Endocrine ———

The nurse explains to a client with thyroid disease that the thyroid gland normally produces:

1. iodine and thyroid-stimulating hormone (TSH).

2. thyrotropin-releasing hormone (TRH) and TSH.

3. TSH, T3, and calcitonin.

4. T3, T4, and calcitonin.

4. T3, T4, and calcitonin. The thyroid gland normally produces thyroid hormone (T3 and T4) and calcitonin. TSH is produced by the pituitary gland to regulate the thyroid gland. TRH is produced by the hypothalamus gland to regulate the pituitary gland.

A client is seen in the clinic with a possible parathormone deficiency. Diagnosis of this condition includes the analysis of serum electrolytes. Which electrolytes would the nurse expect to be abnormal?

1. Sodium

2. Potassium

3. Calcium

4. Chloride

5. Glucose

6. Phosphorous

3. Calcium 6. Phosphorous A client with a parathormone deficiency has abnormal calcium and phosphorous values because parathormone regulates these two electrolytes. Potassium, chloride, sodium, and glucose aren’t affected by a parathormone deficiency.

A client is being returned to the room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client’s bedside?

1. Indwelling urinary catheter kit

2. Tracheostomy set

3. Cardiac monitor

4. Humidifier

2. Tracheostomy set After a subtotal thyroidectomy, swelling of the surgical site (the tracheal area) may obstruct the airway. Therefore, the nurse should keep a tracheostomy set at the client’s bedside in case of a respiratory emergency. Although an indwelling urinary catheter and a cardiac monitor may be used for a client after a thyroidectomy, the tracheostomy set is more important. A humidifier isn’t indicated for this client.

When assessing a client with pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, the nurse is most likely to detect:

1. a blood pressure of 130/70 mm Hg.

2. a blood glucose level of 130 mg/dl.

3. bradycardia.

4. a blood pressure of 176/88 mm Hg.

4. a blood pressure of 176/88 mm Hg. Pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, causes hypertension, tachycardia, hyperglycemia, hypermetabolism, and weight loss. It isn’t associated with the other options.

Which nursing diagnosis takes highest priority for a client with hyperthyroidism?

1. Risk for imbalanced nutrition: More than body requirements related to thyroid hormone excess

2. Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing

3. Disturbed body image related to weight gain and edema

4. Imbalanced nutrition: Less than body requirements related to thyroid hormone excess

4. Imbalanced nutrition: Less than body requirements related to thyroid hormone excess In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism. These conditions may result in a negative nitrogen balance, increased protein synthesis and breakdown, decreased glucose tolerance, and fat mobilization and depletion. This puts the client at risk for marked nutrient and calorie deficiency, making Imbalanced nutrition: Less than body requirements the most important nursing diagnosis. Options 2 and 3 may be appropriate for a client with hypothyroidism, which slows the metabolic rate.

A client with Addison’s disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of:

1. calcium and phosphorus abnormalities.

2. chloride and magnesium abnormalities.

3. sodium and chloride abnormalities.

4. sodium and potassium abnormalities.

4. sodium and potassium abnormalities. In Addison’s disease, a form of adrenocortical hypofunction, aldosterone secretion is reduced. Aldosterone promotes sodium conservation and potassium excretion. Therefore, aldosterone deficiency increases sodium excretion, predisposing the client to hyponatremia, and inhibits potassium excretion, predisposing the client to hyperkalemia. Because aldosterone doesn’t regulate calcium, phosphorus, chloride, or magnesium, an aldosterone deficiency doesn’t affect levels of these electrolytes directly.

Which important instruction concerning the administration of levothyroxine (Synthroid) should the nurse teach a client?

1. "Take the drug on an empty stomach."

2. "Take the drug with meals."

3. "Take the drug in the evening."

4. "Take the drug whenever convenient."

1. "Take the drug on an empty stomach." The nurse should instruct the client to take levothyroxine on an empty stomach (to promote regular absorption) in the morning (to help prevent insomnia and to mimic normal hormone release).

A client is diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?

1. Decreased serum sodium level

2. Decreased serum creatinine level

3. Increased hematocrit

4. Increased blood urea nitrogen (BUN) level

1. Decreased serum sodium level In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia. In SIADH, the serum creatinine level isn’t affected by the client’s fluid status and remains within normal limits. Typically, the hematocrit and BUN level decrease.

During preoperative teaching for a client who will undergo subtotal thyroidectomy, the nurse should include which statement?

1. "The head of your bed must remain flat for 24 hours after surgery."

2. "You should avoid deep breathing and coughing after surgery."

3. "You won’t be able to swallow for the first day or two."

4. "You must avoid hyperextending your neck after surgery."

4. "You must avoid hyperextending your neck after surgery." To prevent undue pressure on the surgical incision after subtotal thyroidectomy, the nurse should advise the client to avoid hyperextending the neck. The client may elevate the head of the bed as desired and should perform deep breathing and coughing to help prevent pneumonia. Subtotal thyroidectomy doesn’t affect swallowing.

Which of the following laboratory test results would suggest to the nurse that a client has a corticotropin-secreting pituitary adenoma?

1. High corticotropin and low cortisol levels

2. Low corticotropin and high cortisol levels

3. High corticotropin and high cortisol levels

4. Low corticotropin and low cortisol levels

3. High corticotropin and high cortisol levels A corticotropin-secreting pituitary tumor would cause high corticotropin and high cortisol levels. A high corticotropin level with a low cortisol level and a low corticotropin level with a low cortisol level would be associated with hypocortisolism. Low corticotropin and high cortisol levels would be seen if there was a primary defect in the adrenal glands.

The nurse is assessing a client with possible Cushing’s syndrome. In a client with Cushing’s syndrome, the nurse would expect to find:

1. hypotension.

2. thick, coarse skin.

3. deposits of adipose tissue in the trunk and dorsocervical area.

4. weight gain in arms and legs.

3. deposits of adipose tissue in the trunk and dorsocervical area. 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.

A 35-year-old female client who complains of weight gain, facial hair, absent menstruation, frequent bruising, and acne is diagnosed with Cushing’s syndrome. Cushing’s syndrome is most likely caused by:

1. an ectopic corticotropin-secreting tumor.

2. adrenal carcinoma.

3. a corticotropin-secreting pituitary adenoma.

4. an inborn error of metabolism.

3. a corticotropin-secreting pituitary adenoma. A corticotropin-secreting pituitary adenoma is the most common cause of Cushing’s syndrome in women ages 20 to 40. Ectopic corticotropin-secreting tumors are more common in older men and are often associated with weight loss. Adrenal carcinoma isn’t usually accompanied by hirsutism. A female with an inborn error of metabolism wouldn’t be menstruating.

A client who suffered a brain injury after falling off a ladder has recently developed syndrome of inappropriate antidiuretic hormone (SIADH). What findings indicate that the treatment he’s receiving for SIADH is effective?

1. Decrease in body weight

2. Rise in blood pressure and drop in heart rate

3. Absence of wheezes in the lungs

4. Increase in urine output

5. Decrease in urine osmolarity

1. Decrease in body weight 4. Increase in urine output 5. Decrease in urine osmolarity SIADH is an abnormality involving an abundance of diuretic hormone. The predominant feature is water retention with oliguria, edema, and weight gain. Successful treatment should result in weight reduction, increased urine output, and a decrease in the urine concentration (urine osmolarity).

A client has recently undergone surgical removal of a pituitary tumor. The physician prescribes corticotropin (Acthar), 20 units I.M. q.i.d., as a replacement therapy. What is the mechanism of action of corticotropin?

1. It decreases cyclic adenosine monophosphate (cAMP) production and affects the metabolic rate of target organs.

2. It interacts with plasma membrane receptors to inhibit enzymatic actions.

3. It interacts with plasma membrane receptors to produce enzymatic actions that affect protein, fat, and carbohydrate metabolism.

4. It regulates the threshold for water resorption in the kidneys.

3. It interacts with plasma membrane receptors to produce enzymatic actions that affect protein, fat, and carbohydrate metabolism. Corticotropin interacts with plasma membrane receptors to produce enzymatic actions that affect protein, fat, and carbohydrate metabolism. It doesn’t decrease cAMP production. The posterior pituitary hormone, antidiuretic hormone, regulates the threshold for water resorption in the kidneys.

The adrenal cortex is responsible for producing which substances?

1. Glucocorticoids and androgens

2. Catecholamines and epinephrine

3. Mineralocorticoids and catecholamines

4. Norepinephrine and epinephrine

1. Glucocorticoids and androgens The adrenal glands have two divisions, the cortex and medulla. The cortex produces three types of hormones: glucocorticoids, mineralocorticoids, and androgens. The medulla produces catecholamines — epinephrine and norepinephrine.

The nurse is performing an admission assessment on a client diagnosed with diabetes insipidus. Which findings should the nurse expect to note during the assessment?

1. Extreme polyuria

2. Excessive thirst

3. Elevated systolic blood pressure

4. Low urine specific gravity

5. Bradycardia

6. Elevated serum potassium level

1. Extreme polyuria 2. Excessive thirst 4. Low urine specific gravity Signs and symptoms of diabetes insipidus include an abrupt onset of extreme polyuria, excessive thirst, dry skin and mucous membranes, tachycardia, and hypotension. Diagnostic studies reveal low urine specific gravity and osmolarity and elevated serum sodium. Serum potassium levels are likely to be decreased, not increased.

The nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do?

1. Monitor laboratory values daily for an elevated thyroid-stimulating hormone.

2. Observe for swelling of the neck, tracheal deviation, and severe pain.

3. Evaluate the quality of the client’s voice postoperatively, noting any drastic changes.

4. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

4. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia. The other options describe complications for which the nurse should also be observing; however, tetany and neurologic alterations are primary indications of hypocalcemia.

The nurse is assessing a client with hyperthyroidism. What findings should the nurse expect?

1. Weight gain, constipation, and lethargy

2. Weight loss, nervousness, and tachycardia

3. Exophthalmos, diarrhea, and cold intolerance

4. Diaphoresis, fever, and decreased sweating

2. Weight loss, nervousness, and tachycardia Weight loss, nervousness, and tachycardia are signs of hyperthyroidism. Other signs of hyperthyroidism include exophthalmos, diaphoresis, fever, and diarrhea. Weight gain, constipation, lethargy, decreased sweating, and cold intolerance are signs of hypothyroidism.

A client visits the physician’s office complaining of agitation, restlessness, and weight loss. The physical examination reveals exophthalmos, a classic sign of Graves’ disease. Based on history and physical findings, the nurse suspects hyperthyroidism. Exophthalmos is characterized by:

1. dry, waxy swelling and abnormal mucin deposits in the skin.

2. protruding eyes and a fixed stare.

3. a wide, staggering gait.

4. more than 10 beats/minute difference between the apical and radial pulse rates.

2. protruding eyes and a fixed stare. Exophthalmos is characterized by protruding eyes and a fixed stare. Dry, waxy swelling and abnormal mucin deposits in the skin typify myxedema, a condition resulting from advanced hypothyroidism. A wide, staggering gait and a differential between the apical and radial pulse rates aren’t specific signs of thyroid dysfunction.

An incoherent client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, the nurse prepares to take emergency action to prevent the potential complication of:

1. thyroid storm.

2. cretinism.

3. myxedema coma.

4. Hashimoto’s thyroiditis.

3. myxedema coma. Severe hypothyroidism may result in myxedema coma, in which a drastic drop in the metabolic rate causes decreased vital signs, hypoventilation (possibly leading to respiratory acidosis), and nonpitting edema. Thyroid storm is an acute complication of hyperthyroidism. Cretinism is a form of hypothyroidism that occurs in infants. Hashimoto’s thyroiditis is a common chronic inflammatory disease of the thyroid gland in which autoimmune factors play a prominent role.

