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

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 50: Nursing Management: Endocrine Problems

Test Bank

MULTIPLE CHOICE

1. A 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.

Are you experiencing tremors or anxiety?

d.

Is there any family history of acromegaly?

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: Application REF: 1255-1256

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

2. During preoperative teaching for a patient scheduled for transsphenoidal hypophysectomy for treatment of a pituitary adenoma, 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.

be positioned flat with sandbags at the head postoperatively.

d.

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

ANS: D

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: Application REF: 1256-1258

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

3. Which nursing action will be included in the postoperative plan of care for a patient who has had a transsphenoidal resection of a pituitary tumor?

a.

Monitor urine output every hour.

b.

Palpate extremities for dependent edema.

c.

Check hematocrit hourly for first 12 hours.

d.

Obtain continuous pulse oximetry for 24 hours.

ANS: A

After pituitary surgery, the patient is at risk for diabetes insipidus caused by cerebral edema and 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: Application REF: 1257-1258 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

4. A patient is suspected of having a pituitary tumor causing panhypopituitarism. During assessment of the patient, the nurse would expect to find

a.

high blood pressure.

b.

elevated blood glucose.

c.

tachycardia and cardiac palpitations.

d.

changes in secondary sex characteristics.

ANS: D

Changes in secondary sex characteristics 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: Application REF: 1257-1259

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

5. Which information will the nurse include when teaching a patient about use of somatropin (Genotropin)?

a.

The medication will improve vaginal dryness.

b.

Inject the medication subcutaneously every day.

c.

Blood glucose levels will 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 adverse effects occur, the health care provider should be notified. Growth hormone will increase blood glucose levels.

DIF: Cognitive Level: Application REF: 1258-1259

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

6. A patient is treated with demeclocycline (Declomycin) to control the symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). The nurse determines that the demeclocycline is effective upon finding that the

a.

peripheral edema is decreased.

b.

patients weight has increased.

c.

urine specific gravity is increased.

d.

patients urinary output is increased.

ANS: D

Demeclocycline blocks the action of 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: Application REF: 1258-1261 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

7. When teaching a patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH) about long-term management of the disorder, the nurse determines that additional instruction is needed when the patient says,

a.

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

b.

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

c.

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

d.

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

ANS: D

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: Application REF: 1258-1261 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

8. A patient is hospitalized with possible syndrome of inappropriate antidiuretic hormone (SIADH). The patient is confused and reports a headache, muscle cramps, and twitching. The nurse would expect the initial laboratory results to include

a.

an elevated hematocrit.

b.

a decreased serum sodium.

c.

an increased serum chloride.

d.

a low urine specific gravity.

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: Comprehension REF: 1258-1259

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

9. A patient with symptoms of diabetes insipidus is admitted to the hospital for evaluation and treatment of the condition. An appropriate nursing diagnosis for the patient is

a.

insomnia related to frequent waking at night to void.

b.

impaired gas exchange related to fluid retention in lungs.

c.

excess fluid volume related to intake greater than output.

d.

risk for impaired skin integrity related to generalized edema.

ANS: A

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: Application REF: 1260-1261 TOP: Nursing Process: Diagnosis

MSC: NCLEX: Physiological Integrity

10. Which information will the nurse include when teaching a 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.

Surgery will eventually be required to remove the thyroid gland.

d.

Antithyroid medications may take several weeks to have an effect.

ANS: D

Medications used to block the synthesis of thyroid hormones may take several weeks before an 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: Application REF: 1265-1267

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

11. A few hours after returning to the surgical nursing unit, a patient who has undergone a subtotal thyroidectomy develops laryngeal stridor and a cramp in the right hand. Which action will the nurse anticipate taking next?

a.

Infuse IV calcium gluconate.

b.

Suction the patients airway.

c.

Prepare for endotracheal intubation.

d.

Assist with emergency tracheostomy.

ANS: A

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: Application REF: 1268-1269 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

12. A patient with Graves disease has exophthalmos. Which nursing action will be included in the plan of care?

a.

Apply eye patches to protect the cornea from irritation.

b.

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

c.

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

d.

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

ANS: C

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. 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: Application REF: 1266-1269 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

13. A patient with hyperthyroidism is treated with radioactive iodine (RAI) at a clinic. Before the patient is discharged, the nurse instructs the patient

a.

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

b.

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

c.

to discontinue the antithyroid medications taken before the radioactive therapy.

d.

about radioactive precautions to take with urine, stool, and other body secretions.

