Ch. 54- Pituitary & Adrenal Disorders
The nurse is caring for a client who had a transsphenoidal hypophysectomy yesterday. Which finding requires the nurse to notify the primary health care provider immediately?
Client report of a headache and stiff neck
Headache and stiff neck (nuchal rigidity) are symptoms of meningitis that have immediate implications for the client’s care. The finding requires the nurse to immediately notify the primary health care provider. Nasal drainage that tests negative for glucose is normal, expected, and not significant. Dry lips and mouth are not unusual after surgery. A urine specific gravity of 1.016 is within normal limits.
Which changing trends in a client’s serum laboratory values indicate to the nurse that thyroid hormone replacement therapy for hypothyroidism is effective?
Rising thyroid hormone (TH) levels; declining thyroid-stimulating hormone (TSH) levels
Drug therapy for hypothyroidism hormone replacement therapy with synthetic thyroid hormones, which would result in rising TH levels. As these levels rise, the negative feedback loop, which tries to stimulate the thyroid gland to produce TH would be suppressed, causes declining TSH levels. Thyroglobulin levels are related to active thyroid tissue. In hypothyroidism, these levels are low and drug therapy does not increase them. TRAbs are not a cause of hypothyroidism and do not develop with drug therapy.
Which assessment finding in a client with diabetes mellitus indicates to the nurse that the disease is damaging the kidneys?
Protein in the urine during a random urinalysis
Urine should not contain protein and the presence of proteinuria in a client with marks the beginning of renal problems known as diabetic nephropathy, that progresses eventually to end-stage renal disease. Chronically elevated blood glucose levels cause renal hypertension and excess kidney perfusion with leakage from the renal vasculature. The excess leakiness allows larger substances, such as proteins, to be filtered into the urine.
A patient is receiving 60 mg of methylprednisolone IM every 8 hours. You
have on hand 75 mg/mL. How much will you draw up?
0.8 mL
Which primary health care provider order will the nurse perform first for a client with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 105 mEq/L (105 mmol/L)?
Administering an infusion of 150 mL hypertonic saline over the next 3 hours
The first intervention the nurse performs is to administer an infusion of 150 mL hypertonic saline over 3 hours. When the serum sodium level is below 115 mEq/L (115 mmol/L), the client is at increased risk for seizures and coma. Drawing blood for hematocrit and hemoglobin levels, inserting an indwelling catheter for urine monitoring, and weighing the admitted client can be subsequently done.
Which action does the postanesthesia care unit (PACU) nurse perform when caring for a client who has just arrived after a total thyroidectomy?
Monitoring oxygen saturation
Airway assessment and management is always the first priority with every client, especially for a client who has had surgery that involves potential bleeding and edema near the trachea. Assessing the wound dressing for bleeding is a high priority, which is performed next after assessing airway and breathing. Pain control is important, but can be addressed after airway assessment. The neck position should be maintained to avoid tension on the incision.
Which action has the highest priority for the nurse to take when a client with type 1 diabetes arrives in the emergency department breathing deeply and stating, “I can’t catch my breath.” Vital signs are: T 98.4°F (36.9°C), P 112 beats/min, R 38 breaths/min, BP 91/54 mm Hg, and O2 saturation 99% on room air.
Assessing blood glucose level
The nurse would first obtain the client’s glucose level. Breathing deeply and stating, “I can’t catch my breath” is indicative of Kussmaul respirations which is a sign of diabetic ketoacidosis (DKA). Based on the oxygen saturation, oxygen administration is not indicated. The diagnosis of DKA does not require ABGs. Cardiac monitoring may be implemented, but the first action would be to obtain the glucose level.
Infuse 1,000 mL Ringer’s lactate in 12
hours. Drop factor is 15 gtt/mL.
21 gtts/min
Which assessment finding in a client with diagnosis of diabetes insipidus (DI) indicates to the nurse that desmopressin therapy is effective?
Urine output of 30 to 50 mL/hr
With DI, insufficient amounts of vasopressin (antidiuretic hormone [ADH]) prevent reabsorption of water, leading to profound diuresis that can result in dehydration. Desmopressin, a synthetic form of ADH, is the drug of choice to stop fluid loss. A blood glucose result of 110 mg/dL (6.1 mmol/L) is within the range of normal blood glucose levels, as are the respiratory rate and the potassium level.
The nurse reviews the vital signs of a client diagnosed with Graves disease and notes that the client’s temperature is 99.6°F (37.6°C). After notifying the primary health care provider, what is the nurse’s next action?