When caring for a client who’s being treated for hyperthyroidism, it’s important to:

1. provide extra blankets and clothing to keep the client warm.

2. monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy.

3. balance the client’s periods of activity and rest.

4. encourage the client to be active to prevent constipation.

3. balance the client’s periods of activity and rest. A client with hyperthyroidism needs to be encouraged to balance periods of activity and rest. Many clients with hyperthyroidism are hyperactive and complain of feeling very warm. Consequently, it’s important to keep the environment cool and to teach the client how to manage his physical reactions to heat. Clients with hypothyroidism — not hyperthyroidism — complain of being cold and need warm clothing and blankets to maintain a comfortable temperature. They also receive thyroid replacement therapy, often feel lethargic and sluggish, and are prone to constipation. The nurse should encourage clients with hypothyroidism to be more active to prevent constipation.

A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client’s hypertension is caused by excessive hormone secretion from which gland?

1. Adrenal cortex

2. Pancreas

3. Adrenal medulla

4. Parathyroid

1. Adrenal cortex Excessive secretion of aldosterone in the adrenal cortex is responsible for the client’s hypertension. This hormone acts on the renal tubule, where it promotes reabsorption of sodium and excretion of potassium and hydrogen ions. The pancreas mainly secretes hormones involved in fuel metabolism. The adrenal medulla secretes the catecholamines — epinephrine and norepinephrine. The parathyroids secrete parathyroid hormone.

A client with Addison’s disease is scheduled for discharge after being hospitalized for an adrenal crisis. Which statements by the client would indicate that client teaching has been effective?

1. "I have to take my steroids for 10 days."

2. "I need to weigh myself daily to be sure I don’t eat too many calories."

3. "I need to call my doctor to discuss my steroid needs before I have dental work."

4. "I will call the doctor if I suddenly feel profoundly weak or dizzy."

5. "If I feel like I have the flu, I’ll carry on as usual because this is an expected response."

6. "I need to obtain and wear a Medic Alert bracelet."

3. "I need to call my doctor to discuss my steroid needs before I have dental work." 4. "I will call the doctor if I suddenly feel profoundly weak or dizzy." 6. "I need to obtain and wear a Medic Alert bracelet." Dental work can be a cause of physical stress; therefore, the client’s physician needs to be informed about the dental work and an adjusted dosage of steroids may be necessary. Fatigue, weakness, and dizziness are symptoms of inadequate dosing of steroid therapy; the physician should be notified if these symptoms occur. A Medic Alert bracelet allows health care providers to access the client’s history of Addison’s disease if the client is unable to communicate this information. A client with Addison’s disease doesn’t produce enough steroids, so routine administration of steroids is a lifetime treatment. Daily weights should be monitored to monitor changes in fluid balance, not calorie intake. Influenza is an added physical stressor and the client may require an increased dosage of steroids. The client shouldn’t "carry on as usual."

Following a transsphenoidal hypophysectomy, the nurse should assess the client carefully for which condition?

1. Hypocortisolism

2. Hypoglycemia

3. Hyperglycemia

4. Hypercalcemia

1. Hypocortisolism The nurse should assess for hypocortisolism. Abrupt withdrawal of endogenous cortisol may lead to severe adrenal insufficiency. Steroids should be given during surgery to prevent hypocortisolism from occurring. Signs of hypocortisolism include vomiting, increased weakness, dehydration and hypotension. After the corticotropin-secreting tumor is removed, the client shouldn’t be at risk for hyperglycemia. Calcium imbalance shouldn’t occur in this situation.

For the first 72 hours after thyroidectomy surgery, the nurse would assess the client for Chvostek’s sign and Trousseau’s sign because they indicate:

1. hypocalcemia.

2. hypercalcemia.

3. hypokalemia.

4. hyperkalemia.

1. hypocalcemia. 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.

Before undergoing a subtotal thyroidectomy, a client receives potassium iodide (Lugol’s solution) and propylthiouracil (PTU). The nurse would expect the client’s symptoms to subside:

1. in a few days.

2. in 3 to 4 months.

3. immediately.

4. in 1 to 2 weeks.

4. in 1 to 2 weeks. Potassium iodide reduces the vascularity of the thyroid gland and is used to prepare the gland for surgery. Potassium iodide reaches its maximum effect in 1 to 2 weeks. PTU blocks the conversion of thyroxine to triiodothyronine, the more biologically active thyroid hormone. PTU effects are also seen in 1 to 2 weeks. To relieve symptoms of hyperthyroidism in the interim, clients are usually given a beta-adrenergic blocker such as propranolol.

During the first 24 hours after a client is diagnosed with Addisonian crisis, which intervention should the nurse perform frequently?

1. Weigh the client.

2. Test urine for ketones.

3. Assess vital signs.

4. Administer oral hydrocortisone.

3. Assess vital signs. Because the client in Addisonian crisis is unstable, vital signs and fluid and electrolyte balance should be assessed every 30 minutes until he’s stable. Daily weights are sufficient when assessing the client’s condition. The client shouldn’t have ketones in his urine, so there is no need to assess the urine for their presence. Oral hydrocortisone isn’t administered during the first 24 hours in severe adrenal insufficiency.

A client with a history of Addison’s disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. When he awoke this morning, his wife noticed that he acted confused and was extremely weak. The client’s blood pressure is 90/58 mm Hg, his pulse is 116 beats/minute, and his temperature is 101° F (38.3° C). A diagnosis of acute adrenal insufficiency is made. What would the nurse expect to administer by I.V. infusion?

1. Insulin

2. Hydrocortisone

3. Potassium

4. Hypotonic saline

2. Hydrocortisone Emergency treatment for acute adrenal insufficiency (Addisonian crisis) is I.V. infusion of hydrocortisone and saline solution. The client is usually given a dose containing hydrocortisone 100 mg I.V. in normal saline every 6 hours until the client’s blood pressure returns to normal. Insulin isn’t indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia. Potassium isn’t indicated because these clients are usually hyperkalemic. The client needs normal — not hypotonic — saline solution.

Following a unilateral adrenalectomy, the nurse would assess for hyperkalemia as indicated by:

1. muscle weakness.

2. tremors.

3. diaphoresis.

4. constipation.

1. muscle weakness. Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which is transient and occurs from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren’t seen in hyperkalemia.

A client is being treated for hypothyroidism. The nurse knows that thyroid replacement therapy has been inadequate when she notes which findings?

1. Prolonged QT interval on electrocardiogram

2. Tachycardia

3. Low body temperature

4. Nervousness

5. Bradycardia

6. Dry mouth

1. Prolonged QT interval on electrocardiogram 3. Low body temperature 5. Bradycardia In hypothyroidism, the body is in a hypometabolic state. Therefore, a prolonged QT interval with bradycardia and subnormal body temperature would indicate that replacement therapy was inadequate. Tachycardia, nervousness, and dry mouth are symptoms of an excessive level of thyroid hormone; these findings would indicate that the client has received an excessive dose of thyroid hormone.

A businesswoman comes into the clinic with a progressively enlarging neck. The client mentions that she has been in a foreign country for the previous 3 months and that she didn’t eat much while she was there because she didn’t like the food. The client also mentions that she becomes dizzy when lifting her arms to do normal household chores or when dressing. What endocrine disorder would the nurse expect the physician to diagnose?

1. Diabetes mellitus

2. Goiter

3. Diabetes insipidus

4. Cushing’s syndrome

2. Goiter A goiter can result from inadequate dietary intake of iodine associated with changes in foods or malnutrition. It’s caused by insufficient thyroid gland production and depletion of glandular iodine. Signs and symptoms of this malfunction include enlargement of the thyroid gland, dizziness when raising the arms above the head, dysphagia, and respiratory distress. Signs and symptoms of diabetes mellitus include polydipsia, polyuria, and polyphagia. Signs and symptoms of diabetes insipidus include extreme polyuria (4 to 16 L/day) and symptoms of dehydration (poor tissue turgor, dry mucous membranes, constipation, dizziness, and hypotension). Cushing’s syndrome causes buffalo hump, moon face, irritability, emotional lability, and pathologic fractures.

When teaching a client with Cushing’s syndrome about dietary changes, the nurse should instruct the client to increase intake of:

1. fresh fruits.

2. dairy products.

3. processed meats.

4. cereals and grains.

1. fresh fruits. Cushing’s syndrome causes sodium retention, which increases urinary potassium loss. Therefore, the nurse should advise the client to increase intake of potassium-rich foods, such as fresh fruit. The client should restrict consumption of dairy products, processed meats, cereals, and grains because they contain significant amounts of sodium.

Early this morning, a client had a subtotal thyroidectomy. During evening rounds, the nurse 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?

1. Diabetic ketoacidosis

2. Thyroid crisis

3. Hypoglycemia

4. Tetany

2. Thyroid crisis 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 client with Cushing’s syndrome is admitted to the medical-surgical unit. During the admission assessment, the nurse notes that the client is agitated and irritable, has poor memory, reports loss of appetite, and appears disheveled. These findings are consistent with which problem?

1. Depression

2. Neuropathy

3. Hypoglycemia

4. Hyperthyroidism

1. Depression Agitation, irritability, poor memory, loss of appetite, and neglect of one’s appearance may signal depression, which is common in clients with Cushing’s syndrome. Neuropathy affects clients with diabetes mellitus — not Cushing’s syndrome. Although hypoglycemia can cause irritability, it also produces increased appetite, rather than loss of appetite. Hyperthyroidism typically causes such signs as goiter, nervousness, heat intolerance, and weight loss despite increased appetite.

A 56-year-old female client is being discharged after undergoing a thyroidectomy. Which discharge instructions would be appropriate for this client?

1. "Report signs and symptoms of hypoglycemia."

2. "Take thyroid replacement medication as ordered."

3. "Watch for changes in body functioning, such as lethargy, restlessness, sensitivity to cold, and dry skin, and report these changes to the physician."

4. "Recognize the signs of dehydration."

5. "Carry injectable dexamethasone at all times."

2. "Take thyroid replacement medication as ordered." 3. "Watch for changes in body functioning, such as lethargy, restlessness, sensitivity to cold, and dry skin, and report these changes to the physician." After the removal of the thyroid gland, the client needs to take thyroid replacement medication. The client also needs to report such changes as lethargy, restlessness, cold sensitivity, and dry skin, which may indicate the need for a higher dosage of medication. The thyroid gland doesn’t regulate blood glucose levels; therefore, signs and symptoms of hypoglycemia aren’t relevant for this client. Dehydration is seen in diabetes insipidus. Injectable dexamethasone isn’t needed for this client.

The nurse is instructing a client with newly diagnosed hypoparathyroidism about the regimen used to treat this disorder. The nurse should state that the physician probably will prescribe daily supplements of calcium and:

1. folic acid.

2. vitamin D.

3. potassium.

4. iron.

2. vitamin D. Typically, clients with hypoparathyroidism are prescribed daily supplements of vitamin D along with calcium because calcium absorption from the small intestine depends on vitamin D. Hypoparathyroidism doesn’t cause a deficiency of folic acid, potassium, or iron. Therefore, the client doesn’t require daily supplements of these substances to maintain a normal serum calcium level.

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

1. Infusing I.V. fluids rapidly as ordered

2. Encouraging increased oral intake

3. Restricting fluids

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

3. Restricting fluids 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.

The nurse is caring for a client in acute addisonian crisis. Which laboratory data would the nurse expect to find?

