrate the infusion of 5% dextrose in water.

b.

Teach the patient how to use desmopressin (DDAVP) nasal spray.

c.

Assess the patients hydration status every 8 hours.

d.

Administer subcutaneous DDAVP.

ANS: D

Administration of medications is included in LPN/LVN education and scope of practice. Assessments, patient teaching, and titrating fluid infusions are more complex skills and should be done by the RN.

DIF: Cognitive Level: Apply (application) REF: 15-16

OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment

38. Which information is most important for the nurse to communicate rapidly to the health care provider about a patient admitted with possible syndrome of inappropriate antidiuretic hormone (SIADH)?

a.

The patient has a recent weight gain of 9 lb.

b.

The patient complains of dyspnea with activity.

c.

The patient has a urine specific gravity of 1.025.

d.

The patient has a serum sodium level of 118 mEq/L.

ANS: D

A serum sodium of less than 120 mEq/L increases the risk for complications such as seizures and needs rapid correction. The other data are not unusual for a patient with SIADH and do not indicate the need for rapid action.

DIF: Cognitive Level: Apply (application) REF: 1193

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

39. After receiving change-of-shift report about the following four patients, which patient should the nurse assess first?

a.

A 31-year-old female with Cushing syndrome and a blood glucose level of 244 mg/dL

b.

A 70-year-old female taking levothyroxine (Synthroid) who has an irregular pulse of 134

c.

A 53-year-old male who has Addisons disease and is due for a scheduled dose of hydrocortisone (Solu-Cortef).

d.

A 22-year-old male admitted with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 130 mEq/L

ANS: B

Initiation of thyroid replacement in older adults may cause angina and cardiac dysrhythmias. The patients high pulse rate needs rapid investigation by the nurse to assess for and intervene with any cardiac problems. The other patients also require nursing assessment and/or actions but are not at risk for life-threatening complications.

DIF: Cognitive Level: Analyze (analysis) REF: 1203

OBJ: Special Questions: Prioritization; Multiple Patients

TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

40. Which question will the nurse in the endocrine clinic ask to help determine a patients risk factors for goiter?

a.

How much milk do you drink?

b.

What medications are you taking?

c.

Are your immunizations up to date?

d.

Have you had any recent neck injuries?

ANS: B

Medications that contain thyroid-inhibiting substances can cause goiter. Milk intake, neck injury, and immunization history are not risk factors for goiter.

DIF: Cognitive Level: Understand (comprehension) REF: 1195

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

41. Which finding by the nurse when assessing a patient with a large pituitary adenoma is most important to report to the health care provider?

a.

Changes in visual field

b.

Milk leaking from breasts

c.

Blood glucose 150 mg/dL

d.

Nausea and projectile vomiting

ANS: D

Nausea and projectile vomiting may indicate increased intracranial pressure, which will require rapid actions for diagnosis and treatment. Changes in the visual field, elevated blood glucose, and galactorrhea are common with pituitary adenoma, but these do not require rapid action to prevent life-threatening complications.

DIF: Cognitive Level: Apply (application) REF: 1192

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

42. Which finding by the nurse when assessing a patient with Hashimotos thyroiditis and a goiter will require the most immediate action?

a.

New-onset changes in the patients voice

b.

Apical pulse rate at rest 112 beats/minute

c.

Elevation in the patients T3 and T4 levels

d.

Bruit audible bilaterally over the thyroid gland

ANS: A

Changes in the patients voice indicate that the goiter is compressing the laryngeal nerve and may lead to airway compression. The other findings will also be reported but are expected with Hashimotos thyroiditis and do not require immediate action.

DIF: Cognitive Level: Apply (application) REF: 1196

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

43. Which information obtained by the nurse in the endocrine clinic about a patient who has been taking prednisone (Deltasone) 40 mg daily for 3 weeks is most important to report to the health care provider?

a.

Patients blood pressure is 148/94 mm Hg.

b.

Patient has bilateral 2+ pitting ankle edema.

c.

Patient stopped taking the medication 2 days ago.

d.

Patient has not been taking the prescribed vitamin D.

ANS: C

Sudden cessation of corticosteroids after taking the medication for a week or more can lead to adrenal insufficiency, with problems such as severe hypotension and hypoglycemia. The patient will need immediate evaluation by the health care provider to prevent and/or treat adrenal insufficiency. The other information will also be reported, but does not require rapid treatment.

DIF: Cognitive Level: Apply (application) REF: 1210-1211

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

44. The cardiac telemetry unit charge nurse receives status reports from other nursing units about four patients who need cardiac monitoring. Which patient should be transferred to the cardiac unit first?

a.

Patient with Hashimotos thyroiditis and a heart rate of 102

b.

Patient with tetany who has a new order for IV calcium chloride

c.

Patient with Cushing syndrome and a blood glucose of 140 mg/dL

d.

Patient with Addisons disease who takes hydrocortisone twice daily

ANS: B

Emergency treatment of tetany requires IV administration of calcium; ECG monitoring will be required because cardiac arrest may occur if high calcium levels result from too-rapid administration. The information about the other patients indicates that they are more stable than the patient with tetany.

DIF: Cognitive Level: Analyze (analysis) REF: 1207

OBJ: Special Questions: Multiple Patients; Prioritization TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

45. After obtaining the information shown in the accompanying figure regarding a patient with Addisons disease, which prescribed action will the nurse take first?

a.

Give 4 oz of fruit juice orally.

b.

Recheck the blood glucose level.

c.

Infuse 5% dextrose and 0.9% saline.

d.

Administer oxygen therapy as needed.

ANS: C

The patients poor skin turgor, hypotension, and hyponatremia indicate an Addisonian crisis. Immediate correction of the hypovolemia and hyponatremia is needed. The other actions may also be needed but are not the initial action for the patient.

DIF: Cognitive Level: Analyze (analysis) REF: 1211

OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

SHORT ANSWER

1. A patient is to receive methylprednisolone (Solu-Medrol) 100 mg. The label on the medication states: methylprednisolone 125 mg in 2 mL. How many milliliters will the nurse administer?

ANS:

1.6

A concentration of 125 mg in 2 mL will result in 100 mg in 1.6 mL.

DIF: Cognitive Level: Apply (application) REF: 1212

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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