ME FIRST!
(PRIORITY INTERVENTIONS)
(PRIORITY INTERVENTIONS)
A female client with Hypothyroidism presents to the clinic complaining of fatigue, cold intolerance, and weight gain. What nursing action should be PRIORITIZED?
a) Obtaining a urine sample for a pregnancy test
b) Documenting her intake of iodine-enriched foods
c) Taking a manual blood pressure on her left arm
d) Adjusting the air conditioner in the exam room
Answer: c) Taking a manual blood pressure on her left arm
Rationale: Monitoring blood pressure is crucial in identifying the most concerning signs and symptoms of Hypothyroidism.
The nurse would recommend to clients with thyroid diseases to sleep with the head of the bed elevated when having WHAT condition? Select all that apply.
a) goiter
b) exophthalmos
c) myxedema
d) insomnia
e) petechiae
Answer:
a) goiter
b) exophthalmos
c) myxedema
Rationale: Elevating the head of the bed can help lower the eyelids of clients with exophthalmos and provide better breathing for clients with a goiter and swollen tongue from myxedema. It would not be recommended based on insomnia. Petechiae is seen in Cushing's.
A male client accidentally blew his nose after having a hypophysectomy. Which subjective data about the drainage coming from his nose indicates the COMPLICATION of cerebral spinal fluid leakage may have occurred after the halo test was performed? Select all that apply.
a) "It has a foul odor!"
b) "It has blood in it!"
c) "It is light yellow!"
d) "It tastes like salt!"
d) "It is very thick!"
Answers:
c) "It is light yellow!"
d) "It tastes like salt!"
Rationale: Yellow and salt-tasting drainage (from electrolytes in the spinal fluid) can indicate a CSF leakage has occurred after a hypophysectomy which involves brain surgery. All the other descriptions may indicate other post-op complications.
The nurse would make which DIETARY recommendations to a client with Grave's Disease about their daily food preparation?
a) "Plan to only eat 2 large meals for lunch and dinner."
b) "Avoid drinking more than 1500 ml of water a day."
c) "Eat frequent, low-calorie meals throughout the day."
d) "Be sure to eat snacks high in protein and carbohydrates."
Answer: d) "Be sure to eat snacks high in protein and carbohydrates."
Rationale: Clients with Hyperthyroidism have increased metabolism and need to eat at least 6 small meals a day that are high in carbohydrates and protein. The calorie intake may increase based on weight loss. They should also increase their intake of fluids due to their risk of dehydration from sweating.
Which increased LAB result would the nurse anticipate seeing in a client with Grave's Disease?
a) ACTH levels
b) TRH levels
c) TSH levels
d) TH levels
Answer: d) TH levels
Rationale: In the Hyperthyroidism condition of Grave's Disease, the TH levels would be increased. Elevated TH in the blood would cause the hypothalamus to decrease releasing TRH and the Pituitary gland to decrease releasing TSH. ACTH is related to the adrenal glands, not the thyroid.
A client with adrenal insufficiency is prescribed, Hydrocortisone (Cortef). What nursing action should be PRIORITIZED when administering this glucocorticoid replacement therapy?
a) Administering the medication 30 minutes before breakfast
b) Checking the client's fingerstick blood glucose levels
c) Encouraging the client to weigh themselves every night
d) Monitoring the blood pressure for signs of hypotension
Answer: b) Checking the client's fingerstick blood glucose levels
Rationale: Glucocorticoid replacement therapy can lead to signs and symptoms of Cushing Syndrome which can be elevated blood glucose and hypertension.
The nurse knows the platelet levels need to be monitored for a client taking WHAT medication to treat Hyperthyroidism?
a) acetylsalicylic acid (Aspirin)
b) mitotane (Lysodren)
c) propylthiouracil (PTU)
d) methimazole (Tapazole)
Answer: c) Propylthiouracil (PTU)
Rationale: PTU can cause thrombocytopenia so platelet levels from a CBC should be obtained. Aspirin will worsen Hyperthyroidism by releasing more TH. Lysodren is not a medication to treat Hyperthyroidism. Tapazole does not affect platelets.
The nurse suspects the client who had been taking Cortef (Hydrocortisone) for 1 year, more likely developed the COMPLICATION of Adrenal Crisis based on which of the following statements?
"I forgot to notify my doctor when I got the Flu immunization."
"I forgot to take my medications this week while on vacation."
"I forgot to take my blood glucose level before I ate breakfast."
"I forgot how to accurately check my manual blood pressure."
Answer: "I forgot to take my medications this week while on vacation."
Rationale: Stopping steroids suddenly can lead to Adrenal Crisis.
The nurse needs to provide DIETARY modifications to a client at risk for Hyperthyroidism when they report buying most of their food from which section of the grocery store?
a) Dairy
b) Seafood
c) Bakery
d) Frozen Foods
Answer: b) Seafood
Rationale: Seafood is high in iodine which causes the increase in the production of TH leading to Hyperthyroidism.