1. Hyperkalemia

2. Reduced blood urea nitrogen (BUN)

3. Hypernatremia

4. Hyperglycemia

1. Hyperkalemia In adrenal insufficiency, the client has hyperkalemia due to reduced aldosterone secretion. BUN increases as the glomerular filtration rate is reduced. Hyponatremia is caused by reduced aldosterone secretion. Reduced cortisol secretion leads to impaired glyconeogenesis and a reduction of glycogen in the liver and muscle, causing hypoglycemia.

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

1. vasopressin (Pitressin Synthetic).

2. furosemide (Lasix).

3. regular insulin.

4. 10% dextrose.

1. vasopressin (Pitressin Synthetic). 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.

In a 28-year-old female client who is being successfully treated for Cushing’s syndrome, the nurse would expect a decline in:

1. serum glucose level.

2. hair loss.

3. bone mineralization.

4. menstrual flow.

1. serum glucose level. Hyperglycemia, which develops from glucocorticoid excess, is a manifestation of Cushing’s syndrome. With successful treatment of the disorder, serum glucose levels decline. Hirsutism is common in Cushing’s syndrome; therefore, with successful treatment, abnormal hair growth also declines. Osteoporosis occurs in Cushing’s syndrome; therefore, with successful treatment, bone mineralization increases. Amenorrhea develops in Cushing’s syndrome. With successful treatment, the client experiences a return of menstrual flow, not a decline in it.

Which nursing diagnosis is most appropriate for a client with Addison’s disease?

1. Risk for infection

2. Excessive fluid volume

3. Urinary retention

4. Hypothermia

1. Risk for infection 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.

The nursing care for the client in addisonian crisis should include which intervention?

1. Encouraging independence with activities of daily living (ADLs)

2. Allowing ambulation as tolerated

3. Offering extra blankets and raising the heat in the room to keep the client warm

4. Placing the client in a private room

4. Placing the client in a private room The client in addisonian crisis has a reduced ability to cope with stress due to an inability to produce corticosteroids. Compared to a multibed room, a private room is easier to keep quiet, dimly lit, and temperature controlled. Also, visitors can be limited to reduce noise, promote rest, and decrease the risk of infection. The client should be kept on bed rest, receiving total assistance with ADLs to avoid stress as much as possible. Because extremes of temperature should be avoided, measures to raise the body temperature, such as extra blankets and turning up the heat, should be avoided.

A client has a serum calcium level of 7.2 mg/dl. During the physical examination, the nurse expects to assess:

1. Trousseau’s sign.

2. Homans’ sign.

3. Hegar’s sign.

4. Goodell’s sign.

1. Trousseau’s sign. This client’s serum calcium level indicates hypocalcemia, an electrolyte imbalance that causes Trousseau’s sign (carpopedal spasm induced by inflating the blood pressure cuff above systolic pressure). Homans’ sign (pain on dorsiflexion of the foot) indicates deep vein thrombosis. Hegar’s sign (softening of the uterine isthmus) and Goodell’s sign (cervical softening) are probable signs of pregnancy.

Which of the following is the most critical intervention needed for a client with myxedema coma?

1. Administering an oral dose of levothyroxine (Synthroid)

2. Warming the client with a warming blanket

3. Measuring and recording accurate intake and output

4. Maintaining a patent airway

4. Maintaining a patent airway Because respirations are depressed in myxedema coma, maintaining a patent airway is the most critical nursing intervention. Ventilatory support is usually needed. Although myxedema coma is associated with severe hypothermia, a warming blanket shouldn’t be used because it may cause vasodilation and shock. Gradual warming with blankets would be appropriate. Thyroid replacement will be administered I.V. and although intake and output are very important, these aren’t critical interventions at this time.

A middle-age female complains of anxiety, insomnia, weight loss, the inability to concentrate, and eyes feeling "gritty". Thyroid function tests reveal the following: thyroid-stimulating hormone (TSH) 0.02 U/ml, thyroxine 20 g/dl, and triiodothyronine 253 ng/dl. A 6-hr radioactive iodine uptake test showed a diffuse uptake of 85%. Based on these assessment findings, the nurse should suspect:

1. thyroiditis.

2. Graves’ disease.

3. Hashimoto’s thyroiditis.

4. multinodular goiter.

2. Graves’ disease. Graves’ disease, an autoimmune disease causing hyperthyroidism, is most prevalent in middle-age females. In Hashimoto’s thyroiditis, the most common form of hypothyroidism, TSH levels would be high and thyroid hormone levels low. In thyroiditis, there is a low (≤2%) radioactive iodine uptake, and multinodular goiter will show an uptake in the high-normal range (3% to 10%).

A 62-year-old client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past 2 years. She’s fatigued from lack of sleep; urinates frequently, even during the night; and has lost weight recently. Tests reveal the following: sodium level 152 mEq/L, osmolarity 340 mOsm/L, glucose level 125 mg/dl, and potassium level 3.8 mEq/L. Which nursing diagnosis is most appropriate for this client?

1. Deficient fluid volume related to inability to conserve water

2. Imbalanced nutrition: Less than body requirements related to hypermetabolic state

3. Deficient fluid volume related to osmotic diuresis induced by hypernatremia

4. Imbalanced nutrition: Less than body requirements related to catabolic effects of insulin deficiency

1. Deficient fluid volume related to inability to conserve water The client has signs and symptoms of diabetes insipidus, probably caused by the failure of her renal tubules to respond to antidiuretic hormone as a consequence of pyelonephritis. The hypernatremia is secondary to her water loss. Imbalanced nutrition related to hypermetabolic state or catabolic effect of insulin deficiency is an inappropriate nursing diagnosis for the client.

Which of the following instructions should be included in the discharge teaching plan for a client after thyroidectomy for Graves’ disease?

1. Keep an accurate record of intake and output.

2. Use nasal desmopressin acetate (DDAVP).

3. Be sure to get regular follow-up care.

4. Be sure to exercise to improve cardiovascular fitness.

3. Be sure to get regular follow-up care. Regular follow-up care for the client with Graves’ disease is critical because most cases eventually result in hypothyroidism. Annual thyroid-stimulating hormone tests and the client’s ability to recognize signs and symptoms of thyroid dysfunction will help detect thyroid abnormalities early. Intake and output is important for clients with fluid and electrolyte imbalances but not thyroid disorders. DDAVP is used to treat diabetes insipidus. While exercise to improve cardiovascular fitness is important, for this client the importance of regular follow-up is most critical.

For a client with Graves’ disease, which nursing intervention promotes comfort?

1. Restricting intake of oral fluids

2. Placing extra blankets on the client’s bed

3. Limiting intake of high-carbohydrate foods

4. Maintaining room temperature in the low-normal range

4. Maintaining room temperature in the low-normal range Graves’ disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client’s room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will prescribe diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client does not comply with the recommended treatment, which complication may arise?

1. Cerebral edema

2. Hypovolemic shock

3. Severe hyperkalemia

4. Tetany

1. Cerebral edema Noncompliance with treatment for SIADH may lead to water intoxication from fluid retention caused by excessive antidiuretic hormone. This, in turn, limits water excretion and increases the risk for cerebral edema. Hypovolemic shock results from, severe deficient fluid volume; in contrast, SIADH causes excess fluid volume. The major electrolyte disturbance in SIADH is dilutional hyponatremia, not hyperkalemia. Because SIADH doesn’t alter renal function, potassium excretion remains normal; therefore, severe hyperkalemia doesn’t occur. Tetany results from hypocalcemia, an electrolyte disturbance not associated with SIADH.

A client with primary diabetes insipidus is ready for discharge on desmopressin (DDAVP). Which instruction should the nurse provide?

1. "Administer desmopressin while the suspension is cold."

2. "Your condition isn’t chronic, so you won’t need to wear a medical identification bracelet."

3. "You may not be able to use desmopressin nasally if you have nasal discharge or blockage."

4. "You won’t need to monitor your fluid intake and output after you start taking desmopressin."

3. "You may not be able to use desmopressin nasally if you have nasal discharge or blockage." Desmopressin may not be absorbed if the intranasal route is compromised. Although diabetes insipidus is treatable, the client should wear medical identification and carry medication at all times to alert medical personnel in an emergency and ensure proper treatment. The client must continue to monitor fluid intake and output and get adequate fluid replacement.

A client is admitted to the health care facility for evaluation for Addison’s disease. Which laboratory test result best supports a diagnosis of Addison’s disease?

1. Blood urea nitrogen (BUN) level of 12 mg/dl

2. Blood glucose level of 90 mg/dl

3. Serum sodium level of 134 mEq/L

4. Serum potassium level of 5.8 mEq/L

4. Serum potassium level of 5.8 mEq/L Addison’s disease decreases the production of aldosterone, cortisol, and androgen, causing urinary sodium and fluid losses, an increased serum potassium level, and hypoglycemia. Therefore, an elevated serum potassium level of 5.8 mEq/L best supports a diagnosis of Addison’s disease. A BUN level of 12 mg/dl and a blood glucose level of 90 mg/dl are within normal limits. In a client with Addison’s disease, the serum sodium level would be much lower than 134 mEq/L, a nearly normal level.

The nurse understands that for the parathyroid hormone to exert its effect, what must be present?

1. Decreased phosphate level

2. Adequate vitamin D level

3. Functioning thyroid gland

4. Increased calcium level

2. Adequate vitamin D level Adequate vitamin D must be present for parathyroid hormone to exert its effect — that is to help regulate calcium metabolism. Vitamin D promotes calcium absorption from the intestines.

The nurse is caring for a client with diabetes insipidus. The nurse should anticipate the administration of:

1. insulin.

2. furosemide (Lasix).

3. potassium chloride.

4. vasopressin (Pitressin).

4. vasopressin (Pitressin). Vasopressin is given subcutaneously in the acute management of diabetes insipidus. Insulin is used to manage diabetes mellitus. Furosemide causes diuresis. Potassium chloride is given for hypokalemia.

Which of the following would the nurse expect to assess in an elderly client with Hashimoto’s thyroiditis?

1. Weight loss, increased appetite, and hyperdefecation

2. Weight loss, increased urination, and increased thirst

3. Weight gain, decreased appetite, and constipation

4. Weight gain, increased urination, and purplish-red striae

3. Weight gain, decreased appetite, and constipation Hashimoto’s thyroiditis, an autoimmune disorder, is the most common cause of hypothyroidism. It’s seen most frequently in women over age 40. Weight gain, decreased appetite, constipation, lethargy, dry cool skin, brittle nails, coarse hair, muscle cramps, weakness, and sleep apnea are symptoms of Hashimoto’s thyroiditis. Weight loss, increased appetite, and hyperdefecation are characteristic of hyperthyroidism. Weight loss, increased urination, and increased thirst are characteristic of uncontrolled diabetes mellitus. Weight gain, increased urination, and purplish-red striae are characteristic of hypercortisolism.

Parathyroid hormone (PTH) has which effects on the kidney?

1. Stimulation of calcium reabsorption and phosphate excretion

2. Stimulation of phosphate reabsorption and calcium excretion

3. Increased absorption of vitamin D and excretion of vitamin E

4. Increased absorption of vitamin E and excretion of vitamin D

1. Stimulation of calcium reabsorption and phosphate excretion PTH stimulates the kidneys to reabsorb calcium and excrete phosphate and converts vitamin D to its active form, 1,25-dihydroxyvitamin D. PTH doesn’t have a role in the metabolism of vitamin E.