ANS: B

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: Comprehension REF: 1266

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

14. A 72-year-old patient is diagnosed with hypothyroidism and levothyroxine (Synthroid) is prescribed. Which assessment is most important for the nurse to make during initiation of thyroid replacement?

a.

Apical pulse rate

b.

Nutritional intake

c.

Intake and output

d.

Orientation and alertness

ANS: A

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: Application REF: 1270-1271

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

15. A 78-year-old patient in a long-term care facility has these medications prescribed. After the patient is diagnosed with hypothyroidism, the nurse will need to consult with the health care provider before administration of

a.

docusate (Colace).

b.

diazepam (Valium).

c.

ibuprofen (Motrin).

d.

cefoxitin (Mefoxin).

ANS: B

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

DIF: Cognitive Level: Application REF: 1270-1271

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

16. When planning teaching for a patient who was admitted with myxedema coma and diagnosed with hypothyroidism, which strategy will be best for the nurse to use?

a.

Delay teaching until patient discharge.

b.

Ensure privacy by asking visitors to leave.

c.

Provide written handouts of all information.

d.

Offer multiple options for management of therapies.

ANS: C

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. Since 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: Application REF: 1271-1273 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

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

a.

Institute routine seizure precautions.

b.

Monitor for positive Chvosteks sign.

c.

Encourage the patient to remain on bed rest.

d.

Encourage 3000 to 4000 mL of oral fluids daily.

ANS: D

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: Application REF: 1271-1275 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

18. Following a parathyroidectomy, a patient develops tingling of the lips and a positive Trousseaus sign. Which action should the nurse take first?

a.

Administer the ordered muscle relaxant.

b.

Give the ordered oral calcium supplement.

c.

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

d.

Have the patient rebreathe using a paper bag.

ANS: D

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: Application REF: 1275-1276

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

19. After radical neck surgery, a patient develops hypoparathyroidism. The nurse should plan to teach the patient about

a.

use of bisphosphonates to reduce bone demineralization.

b.

including whole grains in the diet to prevent constipation.

c.

calcium supplementation to normalize serum calcium levels.

d.

having a high fluid intake to decrease risk for nephrolithiasis.

ANS: C

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: Application REF: 1275-1276 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

20. Which assessment finding for a patient who takes levothyroxine (Synthroid) to treat hypothyroidism indicates that the nurse should contact the health care provider before administering the medication?

a.

Increased thyroxine (T4) level

b.

Blood pressure 102/62 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 Synthroid.

DIF: Cognitive Level: Application REF: 1264 | 1270-1271

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

21. When caring for a patient with a diagnosis of Cushing syndrome, which data will the nurse expect to find during the admission assessment?

a.

Chronically low blood pressure

b.

Bronzed appearance of the skin

c.

Decreased axillary and pubic hair

d.

Purplish red streaks on the abdomen

ANS: D

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: Comprehension REF: 1276-1279

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

22. A patient with Cushing syndrome who is admitted for adrenalectomy has a nursing diagnosis of disturbed body image related to changes in appearance caused by the effects of the disease. Which intervention by the nurse will be most helpful?

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

d.

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

ANS: C

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 physiological 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: Application REF: 1279-1280

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

23. When a patient is hospitalized with acute adrenal insufficiency, which assessment finding by the nurse indicates that the prescribed therapies are effective?

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: Application REF: 1280-1281 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

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

a.

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

b.

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

c.

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

d.

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

ANS: C

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: Application REF: 1281-1282 TOP: Nursing Process: Diagnosis

MSC: NCLEX: Physiological Integrity

25. A patient with systemic lupus erythematosus has a prescription for 2 weeks of high-dose prednisone therapy. When teaching the patient about the prednisone, which information is most important for the nurse to include?

a.

Call the doctor if you experience any mood alterations with the prednisone.

b.

Do not stop taking the prednisone suddenly; it should be decreased gradually.

c.

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

d.

Weigh yourself daily to monitor for weight gain caused by water or increased fat.

ANS: B

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: Application REF: 1282-1283

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

26. When caring for a patient who has an adrenocortical adenoma, causing hyperaldosteronism, the nurse should

a.

provide a potassium-restricted diet.

b.

monitor the blood pressure every 4 hours.

c.

monitor blood glucose level every 4 hours.

d.

relieve edema by elevating the extremities.

ANS: B

Hypertension caused by sodium retention is a common complication of hyperaldosteronism. Hyperaldosteronism does not cause 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: Application REF: 1282-1284

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

27. A patient admitted to the hospital with hypertension is diagnosed with a pheochromocytoma. The nurse will plan to monitor the patient 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 also may occur because of sympathetic nervous system stimulation. Bradycardia and flushing would not be expected.

