ME FIRST!
(PRIORITY INTERVENTIONS)
(PRIORITY INTERVENTIONS)
A client with hypothyroidism presents to the clinic complaining of fatigue, cold intolerance, and weight gain. What nursing action should be PRIORITIZED?
a) Assessing for signs of dehydration
b) Encouraging increased physical activity
c) Educating on intake of iodine-rich foods
d) Monitoring blood pressure and pulse
Answer: d) Monitoring blood pressure and pulse
Rationale: Monitoring the blood pressure and pulse is crucial in identifying the most concerning signs and symptoms of hypothyroidism.
The nurse is providing education to a client with Grave's Disease. The specific instructions to sleep with the head of the bed elevated and eyes taped shut would be provided for WHAT?
a) goiter
b) exophthalmos
c) myxedema
d) insomnia
Answer: b) exophthalmos
Rationale: Exophthalmos involves protrusion of the eyes that someone with Hyperthyroidism (Grave's Disease) can develop. It put's the client at risk of eye injury based on continuous exposure to the environment, especially when sleeping.
A male client accidently blew his nose after having a hypophysectomy. Which assessment finding indicates the COMPLICATION of cerebral spinal fluid leakage may have occurred?
a) sudden hypotension
b) mild nosebleed
c) throbbing headache
d) frequent sneezes
Answer: c) throbbing headache
Rationale: Headache can indicate CSF leakage after a hypophysectomy which involves brain surgery. All the other symptoms listed do not indicate a CSF leakage.
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 to see 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 decreased 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) Reviewing the basic metabolic panel results for hypokalemia
c) Encouraging the client to weight themselves every night
d) Monitoring the blood pressure for signs of hypotension
Answer: b) Reviewing the basic metabolic panel results for hypokalemia
Rationale: Glucocorticoid replacement therapy can lead to signs and symptoms of Cushing Syndrome which can be decreased potassium levels. Hypokalemia can cause cardiac dysrhythmias which are life-threatening.
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 effect platelets.
The nurse suspects the client that was prescribed Cortef (Hydrocortisone) for Addison's Disease 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 cortisol levels
b) suppression cortisol levels
c) non-suppression aldosterone levels
d) suppression aldosterone 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. Aldosterone levels are not tested for the Dexamethasone test.
A client with Hyperthyroidism in Thyroid Storm is admitted to the hospital with symptoms of fever, hypertension and tachycardia. Which appropriate medication should the nurse PRIORITIZED to administer?
a) levothyroxine (Synthroid)
b) propylthiouracil (PTU)
b) 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. Florinef is a mineralocorticoid to treat Addison's disease and would increase BP.
The nurse reviewing a the electronic record would identify the family history of WHAT condition as a risk for the client to develop?
a) Hashimoto's Thyroiditis
b) Hypophysectomy
c) Adrenocorticotopin 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 nurse knows which information about Myxedema Crisis is accurate about this COMPLICATION?
a) It is a common condition in the U.S.
b) It has a low mortality rate
c) It has a slow onset of symptoms
d) It is treated with antithyroid medications
Answer: c) It has a slow onset of symptoms
Rationale- Myxedema is a rare condition in the U.S. that has a high mortality rate. The onset is slow since it is cause by long-lasting hypothyroidism. Untreated Hypothyroidism or someone who has had Hypothyroidism for a long time (unknown) can gradually lead to Myxedema Crisis whose symptoms are worst and must be treated rapidly. Antithyroid medication would worsen symptoms.
Which DIETARY modification would be appropriate to advised for individuals with Hypothyroidism?
a) Decrease foods high in iodine
b) Increase foods high in sodium
c) Increase foods high in fiber
d) Decrease foods high in potassium
Answer: c) Increase 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 appropriate nutrient intake but do not typically encourage high intake of sodium or decrease intake of iodine and 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 glucocorticoids intravenously
b) Providing education on deep breathing exercises
c) Assessing for signs and symptoms of bacterial infection
d) Placing an emergency tracheotomy kit by the bedside
Answer: c) Assessing for signs and symptoms of bacterial infection
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 exercise 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 expected 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 andT3) 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 a total Thyroidectomy suddenly becomes hypertensive with a 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: Client who have had a Thyroidectomy can develop Thyroid storm as the thyroid releases more TH as it is being removed from the body. Some symptoms experienced would be an 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 strong cravings from having Adrenal Insufficiency?
a) banana chips
b) baked potato
c) unsalted pretzels
d) cheese crackers
Answer: d) cheese crackers
Rationale: Bananas and potatoes are high in potassium which levels are usually already elevated in Adrenal Insufficiency. The pretzels are unsalted which is what clients with Adrenal Insufficiency crave. Cheese crackers 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 nursing intervention should be PRIORITIZED?
a) Drawing up insulin into the syringe
b) Infusing a bag of NS or D5NS slowly
c) Administering IV loop diuretics rapidly
d) Checking the serum electrolyte levels
Answer: d) Checking serum electrolyte levels
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. Infusion of NS and D5NS is given rapidly. Loop diuretics should not be given rapidly.
The nurse knows to monitor the client for the side effect of hypertension when taking WHAT types of medications? 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 a potential to increase the client's blood pressure based on increase cortisol, sodium and TH levels, respectively. Answers b) and d) can decrease 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 Disorder
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 Disorder. The autoimmune disorder- Hashimoto's Thyroiditis can cause Cushing Disease.
The nurse knows that DIETARY education was effective when the client with Cushing's Disease reports eating which type of foods?
a) "I will eat more foods with calcium and carbohydrates."
b)" I will eat more foods with potassium and sodium."
c) "I will eat more foods with protein and potassium."
d) "I will eat more foods with sodium and calcium."
Answer: c) I will eat more foods with protein and potassium."
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?
a) An increase in the potassium levels
b) An increase in the sodium levels
c) A decrease in the glucose levels
d) A decrease in the aldosterone levels
Answer: b) An increase in the sodium levels
Rationale: Florinef helps correct electrolyte imbalances and increase blood pressure. Clients with Addison's Disease have abnormally increased potassium and abnormally decreased glucose, aldosterone and sodium levels.