A client with hyperthyroidism is about to receive radioactive iodine as an outpatient. What safety measures should the nurse teach the client to protect his family while he undergoes treatment?

1. Good hand washing

2. How to isolate himself in one room of the house

3. Use of disposable eating utensils

4. Not worrying about precautions

3. Use of disposable eating utensils The client with hyperthyroidism can receive radioactive iodine as an outpatient with some precautions, such as using disposable eating utensils, and avoiding kissing, sexual intercourse, and holding babies. Good hand washing is always necessary to prevent the spread of infection; however, it provides no protection against radioactive iodine therapy. Isolation isn’t necessary, but radiation precautions are.

What does a positive Chvostek’s sign indicate?

1. Hypocalcemia

2. Hyponatremia

3. Hypokalemia

4. Hypermagnesemia

1. Hypocalcemia Chvostek’s sign is elicited by tapping the client’s face lightly over the facial nerve, just below the temple. If the client’s facial muscles twitch, it indicates hypocalcemia. Hyponatremia is indicated by weight loss, abdominal cramping, muscle weakness, headache, and postural hypotension. Hypokalemia causes paralytic ileus and muscle weakness. Clients with hypermagnesemia exhibit a loss of deep tendon reflexes, coma, or cardiac arrest.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention would help prevent complications associated with SIADH?

1. Restricting fluids to 800 ml/day

2. Administering vasopressin as ordered

3. Elevating the client’s head of bed to 90 degrees

4. Restricting sodium intake to 1 gm/day

1. Restricting fluids to 800 ml/day Excessive release of antidiuretic hormone (ADH) disturbs fluid and electrolyte balance in SIADH. The excessive ADH causes an inability to excrete dilute urine, retention of free water, expansion of extracellular fluid volume, and hyponatremia. Symptomatic treatment begins with restricting fluids to 800 ml/day. Vasopressin is administered to clients with diabetes insipidus a condition in which circulating ADH is deficient. Elevating the head of the bed decreases vascular return and decreases atrial-filling pressure, which increases ADH secretion worsening the client’s condition. The client’s sodium is low and, therefore, shouldn’t be restricted.

A client is seen in the clinic with a possible parathormone deficiency. Diagnosis of this condition includes the analysis of serum electrolytes. Which electrolytes would the nurse expect to be abnormal?

1. Sodium

2. Potassium

3. Calcium

4. Chloride

5. Glucose

6. Phosphorous

3. Calcium 6. Phosphorous A client with a parathormone deficiency has abnormal calcium and phosphorous values because parathormone regulates these two electrolytes. Potassium, chloride, sodium, and glucose aren’t affected by a parathormone deficiency.

The nurse teaches a client with newly diagnosed hypothyroidism about the need for thyroid hormone replacement therapy to restore normal thyroid function. Which thyroid preparation is the agent of choice for thyroid hormone replacement therapy?

1. methimazole (Tapazole)

2. thyroid USP desiccated (Thyroid USP Enseals)

3. liothyronine (Cytomel)

4. levothyroxine (Synthroid)

4. levothyroxine (Synthroid) Levothyroxine is the agent of choice for thyroid hormone replacement therapy because its standard hormone content gives it predictable results. Methimazole is an antithyroid medication used to treat hyperthyroidism. Thyroid USP desiccated and liothyronine are no longer used for thyroid hormone replacement therapy because they may cause fluctuating plasma drug levels, increasing the risk of adverse effects.

A client receiving thyroid replacement therapy develops the flu and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication will put the client at risk for developing which life-threatening complication?

1. Exophthalmos

2. Thyroid storm

3. Myxedema coma

4. Tibial myxedema

3. Myxedema coma Myxedema coma, severe hypothyroidism, is a life-threatening condition that may develop if thyroid replacement medication isn’t taken. Exophthalmos, protrusion of the eyeballs, is seen with hyperthyroidism. Thyroid storm is life-threatening but is caused by severe hyperthyroidism. Tibial myxedema, peripheral mucinous edema involving the lower leg, is associated with hypothyroidism but isn’t life-threatening.

A client is transferred to a rehabilitation center after being treated in the hospital for a stroke. Because the client has a history of Cushing’s syndrome (hypercortisolism) and chronic obstructive pulmonary disease (COPD), the nurse formulates a nursing diagnosis of:

1. Risk for imbalanced fluid volume related to excessive sodium loss.

2. Risk for impaired skin integrity related to tissue catabolism secondary to cortisol hypersecretion.

3. Ineffective health maintenance related to frequent hypoglycemic episodes secondary to Cushing’s syndrome.

4. Decreased cardiac output related to hypotension secondary to Cushing’s syndrome.

2. Risk for impaired skin integrity related to tissue catabolism secondary to cortisol hypersecretion. Cushing’s syndrome causes tissue catabolism, resulting in thinning skin and connective tissue loss; along with immobility related to stroke, these factors increase this client’s risk for impaired skin integrity. The exaggerated glucocorticoid activity in Cushing’s syndrome causes sodium and water retention which, in turn, leads to edema and hypertension. Therefore, Risk for imbalanced fluid volume and Decreased cardiac output are inappropriate nursing diagnoses. Increased glucocorticoid activity also causes persistent hyperglycemia, eliminating Ineffective health maintenance related to frequent hypoglycemic episodes as an appropriate nursing diagnosis.

The physician orders laboratory tests to confirm hyperthyroidism in a client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis?

1. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test

2. A decreased TSH level

3. An increase in the TSH level after 30 minutes during the TSH stimulation test

4. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay

1. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. A decreased TSH level indicates a pituitary deficiency of this hormone. Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level also occurs in malnutrition and liver disease and may result from administration of phenytoin and certain other drugs.

When instructing the client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of:

1. restricting fluids.

2. restricting sodium.

3. forcing fluids.

4. restricting potassium.

3. forcing fluids. The client should be encouraged to force fluids to prevent renal calculi formation. Sodium should be encouraged to replace losses in urine. Restricting potassium isn’t necessary in hyperparathyroidism.

Hyperthyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction would experience:

1. heat intolerance and systolic hypertension.

2. weight gain and heat intolerance.

3. diastolic hypertension and widened pulse pressure.

4. anorexia and hyperexcitability.

1. heat intolerance and systolic hypertension. An increased metabolic rate in a client with hyperthyroidism caused by excess serum thyroxine leads to systolic hypertension and heat intolerance. Weight loss — not gain — occurs due to the increased metabolic rate. Diastolic blood pressure decreases due to decreased peripheral resistance. Heat intolerance and widened pulse pressure can occur but systolic hypertension and diastolic hypertension don’t. Clients with hyperthyroidism experience an increase in appetite — not anorexia.

A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?

1. "You must lie flat for 24 hours after surgery."

2. "You must avoid coughing, sneezing, and blowing your nose."

3. "You must restrict your fluid intake."

4. "You must report ringing in your ears immediately."

2. "You must avoid coughing, sneezing, and blowing your nose." After a transsphenoidal hypophysectomy, the client must refrain from coughing, sneezing, and blowing the nose for several days to avoid disturbing the surgical graft used to close the wound. The head of the bed must be elevated, not kept flat, to prevent tension or pressure on the suture line. Within 24 hours after a hypophysectomy, transient diabetes insipidus commonly occurs; this calls for increased, not restricted, fluid intake. Visual, not auditory, changes are a potential complication of hypophysectomy.

The client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for:

1. exophthalmos and conjunctival redness

2. flushed, warm, moist skin

3. systolic murmur at the left sternal border

4. decreased body temperature and cold intolerance

4. decreased body temperature and cold intolerance Hypothyroidism markedly decreases the metabolic rate, causing a reduced body temperature and cold intolerance. Other signs and symptoms include dyspnea, hypoventilation, bradycardia, hypotension, anorexia, constipation, decreased intellectual function, and depression. The other options are typical findings in a client with hyperthyroidism.

For a client in addisonian crisis, it would be very risky for a nurse to administer:

1. potassium chloride.

2. normal saline solution.

3. hydrocortisone.

4. fludrocortisone.

1. potassium chloride. Addisonian crisis results in hyperkalemia; therefore, administering potassium chloride is contraindicated. Because the client will be hyponatremic, normal saline solution is indicated. Hydrocortisone and fludrocortisone are both useful in replacing deficient adrenal cortex hormones.

A client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. Preoperatively, the nurse should assess for potential complications by:

1. testing for ketones in the urine.

2. testing urine specific gravity.

3. checking temperature every 4 hours.

4. performing capillary glucose testing every 4 hours.

4. performing capillary glucose testing every 4 hours. The nurse should perform capillary glucose testing every 4 hours because excess cortisol may cause insulin resistance, placing the client at risk for hyperglycemia. Urine ketone testing isn’t indicated because the client does secrete insulin and, therefore, isn’t at risk for ketosis. Urine specific gravity isn’t indicated because although fluid balance can be compromised, it usually isn’t dangerously imbalanced. Temperature regulation may be affected by excess cortisol and isn’t an accurate indicator of infection.

The nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication?

1. Tetany

2. Hemorrhage

3. Thyroid storm

4. Laryngeal nerve damage

1. Tetany Tetany may result if the parathyroid glands are excised or damaged during thyroid surgery. Hemorrhage is a potential complication after thyroid surgery but is characterized by tachycardia, hypotension, frequent swallowing, feelings of fullness at the incision site, choking, and bleeding. Thyroid storm is another term for severe hyperthyroidism — not a complication of thyroidectomy. Laryngeal nerve damage may occur postoperatively, but its signs include a hoarse voice and, possibly, acute airway obstruction.

During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and:

1. sodium.

2. potassium.

3. magnesium.

4. phosphorus.

4. phosphorus. PTH increases the serum calcium level and decreases the serum phosphate level. PTH doesn’t affect sodium, potassium, or magnesium regulation.

A client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which "related-to" phrase should the nurse add?

1. Related to bone demineralization resulting in pathologic fractures

2. Related to exhaustion secondary to an accelerated metabolic rate

3. Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces

4. Related to tetany secondary to a decreased serum calcium level

1. Related to bone demineralization resulting in pathologic fractures Poorly controlled hyperparathyroidism may cause an elevated serum calcium level. This, in turn, may diminish calcium stores in the bone, causing bone demineralization and setting the stage for pathologic fractures and a risk for injury. Hyperparathyroidism doesn’t accelerate the metabolic rate. A decreased thyroid hormone level, not an increased parathyroid hormone level, may cause edema and dry skin secondary to fluid infiltration into the interstitial spaces. Hyperparathyroidism causes hypercalcemia, not hypocalcemia; therefore, it isn’t associated with tetany.

A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client’s urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes insipidus?

1. Above-normal urine and serum osmolality levels

2. Below-normal urine and serum osmolality levels

3. Above-normal urine osmolality level, below-normal serum osmolality level

4. Below-normal urine osmolality level, above-normal serum osmolality level

4. Below-normal urine osmolality level, above-normal serum osmolality level In diabetes insipidus, excessive polyuria causes dilute urine, resulting in a below-normal urine osmolality level. At the same time, polyuria depletes the body of water, causing dehydration that leads to an above-normal serum osmolality level. For the same reasons, diabetes insipidus doesn’t cause above-normal urine osmolality or below-normal serum osmolality levels.

The nurse is assessing a client with Cushing’s syndrome. Which observation should the nurse report to the physician immediately?

1. Pitting edema of the legs

2. An irregular apical pulse

3. Dry mucous membranes

4. Frequent urination

2. An irregular apical pulse Because Cushing’s syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician. Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. Dry mucous membranes and frequent urination signal dehydration, which isn’t associated with Cushing’s syndrome.