The client started the Dexamethasone Suppression test 3 days ago. When returning to the health clinic for bloodwork, the nurse would expect to review which LAB result, that would confirm the diagnosis of Cushing's Disease?
a) non-suppression of cortisol levels
b) suppression of cortisol levels
c) non-suppression of glucose levels
d) suppression of glucose levels
Answer: a) non-suppression cortisol levels
Rationale: From the Dexamethasone test, increased levels of cortisol indicate non-suppression of cortisol took place which will help diagnose Cushing's Disease. Glucose levels are not tested in the Dexamethasone test.
A client with Hyperthyroidism in Thyroid Storm is admitted to the hospital with symptoms of fever, hypertension and tachycardia. Which of the following medications should the nurse PRIORITIZED to administer to treat this condition?
a) levothyroxine (Synthroid)
b) propylthiouracil (PTU)
c) lisinopril (Zestril)
d) fludrocortisone (Florinef)
Answer: b) propylthiouracil (PTU)
Rationale: A priority in managing thyroid storm is to provide antithyroid medication intravenously. Synthroid would increase TH levels. Beta blockers, not Ace Inhibitors are administered for tachycardia and hypertension in Thyroid storm. Florinef is a mineralocorticoid to treat Addison's disease and would increase BP.
The nurse reviewing the electronic record, would identify the client's family history of WHAT condition as a risk factor for thyroid disease?
a) Hashimoto's Thyroiditis
b) Hypophysectomy
c) Adrenocorticotropin hormone (ACTH) tumors
d) Thyroid Dermopathy
Answer: a) Hashimoto's Thyroiditis
Rationale: Hashimoto's Thyroiditis is an autoimmune disorder that decreases the production of TH. It is also a family risk factor for Hypothyroidism. All the other answer choices are not family history risk factors.
The graduate nurse writing a research paper, knows which information about Myxedema crisis is accurate about this COMPLICATION of thyroid disease?
a) It is rare in the United States
b) It has a very low mortality rate
c) It causes severe fluid overload
d) It is treated with antithyroid drugs
Answer: a) It is rare in the United States
Rationale- Myxedema is a rare condition in the U.S. that has a high mortality rate. It causes swelling that is not from fluid overload. Treatment is thyroid hormone replacement medications.
Which DIETARY modification would be appropriate to advise individuals with Hypothyroidism?
a) Limit the intake of food high in iodine.
b) Limit the intake of foods high in sodium.
c) Increase the intake of foods high in fiber.
d) Increase the intake of foods high in potassium.
Answer: c) Increase the intake of foods high in fiber.
Rationale: Constipation is a common symptom of Hypothyroidism, so increasing dietary fiber can help alleviate this symptom. Additionally, individuals with Hypothyroidism should follow a balanced diet with an appropriate nutrient intake that includes an adequate amount of iodine, needed to produce TH. Clients with Cushing's should limit sodium intake and increase food high in potassium.
The nurse is reviewing the electrolytes for a client in Adrenal Crisis. Which LAB result is expected in this condition?
a) potassium 4.2 mEq/L
b) sodium 130 mEq/L
c) glucose 110 mg/dL
b) calcium 7.8 mg/dL
Answer: b) sodium 130 mEq/L
Rationale- During Adrenal Crisis, potassium and calcium levels are high while sodium and glucose levels are low.
A client with Cushing's Disease is scheduled for surgery to remove an adrenal tumor. What appropriate preoperative nursing action should be PRIORITIZED?
a) Administering glucocorticoid medications intravenously
b) Providing education on deep breathing exercises
c) Obtaining the oral temperature and apical pulse rate
d) Placing an emergency tracheotomy kit by the bedside
Answer: c) Obtaining the oral temperature and apical pulse rate
Rationale: Clients with Cushing's disease are at increased risk of infections due to immunosuppression. Assessing for signs of infection preoperatively is essential to prevent complications. Giving glucocorticoids and education about breathing exercises would be done after surgery. Having a tracheotomy kit available would be done after a Thyroidectomy.
The nurse caring for a client in a Myxedema Coma would expect WHAT lab results to be increased?
a) Thyroxine (T4)
b) Triiodothyronine (T3)
c) TSH receptor antibody (TA)
d) Thyroid stimulating hormone (TSH)
ANSWER: d) Thyroid stimulating hormone (TSH)
Rationale: Severe Hypothyroidism can lead to a client going into a Myxedema Coma. The thyroid hormones (T4 and T3) would be very decreased which would lead to the Pituitary gland releasing more TSH. Increased TSH receptor antibody (TA) levels would indicate Grave's Disease for Hyperthyroidism.
