Chapter 61: Assessment of the Endocrine System Nursing School Test Banks

Chapter 61: Assessment of the Endocrine System
Ignatavicius: Medical-Surgical Nursing, 8th Edition

MULTIPLE CHOICE

1. A nurse cares for a client who is prescribed a drug that blocks a hormones receptor site. Which therapeutic effect should the nurse expect?
a. Greater hormone metabolism
b. Decreased hormone activity
c. Increased hormone activity
d. Unchanged hormone response
ANS: B
Hormones cause activity in the target tissues by binding with their specific cellular receptor sites, thereby changing the activity of the cell. When receptor sites are occupied by other substances that block hormone binding, the cells response is the same as when the level of the hormone is decreased.

DIF: Understanding/Comprehension REF: 1255
KEY: Endocrine system| assessment/diagnostic examination
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

2. A nurse cares for a client with a deficiency of aldosterone. Which assessment finding should the nurse correlate with this deficiency?
a. Increased urine output
b. Vasoconstriction
c. Blood glucose of 98 mg/dL
d. Serum sodium of 144 mEq/L
ANS: A
Aldosterone, the major mineralocorticoid, maintains extracellular fluid volume. It promotes sodium and water reabsorption and potassium excretion in the kidney tubules. A client with an aldosterone deficiency will have increased urine output. Vasoconstriction is not related. These sodium and glucose levels are normal; in aldosterone deficiency, the client would have hyponatremia and hyperkalemia.

DIF: Applying/Application REF: 1258
KEY: Endocrine system| assessment/diagnostic examination
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

3. A nurse cares for a client with excessive production of thyrocalcitonin (calcitonin). For which electrolyte imbalance should the nurse assess?
a. Potassium
b. Sodium
c. Calcium
d. Magnesium
ANS: C
Parafollicular cells produce thyrocalcitonin (calcitonin), which regulates serum calcium levels. Calcitonin has no impact on potassium, sodium, or magnesium balances.

DIF: Applying/Application REF: 1259
KEY: Endocrine system| assessment/diagnostic examination| electrolyte imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

4. A nurse assesses a client who is prescribed a medication that stimulates beta1 receptors. Which assessment finding should alert the nurse to urgently contact the health care provider?
a. Heart rate of 50 beats/min
b. Respiratory rate of 18 breaths/min
c. Oxygenation saturation of 92%
d. Blood pressure of 144/69 mm Hg
ANS: A
Stimulation of beta1 receptor sites in the heart has positive chronotropic and inotropic actions. The nurse expects an increase in heart rate and increased cardiac output. The client with a heart rate of 50 beats/min would be cause for concern because this would indicate that the client was not responding to the medication. The other vital signs are within normal limits and do not indicate a negative response to the medication.

DIF: Applying/Application REF: 1259
KEY: Endocrine system| medications| adverse effects
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

5. A nurse prepares to palpate a clients thyroid gland. Which action should the nurse take when performing this assessment?
a. Stand in front of the client instead of behind the client.
b. Ask the client to swallow after palpating the thyroid.
c. Palpate the right lobe with the nurses left hand.
d. Place the client in a sitting position with the chin tucked down.
ANS: D
The client should be in a sitting position with the chin tucked down as the examiner stands behind the client. The nurse feels for the thyroid isthmus while the client swallows and turns the head to the right, and the nurse palpates the right lobe with the right hand. The technique is repeated in the opposite fashion for the left lobe.

DIF: Understanding/Comprehension REF: 1263
KEY: Endocrine system| assessment/diagnostic examination
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is prescribed a 24-hour urine specimen collection. Which statement should the nurse include when delegating this activity to the UAP?
a. Note the time of the clients first void and collect urine for 24 hours.
b. Add the preservative to the container at the end of the test.
c. Start the collection by saving the first urine of the morning.
d. It is okay if one urine sample during the 24 hours is not collected.
ANS: A
The collection of a 24-hour urine specimen is often delegated to a UAP. The nurse must ensure that the UAP understands the proper process for collecting the urine. The 24-hour urine collection specimen is started after the clients first urination. The first urine specimen is discarded because there is no way to know how long it has been in the bladder, but the time of the clients first void is noted. The client adds all urine voided after that first discarded specimen during the next 24 hours. When the 24-hour mark is reached, the client voids one last time and adds this specimen to the collection. The preservative, if used, must be added to the container at the beginning of the collection. All urine samples need to be collected for the test results to be accurate.