A female client who weighs 210 lb (95 kg) and has been diagnosed with hyperglycemia tells the nurse that her husband sleeps in another room because her snoring keeps him awake. The nurse notices that she has large hands and a hoarse voice. Which disorder would the nurse suspect as a possible cause of the client’s hyperglycemia?

1. Acromegaly

2. Type 1 diabetes mellitus

3. Hypothyroidism

4. Deficient growth hormone

1. Acromegaly Acromegaly, which is caused by a pituitary tumor that releases excessive growth hormone, is associated with hyperglycemia, hypertension, diaphoresis, peripheral neuropathy, and joint pain. Enlarged hands and feet are related to lateral bone growth, which is seen in adults with this disorder. The accompanying soft tissue swelling causes hoarseness and often sleep apnea. Type 1 diabetes is usually seen in children, and newly diagnosed persons are usually very ill and thin. Hypothyroidism isn’t associated with hyperglycemia, nor is growth hormone deficiency.

A client with hyperparathyroidism declines surgery and is to receive hormone replacement therapy with estrogen and progesterone. Which instruction would be most important to include in the client’s teaching plan?

1. "Maintain a moderate exercise program."

2. "Rest as much as possible."

3. "Lose weight."

4. "Jog at least 2 miles per day."

1. "Maintain a moderate exercise program." A moderate exercise program will help strengthen bones and prevent the bone loss that occurs from excess parathyroid hormone. Walking or swimming provides the most beneficial exercise. Because of weakened bones, a rigorous exercise program such as jogging would be contraindicated. Weight loss might be beneficial but it isn’t as important as developing a moderate exercise program.

The nurse should expect a client with hypothyroidism to report which health concern(s)?

1. Increased appetite and weight loss

2. Puffiness of the face and hands

3. Nervousness and tremors

4. Thyroid gland swelling

2. Puffiness of the face and hands 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).

After undergoing a subtotal thyroidectomy, a client develops hypothyroidism. The physician prescribes levothyroxine (Levothroid), 25 mcg P.O. daily. For which condition is levothyroxine the preferred agent?

1. Primary hypothyroidism

2. Graves’ disease

3. Thyrotoxicosis

4. Euthyroidism

1. Primary hypothyroidism Levothyroxine is the preferred agent to treat primary hypothyroidism and cretinism, although it also may be used to treat secondary hypothyroidism. It is contraindicated in Graves’ disease and thyrotoxicosis because these conditions are forms of hyperthyroidism. Euthyroidism, a term used to describe normal thyroid function, wouldn’t require any thyroid preparation.

Which condition would the nurse expect to find in a client diagnosed with hyperparathyroidism?

1. Hypocalcemia

2. Hypercalcemia

3. Hyperphosphatemia

4. Hypophosphaturia

2. Hypercalcemia Hypercalcemia is the hallmark of excess parathyroid hormone levels. Serum phosphate will be low (hyperphosphatemia), and there will be increased urinary phosphate (hyperphosphaturia) because phosphate excretion is increased.

Which of the following would indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?

1. Confusion and seizures

2. Sunken eyeballs and spasticity

3. Flaccidity and thirst

4. Tetany and increased blood urea nitrogen (BUN) levels.

1. Confusion and seizures Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.

Which of the following is the most common cause of hyperaldosteronism?

1. Excessive sodium intake

2. A pituitary adenoma

3. Deficient potassium intake

4. An adrenal adenoma

4. An adrenal adenoma An autonomous aldosterone-producing adenoma is the most common cause of hyperaldosteronism. Hyperplasia is the second most frequent cause. Aldosterone secretion is independent of sodium and potassium intake as well as of pituitary stimulation.

The nurse is developing a teaching plan for a client diagnosed with diabetes insipidus. The nurse should include information about which hormone that’s lacking in clients with diabetes insipidus?

1. Antidiuretic hormone (ADH)

2. Thyroid-stimulating hormone (TSH)

3. Follicle-stimulating hormone (FSH)

4. Luteinizing hormone (LH)

1. Antidiuretic hormone (ADH) ADH is the hormone clients with diabetes insipidus lack. The client’s TSH, FSH, and LH levels won’t be affected.

A client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg P.O. daily. Which finding should the nurse recognize as an adverse reaction to the drug?

1. Dysuria

2. Leg cramps

3. Tachycardia

4. Blurred vision

3. Tachycardia Levothyroxine, a synthetic thyroid hormone, is given to a client with hypothyroidism to simulate the effects of thyroxine. Adverse reactions to this agent include tachycardia. The other options aren’t associated with levothyroxine.

A client with Hashimoto’s thyroiditis and a history of two myocardial infarctions and coronary artery disease is to receive levothyroxine (Synthroid). Because of the client’s cardiac history, the nurse would expect that the client’s initial dose for the thyroid replacement would be:

1. 25 g/day, initially.

2. 100 g/day, initially.

3. delayed until after thyroid surgery.

4. initiated before thyroid surgery.

1. 25 g/day, initially. Elderly clients and clients with cardiac disease should begin with low-dose levothyroxine increased at 2- to 4-week intervals until 100 g/day is reached. This slow titration prevents further cardiac stress. Younger clients would be started on the usual maintenance dose of 100 g/day. Clients with Hashimoto’s thyroiditis don’t require surgical intervention.

When administering spironolactone (Aldactone) to a client who has had a unilateral adrenalectomy, the nurse should instruct the client about which possible adverse effect of the drug?

1. Constipation

2. Menstrual irregularities

3. Hypokalemia

4. Hypernatremia

2. Menstrual irregularities Spironolactone can cause menstrual irregularities and decreased libido. Men may also experience gynecomastia and impotence. Diarrhea, hyponatremia, and hyperkalemia are also adverse effects of spirolactone.

When assessing a client with pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, the nurse is most likely to detect:

1. a blood pressure of 130/70 mm Hg.

2. a blood glucose level of 130 mg/dl.

3. bradycardia.

4. a blood pressure of 176/88 mm Hg.

4. a blood pressure of 176/88 mm Hg. Pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, causes hypertension, tachycardia, hyperglycemia, hypermetabolism, and weight loss. It isn’t associated with the other options.

A 68-year-old client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse would suspect which disorder?

1. Diabetes mellitus

2. Diabetes insipidus

3. Hypoparathyroidism

4. Hyperparathyroidism

4. Hyperparathyroidism Hyperparathyroidism is most common in older women and is characterized by bone pain and weakness from excess parathyroid hormone (PTH). Clients also exhibit hypercalciuria-causing polyuria. While clients with diabetes mellitus and diabetes insipidus also have polyuria, they don’t have bone pain and increased sleeping. Hypoparathyroidism is characterized by urinary frequency rather than polyuria.

The nurse is teaching a client recovering from addisonian crisis about the need to take fludrocortisone acetate and hydrocortisone at home. Which statement by the client indicates an understanding of the instructions?

1. "I’ll take my hydrocortisone in the late afternoon, before dinner."

2. "I’ll take all of my hydrocortisone in the morning, right after I wake up."

3. "I’ll take two-thirds of the dose when I wake up and one-third in the late afternoon."

4. "I’ll take the entire dose at bedtime."

3. "I’ll take two-thirds of the dose when I wake up and one-third in the late afternoon." Hydrocortisone, a glucocorticoid, should be administered according to a schedule that closely reflects the body’s own secretion of this hormone; therefore, two-thirds of the dose of hydrocortisone should be taken in the morning and one-third in the late afternoon. This dosage schedule reduces adverse effects.

Which outcome indicates that treatment of a client with diabetes insipidus has been effective?

1. Fluid intake is less than 2,500 ml/day.

2. Urine output measures more than 200 ml/hr.

3. Blood pressure is 90/50 mm Hg.

4. Heart rate is 126 beats/min.

1. Fluid intake is less than 2,500 ml/day. Diabetes insipidus is characterized by polyuria (up to 8 L/day), constant thirst, and an unusually high oral intake of fluids. Treatment with the appropriate drug should decrease both oral fluid intake and urine output. A urine output of 200 ml/hr indicates continuing polyuria. A blood pressure of 90/50 mm Hg and a heart rate of 126 beats/min indicate compensation for the continued fluid deficit, suggesting that treatment hasn’t been effective.

On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?

1. Hypocalcemia

2. Hyponatremia

3. Hyperkalemia

4. Hypermagnesemia

1. Hypocalcemia Hypocalcemia may follow thyroid surgery if the parathyroid glands were removed accidentally. Signs and symptoms of hypocalcemia may be delayed for up to 7 days after surgery. Thyroid surgery doesn’t directly cause serum sodium, potassium, or magnesium abnormalities. Hyponatremia may occur if the client inadvertently received too much fluid; however, this can happen to any surgical client receiving I.V. fluid therapy, not just one recovering from thyroid surgery. Hyperkalemia and hypermagnesemia usually are associated with reduced renal excretion of potassium and magnesium, not thyroid surgery.

For a client with hyperthyroidism, treatment is most likely to include:

1. a thyroid hormone antagonist.

2. thyroid extract.

3. a synthetic thyroid hormone.

4. emollient lotions.

1. a thyroid hormone antagonist. Thyroid hormone antagonists, which block thyroid hormone synthesis, combat increased production of thyroid hormone. Treatment of hyperthyroidism also may include radioiodine therapy, which destroys some thyroid gland cells, and surgery to remove part of the thyroid gland; both treatments decrease thyroid hormone production. Thyroid extract, synthetic thyroid hormone, and emollient lotions are used to treat hypothyroidism.

Before discharge, what should a client with Addison’s disease be instructed to do when exposed to periods of stress?

1. Administer hydrocortisone I.M.

2. Drink 8 oz of fluids.

3. Perform capillary blood glucose monitoring four times daily.

4. Continue to take his usual dose of hydrocortisone.

1. Administer hydrocortisone I.M. Clients with Addison’s disease and their family members should know how to administer I.M. hydrocortisone during periods of stress. It’s important to keep well hydrated during stress, but the critical component in this situation is to know how and when to use I.M. hydrocortisone. Capillary blood glucose monitoring isn’t indicated in this situation because the client doesn’t have diabetes mellitus. Hydrocortisone replacement doesn’t cause insulin resistance.

A client is admitted to an acute care facility with a tentative diagnosis of hypoparathyroidism. The nurse should monitor the client closely for the related problem of:

1. severe hypotension.

2. excessive thirst.

3. profound neuromuscular irritability.

4. acute gastritis.

3. profound neuromuscular irritability. Hypoparathyroidism may slow bone resorption, reduce the serum calcium level, and cause profound neuromuscular irritability (as evidenced by tetany). Hypoparathyroidism doesn’t alter blood pressure or affect the thirst mechanism, which usually is triggered by fluid volume deficit. Gastritis doesn’t cause or result from hypoparathyroidism.