The client who had a total Thyroidectomy suddenly becomes confused, and hypertensive with an extremely high fever. The nurse anticipates the client is more likely experiencing which COMPLICATION?
a) Hyperfunctioning Thyroid Nodule
b) Hyperparathyroidism
c) Thyroid Storm
d) Thyroiditis
Answer: c) Thyroid Storm
Rationale: A client who has had a Thyroidectomy can develop a Thyroid storm as the thyroid releases more TH as it is being removed from the body. Some symptoms experienced would be AMS, elevated BP, and temperature. Answer a) is a cause of Hyperthyroidism, Answer b) involves the parathyroid d) is inflammation of the thyroid
The nurse would recommend which DIETARY option to a client experiencing Adrenal Insufficiency?
a) baby bananas
b) potato chips
c) unsalted pretzels
d) dill pickles
Answer: d) dill pickles
Rationale: Bananas and potatoes are high in potassium which levels are usually already elevated in Adrenal Insufficiency. The pretzels are unsalted which doesn't include sodium, which clients with Adrenal Insufficiency lack and crave. Pickles are high in salt and would be the best option.
The perioperative nurse knows to monitor which LAB test more closely for a client who recently had a Total Thyroidectomy?
a) glucose
b) sodium
c) calcium
d) potassium
Answer: c) calcium
Rationale: When the thyroid is removed during a Thyroidectomy, the parathyroid also can be removed which helps regulate calcium levels in the blood via the parathyroid hormone which stimulates the bone to breakdown and release calcium into the blood. So when the parathyroid is removed, the calcium level can decrease. The other electrolytes are not as directly related or at a higher risk of changing after a Thyroidectomy.
A client with a medical history of adrenal insufficiency presents to the ED with signs of adrenal crisis. Which appropriate nursing intervention should be PRIORITIZED? Select only 2 interventions.
a) Starting a 20 gauge peripheral IV line
b) Drawing up insulin into the syringe
c) Infusing a bag of NS or D5NS slowly
d) Administering IV loop diuretics rapidly
e) Checking the levels of the electrolytes
Answers:
a) Starting a 20 gauge peripheral IV line
e) Checking the levels of the electrolytes
Rationale: Adrenal crisis is a life-threatening condition characterized by severe electrolyte imbalances of hypoglycemia and hyperkalemia. Blood glucose and potassium levels should be checked before administering diuretics and insulin. An Intravenous line should also be started. Infusion of NS and D5NS is given rapidly. Loop diuretics should not be given rapidly.
The nurse knows to monitor the client for hypertensive effects when taking WHAT type of medication to treat adrenal and thyroid diseases? Select all that apply.
a) Glucocorticoid Replacement
b) Angiotensin-converting enzyme inhibitors
c) Mineralocorticoid Replacement
d) Adrenal Corticosteroid Inhibitor
e) Thyroid Hormone Replacement
Answer: a) Glucocorticoid Replacement
c) Mineralocorticoid Replacement
e) Thyroid Hormone Replacement
Rationale: Answers a, c, and e have the potential to increase the client's blood pressure based on increased cortisol, sodium, and TH levels, respectively. ACE Inhibitors decrease blood pressure and do not treat thyroid or adrenal diseases. Adrenal Cortiosteroid Inhibitors help reduce cortisol levels with a side effect of dizziness from lowered blood pressure.
The nurse would educate a client with Cushing's Disease about their risk of developing which COMPLICATION? Select all that apply.
a) Autoimmune Disease
b) Primary Hypertension
c) Morbid Obesity
d Type I Diabetes
e) Osteoporosis
Answer: c) Morbid Obesity
e) Osteoporosis
Rationale: In addition to Obesity and Osteoporosis, Cushing Disease can also lead to SECONDARY Hypertension and TYPE II Diabetes. It DOES NOT lead to an Autoimmune Disease. Long-term steroid treatments for Autoimmune Diseases can lead to Cushing's Syndrome.
The nurse knows that DIETARY education was effective when the client with Cushing's Disease reports eating more food with which nutrient? Select all that apply.
a) calcium
b) carbohydrates
c) fat
d) iodine
e) potassium
f) protein
g) sodium
Answer: a) calcium, e) potassium, f) protein
Rationale: Clients with Cushing's Disease usually have decreased calcium and potassium as well as problems with protein metabolism, therefore they should be encouraged to eat more foods with calcium, potassium, and protein. They should eat less foods with sodium, sugar (carbs), and fat.
Which LAB result indicates the treatment for Addison's Disease with Florinef (Fludrocortisone) has had successful therapeutic effects? Select all that apply.
a) increase in the potassium levels
b) increase in the sodium levels
c) increase in the calcium levels
d) decrease in the aldosterone levels
e) decrease in the glucose levels
f) decrease in cortisol levels
Answer: b) An increase in the sodium levels
Rationale: Florinef increases low sodium levels. It does not increase calcium levels. Clients with Addison's Disease have increased potassium levels with decreased cortisol, glucose, aldosterone and sodium levels.