DIF: Cognitive Level: Application REF: 1283-1284 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

28. After a patient with a pituitary adenoma has had a hypophysectomy, the nurse will plan to do discharge teaching about the need for

a.

oral corticosteroids to replace endogenous cortisol.

b.

chemotherapy to prevent reoccurrence of the tumor.

c.

insulin use to maintain blood glucose at normal levels.

d.

sodium restriction to prevent fluid retention and hypertension.

ANS: A

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: Application REF: 1256-1258 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

29. When developing a plan of care for a patient with syndrome of inappropriate antidiuretic hormone (SIADH), which interventions will the nurse include?

a.

Encourage fluids to 2000 mL/day.

b.

Offer patient hard candies to suck on.

c.

Monitor for increased peripheral edema.

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: Application REF: 1259-1261 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

30. Which action should the nurse take first when caring for a patient who has just arrived on the unit after a thyroidectomy?

a.

Check the dressing for bleeding.

b.

Assess respiratory rate and effort.

c.

Take the blood pressure and pulse.

d.

Support the patients head with pillows.

ANS: B

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

DIF: Cognitive Level: Application REF: 1268-1269

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

MSC: NCLEX: Physiological Integrity

31. A patient with Cushing syndrome returns to the surgical unit following an adrenalectomy. During the initial postoperative period, the nurse gives the highest priority to

a.

monitoring for infection.

b.

protecting the patients skin.

c.

maintaining fluid and electrolyte status.

d.

preventing severe 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 also are 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: Application REF: 1279-1280

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

MSC: NCLEX: Physiological Integrity

32. Which information obtained by the nurse when caring for a patient who has diabetes insipidus (DI) is most important to report to the health care provider?

a.

The patient had a recent head injury.

b.

The patient is confused and lethargic.

c.

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

d.

The patients urine specific gravity is 1.003.

ANS: B

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: Application REF: 1261

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

MSC: NCLEX: Physiological Integrity

33. A patient with Graves disease is admitted to the emergency department with thyroid storm. Which of these prescribed medications should the nurse administer first?

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: Application REF: 1265-1266

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

MSC: NCLEX: Physiological Integrity

34. Which assessment finding for a 24-year-old patient admitted with Graves disease requires the most rapid intervention by the nurse?

a.

BP 166/100 mm Hg

b.

Bilateral exophthalmos

c.

Heart rate 136 beats/minute

d.

Temperature 104.8 F (40.4 C)

ANS: D

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: Application REF: 1264-1266

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

MSC: NCLEX: Physiological Integrity

35. While assessing a patient who has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy, the nurse obtains these data. Which information is most important to communicate to the surgeon?

a.

The patient is sleepy and hard to arouse.

b.

The patient has increasing swelling of the neck.

c.

The patient is complaining of 7/10 incisional pain.

d.

The patients cardiac monitor shows a heart rate of 112.

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: Application REF: 1268-1269

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

MSC: NCLEX: Physiological Integrity

36. When providing postoperative care for a patient who had a bilateral adrenalectomy, which assessment information requires the most rapid action by the nurse?

a.

The blood glucose is 176 mg/dL.

b.

The lungs have bibasilar crackles.

c.

The patients BP is 88/50 mm Hg.

d.

The patient has 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: Application REF: 1279-1280

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

MSC: NCLEX: Physiological Integrity

37. Which of these nursing actions in the plan of care for a patient who has diabetes insipidus will be most appropriate for the RN to delegate to an experienced LPN/LVN?

a.

Titrate the infusion of 5% dextrose in water.

b.

Teach patient how to use DDAVP nasal spray.

c.

Assess patients hydration status every 8 hours.

d.

Administer subcutaneous desmopressin (DDAVP).

ANS: D

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

DIF: Cognitive Level: Application REF: 1261

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

MSC: NCLEX: Safe and Effective Care Environment

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

a.

The patient complains of dyspnea with activity.

b.

The patient has a urine specific gravity of 1.025.

c.

The patient has a recent weight gain of 8 lb.

d.

The patient has a serum sodium level of 119 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: Application REF: 1259-1260

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 with Cushing syndrome and a blood glucose level of 244 mg/dL

b.

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

c.

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

d.

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

ANS: C

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: Analysis REF: 1270-1271

OBJ: Special Questions: Multiple Patients

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

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