DIF: Applying/Application REF: 1263
KEY: Endocrine system| supervision| delegation| unlicensed assistive personnel (UAP)
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

7. A nurse assesses a female client who presents with hirsutism. Which question should the nurse ask when assessing this client?
a. How do you plan to pay for your treatments?
b. How do you feel about yourself?
c. What medications are you prescribed?
d. What are you doing to prevent this from happening?
ANS: B
Hirsutism, or excessive hair growth on the face and body, can result from endocrine disorders. This may cause a disruption in body image, especially for female clients. The nurse should inquire into the clients body image and self-perception. Asking about the clients financial status or current medications does not address the clients immediate problem. The client is not doing anything to herself to cause the problem, nor can the client prevent it from happening.

DIF: Applying/Application REF: 1262
KEY: Endocrine system| assessment/diagnostic examination| psychosocial response
MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity

8. A nurse teaches a client who has been prescribed a 24-hour urine collection to measure excreted hormones. The client asks, Why do I need to collect urine for 24 hours instead of providing a random specimen? How should the nurse respond?
a. This test will assess for a hormone secreted on a circadian rhythm.
b. The hormone is diluted in urine; therefore, we need a large volume.
c. We are assessing when the hormone is secreted in large amounts.
d. To collect the correct hormone, you need to urinate multiple times.
ANS: A
Some hormones are secreted in a pulsatile, or circadian, cycle. When testing for these substances, a collection that occurs over 24 hours will most accurately reflect hormone secretion. Dilution of hormones in urine, secretion of hormone amounts, and ability to collect the correct hormone are not reasons to complete a 24-hour urine test.

DIF: Applying/Application REF: 1264
KEY: Endocrine system| assessment/diagnostic examination
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

9. A nurse plans care for an older adult who is admitted to the hospital for pneumonia. The client has no known drug allergies and no significant health history. Which action should the nurse include in this clients plan of care?
a. Initiate Airborne Precautions.
b. Offer fluids every hour or two.
c. Place an indwelling urinary catheter.
d. Palpate the clients thyroid gland.
ANS: B
A normal age-related endocrine change is decreased antidiuretic hormone (ADH) production. This results in a more diluted urine output, which can lead to dehydration. If no contraindications are known, the nurse should offer (or delegate) the client something to drink at least every 2 hours. A client with simple pneumonia would not require Airborne Precautions. Indwelling urinary catheterization is not necessary for this client and would increase the clients risk for infection. The nurse should plan a toileting schedule and assist the client to the bathroom if needed. Palpating the clients thyroid gland is a part of a comprehensive examination but is not specifically related to this client.

DIF: Applying/Application REF: 1261
KEY: Endocrine system| hydration
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

10. A nurse cares for a client who is prescribed a 24-hour urine collection. The unlicensed assistive personnel (UAP) reports that, while pouring urine into the collection container, some urine splashed his hand. Which action should the nurse take next?
a. Ask the UAP if he washed his hands afterward.
b. Have the UAP fill out an incident report.
c. Ask the laboratory if the container has preservative in it.
d. Send the UAP to Employee Health right away.
ANS: A
For safety, the nurse should find out if the UAP washed his or her hands. The UAP should do this for two reasons. First, it is part of Standard Precautions to wash hands after client care. Second, if the container did have preservative in it, this would wash it away. The preservative may be caustic to the skin. The nurse can call the laboratory while the UAP is washing hands, if needed. The UAP would then need to fill out an incident or exposure report and may or may not need to go to Employee Health. The UAP also needs further education on Standard Precautions, which include wearing gloves.

DIF: Applying/Application REF: 1263
KEY: Endocrine system| delegation| supervision| infection control| unlicensed assistive personnel (UAP) MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

11. A nurse evaluates laboratory results for a male client who reports fluid secretion from his breasts. Which hormone value should the nurse assess first?
a. Posterior pituitary hormones
b. Adrenal medulla hormones
c. Anterior pituitary hormones
d. Parathyroid hormone
ANS: C
Breast fluid and milk production are induced by the presence of prolactin, secreted from the anterior pituitary gland. The other hormones would not cause fluid secretion from the clients breast.

DIF: Applying/Application REF: 1256
KEY: Endocrine system| assessment/diagnostic examination
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

12. A nurse cares for a client who has excessive catecholamine release. Which assessment finding should the nurse correlate with this condition?
a. Decreased blood pressure
b. Increased pulse
c. Decreased respiratory rate
d. Increased urine output
ANS: B
Catecholamines are responsible for the fight-or-flight stress response. Activation of the sympathetic nervous system can be correlated with tachycardia. Catecholamines do not decrease blood pressure or respiratory rate, nor do they increase urine output.