*benefit of progesterone in HRT

protect against uterine cancer

*what patient should you assign the LPN?

patient with DM and hypothyroidism (LPNs can not teach and they cannot assess)

*what important vital sign should be reported immediately in a patient with hypothyroidism?

rapid irregular heart rate

*presurgical medication teaching for a patient with acromegaly?

admin sandostatin IM

*what diet should you provide a patient with hypoparathyroidism?

calcium and vitamin d supplements (not milk and milk products because they are high in phosphorous)

*patient that is diagnosed with an incurable disease is recommended what kind of care?

palliative

*what is covered by medicare and medicaid – inpatient stay with 5 days – rest for family member caring for patient

respite care

*M/M – what are come recommendation you can give to a menopausal woman to relieve hot flashes and insomnia?

vitamin e, yoga, medication, avoid strenuous activity at night – NOT ask md for hypnotic

*patient with cushings – what finding should be reported immediately?

temp of 101.6

*what can you assign the NA to do?

remind patient to turn q2h

*M/M – instructions for 24 hour urine collection for catecholamines?

store in cold place and no stress 3 days before and during test

*hypothyroid patient has numbness and tingling – what is the nurse’s priority action?

admin calcium gluconate

*post thyroidectomy – patient develops stridor and right hand cramp – nurse expects to…

admin calcium gluconate

*question to ask patient with hypoparathyroidism?

do you have bone pain?

*important assessment question to ask a hypothyroid patient

do you feel fatigued even if you sleep a lot?

*patient yells and throws a fit at the nurse – what stage of dying?

anger

*RN knowns declomycin is effective in SIADH when?

urine output increases

child with pituitary dwarfism – tx goal is…

to see linear growth

*MD must be informed when a patient with cushings develops

bilateral lung crackles

*what to expect to see in a patient with cushings…

hypertension, peripheral edema, and petichiae

*prolactin excess in male – major complaint?

decreased libido and impotence

*post hypophysectomy for pituitary adenoma – patient will not be able to…

use toothbrush – brush teeth for several days

*small pox vaccine administration method

multiple punctures

*most likely available form of weaponized biological agent

anthrax

*patient receiving thyroid scan is afraid of being radioactive – I131 – appropriate response by nurse

this is a tracer dose – it wont harm you or others

*patient with graves disease is receiving RAI therapy – I131 – should be informed?

not to expect relief from symptoms immediately

*statement made by patient with DI requires further teaching

I will wean myself out ADH inhalant

*What do you want to monitor in a patient with addison’s?

thready pulse

*a patient with thyroid storm – the nurse should expect to admin

tylenol and steroids – never aspirin

*signs to look for in person with thyroid dysfunction

fatigue after sleeping long periods

*what indicates patient with DI or addison’s needs further treatment?

weaning off vasopressin

*what should nurse do when assess CVAD?

always document site

*s&s hypocalcemia

loss of sensation in hands/legs – involuntary muscle spasms?

*78 y/o hypotyhroid, lethargy, depression – what would you check?

AMS or CV function

*Women with HRT – should not have if…

CV issues

*monitor cushings for…

CV issues

*nursing dx for patient with DI

disturbed sleep pattern r/t nocturia

*patient with primary aldosteronism

quiet comfortable room – hypertension – hypokalemia

*addisons crisis patient admitted

administer IV NS

*patient with graves given beta blockers because

reduces s&s

*patient with cushings

no strenuous exercise

*bilateral adrenalectomy

risk for infection r/t open wound

*assess client following thyroidectomy

state name b/c checking for laryngeal nerve damage

*patient to delegate to LPN/UAP

woman who had MI and will soon be discharged

*how would you give instructions to patient diagnosed with hyperthyroidism

give written instructions

*PTU adverse effect

low WBC agranulocytosis

*patient asks why she must take steroid every other day – feels better the days she takes it

gives change for adrenal gland to function normally

*hyperthyroid patient

report tachycardia

*pheochromocytoma

will have high BP

*presurgery for GH excess

patient will take sandostatin to reduce levels

*patient with cushings – teach

moderate exercise

*post partial thyroidectomy – nurse knows patient has airway clearance b/c

no tracheal stridor, speaks clearly, denies numbness & tingling

*RN would not administer morphine to patient w/…

hypothyroidism

*woman on menopause complains of painful sex

experiencing vaginal dryness

*priority patient with hypothyroidism

heart rate 48

*patient with severe high calcium – increased urine ca and BUN

NOT maintain seizure precautions

bioterrorism – category a

high priority agents including organisms that pose a risk to large number of people at once – intentional attack – criminal act – results in high mortality rate – easily transmitted – ie. anthrax, small pox

anthrax transmission

occurs in humans when they come in contact with infected sick animals, contaminated products, or when directly exposed to spores – not transmitted from person to person

anthrax first line treatment

cipro

cutaneous anthrax s&s

itchy sore lesion similar to insect bite – develops 1-12 days after exposure – painful lymph nodes, fever, malaise, headache

cutaneous anthrax diagnostics

culture of the skin lesion punch bx

inhalation anthrax s&s

stage 1 – hours-days flu like sx stage 2 – severe dyspnea, shock, mediastinitis, neurological sx, hemorrhagic meningitis (cause of death)

inhalation anthrax diagnostics

chest x-ray (pleural effusion, widened mediastinum) blood culture sputum culture ELISA for IgG spinal tap for CSF

GI (intestinal/abdominal) anthrax s&s

nausea, vomiting, fever, anorexia, abdominal pain, hematemesis, bloody diarrhea, septicemia, toxemia, cyanosis, shock, death

oropharyngeal anthrax s&s

lesions at base of tongue or tonsils sore throat, dysphagia, fever, lymphadenopathy

GI anthrax diagnostics

culture and gram stain of peritoneal fluid or ulcers for gram positive rods – stool culture

small pox transmission

airborne through direct deposit of infective droplets, bodily fluids, contaminated objects

small pox vs chicken pox fever

small pox: 2-4 days before rash chicken pox: at time of rash

small pox vs chicken pox stages

small pox: pocks in same stage chicken pox: pocks in several stages

small pox vs chicken pox development

small pox: pocks slow – starts in mouth and spreads to face, forearms, then hands, lower limbs, then trunk chicken pox: rapid – from arms to legs, to trunk

small pox vs chicken pox distribution

small pox: more on arms and legs – on palms and soles chicken pox: more on body – absent on palms and soles

small pox vs chicken pox death

small pox: 1/10 chicken pox: uncommon

small pox diagnostics

dx based on hx and px findings – throat swab and/or pustule swab

small pox treatment

no cure – supportive care while body fights – alleviating sx – antipyretics, IV fluids, pain relief, skin care, antibiotics, vaccine within 4 days after exposure

small pox vaccine site care

avoid contact with site thorough hand washing after contact with site loosely cover site with porous bandage change dressing daily dispose of contaminated bandages and site scab properly immunity = major reaction at site – scab separates – scar

hypothalamus

Maintains homeostasis by regulating the internal environment such as the heart rate, body temperature, water balance and the pituitary gland secretions

hormones that stimulate anterior pituitary

* Corticortropin-Releasing Hormone (CRH) * Thyrotropin-Releasing Hormone (TRH) * Growth-Releasing Hormone (GHRH) * Prolactin-Releasing Hormone (PRH)

hormones that inhibit the anterior pituitary

-Prolactin-inhibiting hormone (PIH) -Somatostatin – inhibits growth hormone -TRH and TSH -Dopamine – inhibits TSH and prolactin -Antidiuretic hormone (ADH/Vasopressin)-regulate blood osmolality -Oxytocin – causes uterine contractions and milk ejection reflex in the breast

FSH

– secreted by anterior pituitary – regulates the development and growth of the reproductive growth and processes – stimulates growth of ovarian Graafian follicle, ovulation, estrogen production in females and spermatogenesis in males

LH

– secreted by anterior pituitary – stimulates development of corpus luteum, release of oocyte, production of estrogen and progesterone in females – stimulates testosterone production/secretion and development of interstitial tissue of testes in males

Growth hormone (GH) or Somatotropin

– secreted by anterior pituitary – regulates body growth of bone and muscle – promotes protein synthesis and fat metabolism – increases blood sugar and stimulates glucose metabolism – secreted in response to hypoglycemia, exercise and protein depletion

TSH

– secreted by anterior pituitary – stimulates synthesis and secretion of the thyroid hormone/regulates the thyroid gland

Adrenocorticotropic Hormone (ACTH)/
Corticotropin

– secreted by anterior pituitary – stimulates the release of corticosteroids by the adrenal glands in situations of physiological stress

prolactin

– secreted by anterior pituitary – prepares female breast for milk production – at high levels suppresses gonadotropins

Melanin Stimulating Hormone (MSH)

– secreted by anterior pituitary – produces pigmented cells called melanin – increase skin pigmentation

ADH/Vasopressin

– secreted by posterior pituitary – inhibits urine production by causing renal tubules to reabsorb water from the urine and return it to the circulatory blood

Oxytocin

– secreted by posterior pituitary – induces the contraction of the smooth muscles from the reproductive organs in women – stimulates the myometrium of the uterus to contract during labor – stimulates the milk releasing reflex while breastfeeding

DIAGNOSTICS OF THE PITUITARY GLAND

– through H/P exams – visual acuity and visual fields – X-rays of the epyphysis – CT scan and MRI to diagnose the presence or extent of pituitary tumors – GH studies: Serum Essay – fasting venous blood drawn early in the a.m. Normal: Female – <5 ng/ml Male – <10 ng/ml FSH, LH, ACTH, TSH

IGF (Insulin-like Growth Factor)

more reliable measure of the GH levels (normal 135-250 ng/ml)

Glucose GH challenge

a 2 hr oral glucose tolerance test (OGTT) with 75-100 gm glucose – a sample is taken before the test begins and again 30-60 minutes after drinking the glucose solution (test takes up to 3 hrs) – High levels may be r/t Cushing’s Syndrome or diabetes (normal GH <2 ng/ml)

GH challenge

– Fasting GH level is drawn – Drug used to stimulate GH secretions – Arginine HCL, L-dopa, Insulin – Normal: The increase in GH will peak in 60 minutes – There’s risk for hypoglycemia if insulin is used

Serum prolactin

– crucial to fast at least 3-4 hrs after awakening – Normal <20 ng/ml (non-lactating) and >200 ng/ml indicate prolactin-secreting tumor

ADH water deprivation test

Designed to see how concentrated the urine and blood are in the absence of water for several hrs and what the cause is – Need to be NPO after midnight on a.m. of exam – no coffee, tea or smoking – Weight, BP, urine output, specific gravity and plasma osmolality are obtained for baseline data and then monitored every hr there after – ADH (vasopressin) is then given in NS iv over 2 hrs (exam can take up to 8 hrs) – Test distinguishes ADH deficit from renal dysfunction) – Increase in urine osmolality and decreased plasma osmolality after ADH is given confirms ADH Deficit – No change after ADH is given indicates Renal Disorder/Dysfunction

anterior pituitary hypofunction

Hyposecretion of one or more of the pituitary hormones caused by tumors, trauma, encephalitis, autoimmunity, or stroke Hormones most often affected are growth hormone (GH) and gonadotropic hormones (luteinizing hormone, follicle-stimulating hormone), but thyroid-stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), or antidiuretic hormone (ADH) may be involved.

Sheehan’s Syndrome

damage to a woman’s pituitary gland caused by severe bleeding or extreme low BP during child birth

assessment findings for anterior pituitary hypofunction

a. Mild to moderate obesity (GH, TSH) b. Reduced cardiac output (GH, ADH) c. Infertility, sexual dysfunction (gonadotropins, ACTH) d. Fatigue, low blood pressure (TSH, ADH, ACTH, GH) e. Tumors of the pituitary also may cause headaches and visual defects (pituitary is located near the optic nerve).

