AG2 Endocrine

Which of the following assessment findings characterize thyroid storm?

• increased body temperature, decreased pulse, and increased blood pressure

• increased body temperature, increased pulse, and increased blood pressure

• increased body temperature, decreased pulse, and decreased blood pressure

• increased body temperature, increased pulse, and decreased blood pressure

Answer explanation

Thyroid storm is characterized by SNS activation. Thyroid hormones potentiate effects of cathecolamines (epinephrine/norepinephrine). Therefore, all vital signs will be increased.

The nurse is planning care for a client with hyperthyroidism. Which of the following nursing interventions are appropriate? Select all that apply

• instill isotonic eye drops as necessary

• provide several, small, well-balanced meals

• provide rest periods

• keep environment warm

• weigh the client daily

Answer explanation

(a) The client with hyperthyroidism may experience exopthalmos. This requires instillation of eye drops to prevent dryness and ulceration of the cornea.

(b and f) The client experiences weight loss because of hypermetabolism. Several, small, well-balanced meals are given to improve nutritional status of the client and daily weights should be monitored. Weight is the most objective indicator of nutritional status.

(c) The client is usually exhausted due to restlessness and agitation. Frequent rest periods help the client regain energy.

After thyroidectomy, which of the following is the priority assessment to observe laryngeal nerve damage?

• hoarseness of voice

• difficulty in swallowing

• tetany

• fever

Answer explanation

Laryngeal nerve damage is manifested by severe hoarseness of voice of "whispery voice".

When caring for a male client with diabetes insipidus, nurse Juliet expects to administer:

• furosemide (Lasix)

• regular insulin

• vasopressin

• 10% dextrose

Answer explanation

Because diabetes insipidus results from decreased antidiuretic hormone (vasopressin) production, the nurse should expect to administer synthetic vasopressin for hormone replacement therapy. Furosemide, a diuretic, is contraindicated because a client with diabetes insipidus experiences polyuria. Insulin and dextrose are used to treat diabetes mellitus and its complications, not diabetes insipidus.

Nurse Ronn is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find:

• Hypotension

• Thick, coarse skin

• Deposits of adipose tissue in the trunk and dorsocervical area.

• Weight gain in arms and legs

Answer explanation

Because of changes in fat distribution, adipose tissue accumulates in the trunk, face (moonface), and dorsocervical areas (buffalo hump). Hypertension is caused by fluid retention. Skin becomes thin and bruises easily because of a loss of collagen. Muscle wasting causes muscle atrophy and thin extremities.

For the first 72 hours after thyroidectomy surgery, nurse Jamie would assess the female client for Chvostek's sign and Trousseau's sign because they indicate which of the following?

• Hypocalcemia

• Hypercalcemia

• Hypokalemia

• Hyperkalemia

Answer explanation

The client who has undergone a thyroidectomy is at risk for developing hypocalcemia from inadvertent removal or damage to the parathyroid gland. The client with hypocalcemia will exhibit a positive Chvostek's sign (facial muscle contraction when the facial nerve in front of the ear is tapped) and a positive Trousseau's sign (carpal spasm when a blood pressure cuff is inflated for a few minutes). These signs aren't present with hypercalcemia, hypokalemia, or hyperkalemia.

Nurse Oliver should expect a client with hypothyroidism to report which health concerns?

• Increased appetite and weight loss

• Nervousness and tremors

• Thyroid gland swelling

• Puffiness of the face and hands

Answer explanation

Hypothyroidism (myxedema) causes facial puffiness, extremity edema, and weight gain. Signs and symptoms of hyperthyroidism (Graves' disease) include an increased appetite, weight loss, nervousness, tremors, and thyroid gland enlargement (goiter).

Early this morning, a female client had a subtotal thyroidectomy. During evening rounds, nurse Tina assesses the client, who now has nausea, a temperature of 105° F (40.5° C), tachycardia, and extreme restlessness. What is the most likely cause of these signs?

• Diabetic ketoacidosis

• Thyroid crisis

• Hypoglycemia

• Tetany

Answer explanation

Thyroid crisis usually occurs in the first 12 hours after thyroidectomy and causes exaggerated signs of hyperthyroidism, such as high fever, tachycardia, and extreme restlessness. Diabetic ketoacidosis is more likely to produce polyuria, polydipsia, and polyphagia; hypoglycemia, to produce weakness, tremors, profuse perspiration, and hunger. Tetany typically causes uncontrollable muscle spasms, stridor, cyanosis, and possibly asphyxia.

A male client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?

• Infusing I.V. fluids rapidly as ordered

• Encouraging increased oral intake

• Restricting fluids

• Administering glucose-containing I.V. fluids as ordered

Answer explanation

To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load

Nurse Troy is aware that the most appropriate for a client with Addison's disease?

• Risk for infection

• Excessive fluid volume

• Urinary retention

• Hypothermia

Answer explanation

Addison's disease decreases the production of all adrenal hormones, compromising the body's normal stress response and increasing the risk of infection. Other appropriate nursing diagnoses for a client with Addison's disease include Deficient fluid volume and Hyperthermia. Urinary retention isn't appropriate because Addison's disease causes polyuria.