DIF: Applying/Application REF: 1259
KEY: Endocrine system| assessment/diagnostic examination
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

13. A nurse assesses a client diagnosed with adrenal hypofunction. Which client statement should the nurse correlate with this diagnosis?
a. I have a terrible craving for potato chips.
b. I cannot seem to drink enough water.
c. I no longer have an appetite for anything.
d. I get hungry even after eating a meal.
ANS: A
The nurse correlates a clients salt craving with adrenal hypofunction. Excessive thirst is related to diabetes insipidus or diabetes mellitus. Clients who have hypothyroidism often have a decrease in appetite. Excessive hunger is associated with diabetes mellitus.

DIF: Applying/Application REF: 1261
KEY: Endocrine system| assessment/diagnostic examination
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

14. A nurse teaches an older adult with a decreased production of estrogen. Which statement should the nurse include in this clients teaching to decrease injury?
a. Drink at least 2 liters of fluids each day.
b. Walk around the neighborhood for daily exercise.
c. Bathe your perineal area twice a day.
d. You should check your blood glucose before meals.
ANS: B
An older adult client with decreased production of estrogen is at risk for decreased bone density and fractures. The nurse should encourage the client to participate in weight-bearing exercises such as walking. Drinking fluids and performing perineal care will decrease vaginal drying but not decrease injury. Older adults often have a decreased glucose tolerance, but this is not related to a decrease in estrogen.

DIF: Applying/Application REF: 1261
KEY: Endocrine system| safety| exercise MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance

15. A nurse cares for a client who is prescribed a serum catecholamine test. Which action should the nurse take when obtaining the sample?
a. Discard the first sample and then begin the collection.
b. Draw the blood sample after the client eats breakfast.
c. Place the sample on ice and send to the laboratory immediately.
d. Add preservatives before sending the sample to the laboratory.
ANS: C
A blood sample for catecholamine must be placed on ice and taken to the laboratory immediately. This sample is not urine, and therefore the first sample should not be discarded nor should preservatives be added to the sample. The nurse should use the appropriate tube and obtain the sample based on which drugs are administered, not dietary schedules.

DIF: Applying/Application REF: 1263
KEY: Endocrine system| assessment/diagnostic examination
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE

1. A nurse cares for clients with hormone disorders. Which are common key features of hormones? (Select all that apply.)
a. Hormones may travel long distances to get to their target tissues.
b. Continued hormone activity requires continued production and secretion.
c. Control of hormone activity is caused by negative feedback mechanisms.
d. Most hormones are stored in the target tissues for use later.
e. Most hormones cause target tissues to change activities by changing gene activity.
ANS: A, B, C
Hormones are secreted by endocrine glands and travel through the body to reach their target tissues. Hormone activity can increase or decrease according to the bodys needs, and continued hormone activity requires continued production and secretion. Control is maintained via negative feedback. Hormones are not stored for later use, and they do not alter genetic activity.

DIF: Understanding/Comprehension REF: 1255
KEY: Endocrine system| pathophysiology
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A nurse cares for a client with a hypofunctioning anterior pituitary gland. Which hormones should the nurse expect to be affected by this condition? (Select all that apply.)
a. Thyroid-stimulating hormone
b. Vasopressin
c. Follicle-stimulating hormone
d. Calcitonin
e. Growth hormone
ANS: A, C, E
Thyroid-stimulating hormone, follicle-stimulating hormone, and growth hormone all are secreted by the anterior pituitary gland. Vasopressin is secreted from the posterior pituitary gland. Calcitonin is secreted from the thyroid gland.

DIF: Remembering/Knowledge REF: 1256
KEY: Endocrine system| pathophysiology
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

3. A nurse assesses clients who have endocrine disorders. Which assessment findings are paired correctly with the endocrine disorder? (Select all that apply.)
a. Excessive thyroid-stimulating hormone Increased bone formation
b. Excessive melanocyte-stimulating hormone Darkening of the skin
c. Excessive parathyroid hormone Synthesis and release of corticosteroids
d. Excessive antidiuretic hormone Increased urinary output
e. Excessive adrenocorticotropic hormone Increased bone resorption
ANS: A, B
Thyroid-stimulating hormone targets thyroid tissue and stimulates the formation of bone. Melanocyte-stimulating hormone stimulates melanocytes and promotes pigmentation or the darkening of the skin. Parathyroid hormone stimulates bone resorption. Antidiuretic hormone targets the kidney and promotes water reabsorption, causing a decrease in urinary output. Adrenocorticotropic hormone targets the adrenal cortex and stimulates the synthesis and release of corticosteroids.

DIF: Understanding/Comprehension REF: 1258
KEY: Endocrine system| assessment/diagnostic examination
MSC: Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

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