GH Deficit in Children

– Congenital lack of GH – retarded bone age in x-rays – Failure to grow – GH and IGF levels noted to be low – Slow/delayed sexual development – no GH increase, results in pituitary dwarfism with GH challenge test

GH Deficit in Adults

– Decreased body mass with structure – Onset noted in either childhood or adulthood – Skin thin and wrinkled – Insomnia /sleep pattern disturbances – Increased body fat/elevated cholesterol and LDH level – Lack of energy with decreased muscle strength – Depression – Ostopenia

TSH Deficit Replacement

need to replace the thyroid hormone

ACTH Deficit Replacement

need to replace cortisol

treatment for pituitary hypofunction

* Surgical removal of tumor (hypophysectomy) through a transphenoidal approach is the usual treatment * Possible radiation depending on tumor size – may be used to deliver external beam radiation therapy right on the tumor (minimal effect on normal tissue) * Hormone replacement therapy

nursing interventions for pituitary hypofunction

a. Provide emotional support to the client and family. b. Encourage the client and family to express feelings related to disturbed body image or sexual dysfunction. c. Client may need hormone replacement for the specific deficient hormones. d. Client education is needed regarding the signs and symptoms of hypofunction and hyperfunction related to insufficient or excess hormone replacement

hyperpituitarism

a. Hypersecretion of growth hormone by the anterior pituitary gland in an adult; caused primarily by pituitary tumors b. Leads to conditions such as acromegaly and Cushing’s disease

assessment findings for hyperpituitarism

a. Large hands and feet b. Thickening and protrusion of the jaw c. Arthritic changes and joint pain d. Visual disturbances e. Diaphoresis f. Oily, rough skin g. Organomegaly h. Hypertension i. Dysphagia j. Deepening of the voice

GH excess

– Increase growth in all tissues – Lead to gigantism in children – these children are extremely tall/excessive height (may be 7 to 8 feet tall) – Lead to acromegally in adults – result in soft tissue and bone deformities, prominent and course facial features such as nose, tongue, nose, lips, etc. – slow in progression

acromegaly

– Enlargement of viscera – thyroid, pancreas, spleen, heart, kidneys without increase in height – Increased cardiac workload, htn, metabolic rate, acne, thick/course skin, glucose intolerance, hypoglycemia, diabetes – Respiratory issues such as sleep apnea, dyspnea, may lead to respiratory failure if untreated

TREATMENT AND NURSING MANAGEMENT OF
THE PITUITARY GLAND HYPERFUNCTION

– Crucial to monitor and reduce elevated hormone levels with appropriate medications accordingly – Radiation therapy may be indicated in some cases and/or surgery – ongoing patient/family teaching on symptom management – Medication regimen and side effects – Electrolyte management – Post operative care if applicable/supportive care * Prolactin excess treatment – e.g. in pituitary tumors

meds to supress prolactin

dostinex, paroldel

med to treat acromegaly

…

POST OP HYPOPHYSECTOMY

a. Initiate postoperative care similar to craniotomy care. b. Monitor vital signs, neurological status, and level of consciousness. c. Elevate the head of the bed. d. Monitor for increased intracranial pressure. e. Monitor for bleeding. f. Instruct the client to avoid sneezing, coughing, and blowing the nose. g. Monitor for signs of temporary diabetes insipidus or syndrome of inappropriate antidiuretic hormone resulting from ADH disturbances. h. Monitor intake and output, and avoid water intoxication. i. Administer glucocorticoids and other hormone replacements as prescribed. j. Administer antibiotics, analgesics, and antipyretics as prescribed. k. Instruct the client in the administration of prescribed medications.

POST OP COMPLICATIONS HYPOPHYSECTOMY

DIABETES INSIPIDUS

DIABETES INSIPIDUS

a. Hyposecretion of ADH caused by stroke or trauma, or may be idiopathic b. Kidney tubules fail to reabsorb water

ASSESSMENT FINDINGS FOR DI

a. Polyuria of 4 to 24 L/ day b. Polydipsia c. Dehydration (decreased skin turgor and dry mucous membranes) d. Inability to concentrate urine e. Low urinary specific gravity, 1.006 or lower f. Fatigue g. Muscle pain and weakness h. Headache i. Postural hypotension that may progress to vascular collapse without rehydration j. Tachycardia

INTERVENTIONS FOR DI

a. Monitor vital signs and neurological and cardiovascular status. b. Provide a safe environment, particularly for the client with postural hypotension. c. Monitor electrolyte values and for signs of dehydration. d. Maintain client intake of adequate fluids. e. Monitor intake and output, weight, serum osmolality, and specific gravity of urine. f. Instruct the client to avoid foods or liquids that produce diuresis. g. Vasopressin tannate (Pitressin) or desmopressin acetate (DDAVP, Stimate) may be prescribed; these are used when the ADH deficiency is severe or chronic. h. Instruct the client in the administration of medications as prescribed; DDAVP may be administered by injection, intranasally, or orally. i. Instruct the client to wear a Medic-Alert bracelet.

Acute Adrenal Insufficiency/Adrenal Crisis

inadequate secretion of ACTH from the pituitary gland d/t decreased stimulation of the adrenal cortex or stress from surgery

Signs/symptoms of adrenal insufficiency

anorexia, nausea, vomiting, abdominal pain, fatigue, lethargy, fever, confusion or coma if left uncorrected

interventions for adrenal insufficiency

– Administer IV fluids and corticosteroids, monitor vital signs – If the adrenal gland does not regain function patient may need life long corticosteroid replacement and mineralocorticoids to prevent recurring of adrenal insufficiency

nursing care post hypophysectomy

– High risk for infection – monitor vital signs – Give antibiotics as ordered – Administer pain medications a ordered – Ineffective airway breathing – assess RR, rhythm, depth and effort – Give humidified oxygenation as ordered

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

– secretion includes excessive ADH secretion from the pituitary gland – Patient cannot excrete dilute urine, retains fluids and develops a sodium deficency (dilutional hyponatremia) – SIADH does not only occur in patients after brain surgery but brain trauma or even infection such as meningitis, tuberculosis, encephalitis, etc. – May also be d/t malignancies such as lung, pancreas and malignant tumors affecting other organs

s&amp;s SIADH

Decreased urine output, thirst, confusion, lethargy, agitation, seizures, coma, etc.

nursing care for SIADH

– Infuse hypertonic solution of Normal Saline (contain sodium) – e.g. 3% NS, 0.45% NS, etc. (give slowly) – May give diuretics such as lasix iv in cases with severe hyponatremia – Administer demeclocycline (nephrotoxic) for chronic SIADH as ordered – ADH inhibitors such as lithium – Fluid restriction – Strict monitoring of weight, intake and output – Monitor electrolytes – chemistry daily – Ongoing patient/family teaching – Supportive care

DI diagnostics

– Fluid Deprivation Test – 8 to 12 hrs or until 3 to 5% of body weght is lost – person is weighed frequently – Plasma and urine osmolality studies performed…Inability for the specific gravity to increase is characteristic of DI… – ADH test – measures how much ADH is in the blood usually used in combination with other tests to determine what is causing the increase or decrease in ADH levels – The increase in urine osmolality and decreased urine output with this test is characteristic of DI

thyroid hormones

calcitonin, T3, T4

calcitonin

decrease serum calcium which inhibits bone reabsorption

T3

fast and short acting

T4

slow and long acting

Goitrogens

Inhibit T3 andT4 synthesis – soybeans, cabbage, strawberries, etc

Goiter

enlargement of the thyroid – Occurs in both hyperthyroidism and hypothyroidism – Diffuse – enlarging the whole thyroid

thyroid nodules – hot-warm-cold

Hot nodules – hyperfunctioning of thyroid tissue – cancer in 5-9% – Warm nodules – moderate functioning of thyroid – cancer in 5-9% – Cold nodules – hypofunctioning of thyroid tissue – cancer in 15-20%

Thyrotropin-releasing hormone (TRH) Test

Measures TSH before and after giving TSR Excessive increase in TSH – primary hypothyroidism

Radioactive Iodine Uptake (RAIU)

– Measures the rate of iodine uptake by the thyroid gland – Patient is given a tracer dose of iodine 123 – Simple test and provides reliable results – patients with hyperthyroidism exhibit a very high uptake of iodine 123 and those with hypothyroidism exhibit a very low uptake of iodine 123

thyroid hypofunction causes…

– Untreated permanent/physical retardation – Congenital lack of T3 and T4 – Cretinism (A congenital condition caused by a deficiency of thyroid hormone during prenatal development and characterized in childhood by dwarfed stature, mental retardation, dystrophy of the bones, childhood by dwarfed stature, mental retardation, dystrophy of the bones, and a low basal metabolism – also called congenital myxedema.

causes of primary hypothyroidism

– thyroid can’t produce amount of hormone pituitary calls for – Iodine deficiency – Auto immune Hashimoto’s thyroiditis – The most common cause of inadequate formation of the gland hypothyroidism – caused by the inflammation of the thyroid gland

causes of secondary hypothyroidism

– thyroid isn’t being stimulated by pituitary to produce hormones – Thyroidectomy or irradiation of the thyroid gland – T4 synthesis defect

causes of congenital hypothyroidism

– In most cases, the cause of congenital hypothyroidism is unknown. – Medication during pregnancy, such as radioactive iodine therapy – Maternal autoimmune disease – Too much iodine during pregnancy – Anatomic defect in thyroid gland

s&amp;s of congenital hypothyroidism

puffy face, coarse facial features, dull look, thick protruding tongue, poor feeding, choking episodes, constipation or reduced stooling, jaundice prolonged, short stature, swollen, protuberant belly button, decreased activity, sleeps a lot, rarely cries or hoarse cry, dry brittle hair; low hairline, poor muscle tone, cool and pale skin, goiter, (enlarged thyroid), birth defects (eg, heart valve abnormality), poor weight gain due to poor appetite, poor growth, difficult breathing, slow pulse, swollen hands, feet and genitals

treatment for congenital hypothyroidism

treated with hormone replacement therapy e.g.,Levothroid, Levoxyl, Synthroid, Levothyroxine

cardiac changes in hypothyroidism

– Include a decrease in cardiac output and cardiac contractility – Reduction in heart rate – Also significant changes including diastolic htn **For people with almost any type of heart disease, disorders of the thyroid gland can worsen old cardiac symptoms or cause new ones, and can accelerate the underlying heart disorder. *Thyroid disease can even cause cardiac problems in people with healthy hearts*

cardiac s&amp;s of hypothyroidism

-Dyspnea on exertion and poor exercise tolerance – In people who also have heart disease dyspnea may be due to worsening heart failure -Bradycardia – heart rate is modulated by thyroid hormone with hypothyroidism the heart rate is typically 10 – 20 beats per minute slower than normal – Arteries are stiffer in hypothyroidism – causes the diastolic blood pressure to rise – Diastolic hypertension – one might think that, because a lack of thyroid hormone slows down the metabolism, people with hypothyroidism might suffer from hypotension – usually the opposite is true – Worsening of heart failure or the new onset of heart failure – Edema – can occur as a result of worsening heart failure – In addition, hypothyroidism itself can produce a type of edema called myxedema – Worsening of coronary artery disease (CAD) – The increase in LDL cholesterol (bad cholesterol) and in C-reactive protein seen with hypothyroidism can accelerate any underlying CAD hypothyroidism and suppressing nontoxic goiters