Assess cardiac status.
Graves disease is manifested by symptoms of hyperthyroidism and increased metabolic rate, including fever. The nurse must next assess the client’s cardiac status as atrial fibrillation or other dysrhythmias may have developed. If the client has a cardiac monitor, the nurse needs to check for any dysrhythmias. Administering aspirin is contraindicated. Activating the Rapid Response Team is not needed at this time as no instability has been noted. Unlike with infection, temperature elevations in a client with hyperthyroidism are not associated with chills.
Which nursing action is appropriate when assessing that a client who has had diabetes for 15 years has decreased sensory perception in both feet?
Examining both feet for indications of injury
When reduced peripheral sensory perception is present, the likelihood of injury is high. Any open area or other problem on the foot of a person with diabetes is at great risk for infection and must be managed carefully and quickly. Checking for sensory perception on the hands and other areas is important but can come after a thorough foot examination.
Order: Heparin 1450 units/hr
Available: Heparin 25,000 units in 500 mL D5W
The IV flow rate is
29 mL/hr
Which assessment finding in a client with hyperaldosteronism indicates to the nurse that the condition is increasing in severity?
Numbness and tingling reported around the mouth.
Hyperaldosteronism causes potassium to be excreted excessively. As hypokalemia becomes more severe, paresthesias occur with numbness and tingling around the mouth and of the fingers and toes. The pH shown is normal. Temperature elevation and increased urine output are not associated with a worsening of hyperaldosteronism.
Which assessment finding in a client who had a parathyroidectomy yesterday indicates to the nurse that immediate action is needed?
Bilateral leg muscle twitching
Clients are at risk for hypocalcemia and seizures after removal of the parathyroid glands. Muscle twitching is an indication of hypocalcemia and requires assessment and intervention. The other findings are normal findings after surgery.
How will the nurse reply when a client with type 2 diabetes tells the nurse that he would like to have a 12-ounce glass of beer with supper but believes that is now impossible?
“You can have a beer with a meal if you test yourself for hypoglycemia an hour later.”
Alcohol consumption contributes to hypoglycemia. This risk is reduced if the alcohol is consumed with or shortly after a meal. The client is instructed to check blood glucose levels about an hour after alcohol is consumed to determine if either more food is needed or if insulin dosage needs to be adjusted.
Calculate the fluid intake in milliliters (mL) for the following meal.
(Assume a cup = 6 oz and a glass = 8 oz)
1/3 glass orange juice
1/2 cup tea
1/2 pt milk
1 tuna fish sandwich
1 Popsicle (3 oz)
510 mL
In collaboration with the registered dietitian nutritionist, which dietary alterations will the nurse teach a client with Cushing disease to make?
Low carbohydrate, high calorie, and low sodium
The client with Cushing disease has weight gain, muscle loss, hyperglycemia, and sodium retention. Dietary modifications need to include reduction of total calories and carbohydrates to prevent or reduce the degree of hyperglycemia. The sodium retention causes water retention and hypertension. Clients are encouraged to moderately restrict sodium intake. Other choices are inappropriate.
With which client will the nurse be aware of an increased risk for hypoparathyroidism?
Client who had radiation therapy for Graves disease
Hypoparathyroidism is a relatively rare disorder. It is most often caused by treatment for hyperthyroidism that resulted in injury to the parathyroid glands.
How will the nurse evaluate the level of glycemic control for a client with diabetes whose laboratory values include a fasting blood glucose level of 82 mg/dL (mmol/L) and an A1C of 5.9%?
The values indicate that the client has managed the disease well.
Fasting blood glucose levels provide an indication of the client’s adherence to drug and nutrition therapy for DM has been for the previous 24 hours. This client’s FBG is well within the normal range. A1c provides an indication of general blood glucose control for the past several months because when glucose attaches to hemoglobin, the attachment is permanent for as long as those hemoglobin molecules are present within red blood cells. Normal red blood cell life span is about 120 days. This client’s A1c level is within the desirable range, indicating good long-term glucose control as well as short-term control.
Order: Humulin NPH 40 units and Humulin Regular 25 units SC every morning. The
AM finger-stick blood sugar is 213mg/dL. What is the total number of units to be
administered? Use the sliding scale below. ________ units
Blood Sugar Regular Insulin
0-180 0 units
181-200 2 units
201-220 4 units
221-240 6 units
> 240 Call physician
69 units