GI s&amp;s hypothyroid

decreases and slows down the movement in the GI tract – this often results in constipation – Other GI problems associated are irritable bowel syndrome (IBS)

myxedema

a severe form of hypothyroid disease where the brain is unable to control crucial processes like breathing – in some cases, myxedema is fatal

hair, skin, nails s&amp;s hypothyroid

– Thickened dry skin, the face becomes expressionless and masklike, the tongue enlarges, the hands and feet enlarge in size – Reports of thinning hair leading to hair loss – The nails are weak and brittle

musculoskeletal s&amp;s hypothyroid

– General muscular weakness and pain, including cramps, and stiffness – General joint pain, achiness, stiffness, known as "arthropathy" – Tendonitis in the arms and legs involves pain, tingling, weakness, achiness or numbness in the wrist, fingers or forearm – Tarsal tunnel syndrome – similar to carpal tunnel, with pain, tingling, burning and other discomfort in the arch of your foot – Carpel tunnel syndrome – which involves pain, tingling, weakness, achiness or numbness in the wrist, fingers or forearm

reproductive s&amp;s hypothyroid

Hypothyroidism influences ovarian function by decreasing levels of sex-hormone-binding-globulin (SHBG) and increasing the secretion of prolactin – Prolactin, the hormone which stimulates milk production for breastfeeding, also affects ovulation and menstrual cycles. – Prolactin inhibits Follicle-Stimulating Hormone (FSH) and gonadotropin releasing hormone (GnRH) – With high levels of prolactin, which can be caused by hypothyroidism, ovulation is not triggered and a woman cannot get pregnant – In men, low FSH and GnRH caused by elevated levels of prolactin can prevent the maturation of sperm

hematologic s&amp;s hnypothyroid

A moderate anemia is usual and may be caused by lack of thyroxine – The blood film may show mild macrocytosis and acanthocytosis – There is also a reduced oxygen need and thus reduced erythropoietin secretion – Autoimmune thyroid disease, especially myxedema or Hashimoto’s disease, is associated with pernicious anemia

Myxedema coma

Initially patient may show signs of depression, lethargy and diminished cognitive status -Respiratory drive depression resulting in alveolar hypoventilation, progressive carbon dioxide retention and coma

cardiac s&amp;s hyperthyroid

cardiac effects may include a heart rate ranging from 90 to 160 bpm, atrial fibrillation may occur, cardiac decompensation e.g. heart failure is common especially in the elderly

respiratory s&amp;s hyperthyroid

dyspnea due to oxygen demands/hypoxia

GI s&amp;s hyperthyroid

increased appetite and dietary intake, abdominal pain, changes in bowel function – diarrhea

neurological s&amp;s hyperthyroid

it also stimulated the person becomes highly irritable, anxious and nervous

skeletal s&amp;s hyperthyroid

premature osteoporosis and fractures

hair, skin, nails s&amp;s hyperthyroid

skin is flushed, soft and may feel warm and moist and to the touch due to excessive perspiration; occasionally raised and thickened over the shins, back of feet The nails margins are irregular, may grow more rapidly and separate from the nail bed

renal s&amp;s hyperthyroid

results in increased GFR as well as increased renin – angiotensin -aldosterone activation

hematologic s&amp;s hyperthyroid

hyperthyroidism emerged to have an increased risk of thrombotic events – A number of case reports have documented acute venous thrombosis complications in patients with overt hyperthyroidism, especially at cerebral sites – A small fall in hemoglobin is therefore usual in hyperthyroidism – may sometimes be sufficient to cause a mild degree of anemia

Thyroid Storm (Thyrotoxicosis)

– a medical emergency condition and needs to be treated emergently; even before all confirmatory diagnostic tests are performed – a severe hypermetabolic state, hyperthemia associated with untreated or undertreated hyperthyroidism. – During thyroid storm person is critically ill and requires aggressive and supportive nursing care during and after the acute stage of illness – Individual’s heart rate, blood pressure, and body temperature can soar to dangerously high levels – without prompt, aggressive treatment, thyroid storm is often fatal

Thioamides

block synthesis of T3 and T4

treatment for hyperthyroid

often consists of a combination of therapies including antithyroid agents, radioactive iodine (the most common treatment for Graves’ disease) and surgery

treatment for thyroid storm

-High doses of thioamides -Replace fluids -Reduce fever (no aspirin – it displaces the thyroid hormone from binding proteins; as a result, worsens the hypermetabolism) -Corticosteroids – inhibit peripheral conversion of T4 into T3 and have been shown to improve outcomes in patients with thyroid storm. – Propanolol ( beta blocker) – lowers the heart rate; hold for bradycardia

post op thyroidectomy

Airway clearance – laryngeal nerve damage, laryngospasm – requires an airway inserted – tracheotomy set is kept at bedside) – dyspnea – can also occur as a result of edema in the glottis or hematoma formation )surgical evacuation of the hematoma is required) – Bleeding – may be due to subcutaneous hemorrhage or a hematoma formation – (observe the sides and back of patient’s neck plus the anterior dressing for bleeding) – monitor vital signs, c/o sensation of fullness or pressure at the incision site -Protect the incision – keep dressing intact – Risk of hypocalcemic tetany (The most common complication after total or near-total thyroidectomy secondary to hypoparathyroidism, which occurs in about a third of cases – When symptoms develop they can range from mild paresthesias to painful tetany and even life-threatening complications, such as laryngeal spasm or arrhythmia. – Symptomatic hypocalcemia is also the primary reason for a prolonged hospitalization after thyroidectomy. – A successful thyroid operation is dependent in part on preventing or effectively treating hypocalcemia-related symptoms: parathyroid trauma/removal – treat with calcium gluconate

post op teaching thyroidectomy

– Exercise – inform patient to do head and neck exercises 2 to 3 times a day as tolerated – Avoid iodine – Avoid premature use of hormone replacement – Risk for thyroid storm (thyroidectomy) – Teach s/s of hypothyroidism – Alternate exposure to hot and cold.

PTH

– Regulates serum calcium and phosphorus/tends to lower the blood phosphorus level and increases calcium – Activates vitamin D in the kidney – Stimulates osteoclastic activity thus increasing bone resorption – Stimulated by hypocalcemia and hyperphosphatemia – Increases renal excretion of phosphorus – Inhibited by high calcium levels (hypercalcemia) and low phosphorus levels (hypophosphatemia)

Hypocalcemia causes…

tetany

Hypercalcemia causes…

neuromuscular irritation

PTH intact

measures the level of parathyroid hormone in the blood – This test is used to help identify hyperparathyroidism or to find the cause of abnormal calcium levels – 10-65 pg/ml

diagnostics for PTH

– PTH intact – Serum calcium as well as phosphorus – The urinary phosphorus is elevated in the hypersecretion of the parathyroid hormone

HYPERPARATHYROIDISM/
PARATHYROID HYPERFUNCTION

Primary: Tumor, often benign, most common in people between the age of 60-70 Secondary: Occurs in those who have chronic renal failure – Constant stimulation of the parathyroid – Also due to chronic hypocalcemia, malabsorption syndromes

assessment findings for hyperpatathyroidism

PTH excess causes hypercalcemia and destruction of bones – Neurological irritation or depression – Cardiovascular: Arrythmias, hypertension, etc. – Gastrointestinal: Nausea, vomiting, constipation, decreased peristalsis

diagnostics for hyperpatathyroidism

– Primary parathyroidism – persistent elevation of serum calcium levels >10 and elevated parathyroid hormone – Decreased serum phosphorus – Increased urinary phosphorus and calcium – Xray showing bone changes

treatment and nursing care for hyperparathyoidism

– Resection of the tumor – parathyroidectomy – For asymptomatic patients with mildly elevated calcium levels, and normal renal function surgery may be delayed – Restore fluid and electrolyte balance – Replace fluids accordingly – Reduce calcium levels – Monitor lab values/potassium levels and assess arrhythmias – Administer lasix IV – Assist with ADL’s and encourage weight bearing activity

causes of hypoparathyroid

Most common cause is inadequate secretion of the parathyroid hormone – Could be due to the interruption of the blood supply or surgical removal of the parathyroid gland tissue during thyroidectomy, parathyroidectomy or radical neck resection – Idiopathic – spontaneously or from an unknown cause – Surgical removal may be another cause

assessment findings for hypoparathyroidism

Hypocalcemia and tetany – Neurological symptoms such as stridor, tingling sensation, and spasms, seizures, Trusseau’s sign (positive when carpopedal spasm is induced by occluding the blood flow to the arm for 30 minutes with a BP cuff – Autoimmune – occurs when the body tissues are attacked by its own immune system – Positive Chvostek’s sign (when a sharp tapping over the facial nerve in front of the parotid gland and anterior to the ear causes spasm or twitching of the mouth – Cardiovascular: arrhythmias, prolonged QT interval, cardiac arrest – Calcifications: cataracts, soft tissues,malformations of the teeth, including weakened tooth enamel and misshapen roots of the teeth -Hypocalcemia, hyperphosphatemia

treatment and nursing care for hypoparathyroid

– Treatment is usually not with PTH replacement – Assess for signs of hypocalcemia – tetany, etc. – Offer lifetime calcium replacement – Give a high calcium and lowphosphorus diet – Give tums, phoslo, aluminum based anti acids with meals – they bind with phosphorus by preventing the body from absorbing the phosphorus from the food one eats, help to pass excess phosphorus out of the body in the stool, reducing the amount of phosphorus that gets into the blood (usually taken 5-10 minutes before meals)

Adrenal Cortex

outer layer of the gland and is necessary for life – Adrenocortical secretions make it possible for the body to adapt to stress of all kinds – ACTH maintains cortex function – Produces 3 types of steroid hormones which are glucocorticoids, mineralocorticoids, and androgens.

Glucocorticoids

(the "sugar" hormones) – have an influence on glucose metabolism – cortisol – essential to life – The prototype is hydrocortisone – increased hydrocortisone secretions result in high glucose levels/gluconeogenesis – Decreases protein synthesis, increase protein catabolism/breakdown

corticosteroids

– given frequently to inhibit the inflammatory response to tissue injury (i.e. Produces anti-inflammatory effect) and to suppress allergic manifestations – Their side effects include the development of diabetes mellitus, osteoporosis, peptic ulcer, increased protein breakdown resulting in muscle wasting and poor wound healing and redistribution of fat – Diurnal secretion pattern (i.e. occurring or active during the daytime rather than at night – peaks early in the morning) – Mobilizes fat for energy production

Mineralocorticoids

exert their main effects on electrolyte metabolism (the "salt" hormones) aldosterone – essential to life – The release of aldosterone is also increased by hyperkalemia – Aldosterone is the long-term regulation of sodium balance – Increases retention of sodium and water by the kidneys – Stimulated by changes in serum sodium, sodium and the renin-angiotensin system – maintains blood volume and BP – Increases excretion of potassium

Androgens

(adrenal sex hormones/sex steroids) -the 3rdmajor type of steroid hormones produced by the adrenal cortex – Not essential to life – Play some role in female adolescent – The adrenal gland may also secrete small amounts of estrogens (female hormones) – ACTH controls the secretion of adrenal androgens

Adrenal Medulla

Inner layer of the adrenal gland, functions as part of the autonomic nervous system -often released into the bloodstream in response to stress or fright and prepare the body for "fight-or-flight"/produces "fight or flight" catecholamines -catecholamines are adrenaline (epinephrine), noradrenaline (norepinephrine), and dopamine.

Epinephrine

– secreted by the adrenal medulla – increases HR, BP, respiratory rate, muscle strength, blood sugar, bronchodilation, and mental alertness. – Reduces the amount of blood going to the skin and increase blood flow to the major organs, the such as the brain, heart, GI system, and kidneys

norepinephrine

constricts all blood vessels to increase BP greatly

ADRENOCORTICAL INSUFFICIENCY/ADRENAL CORTICAL HYPOFUNCTION

– Reduced adrenal gland activity due to damage to the adrenal gland or lack of stimulation of the gland – Deficiency of cortisol, aldosterone and adrenal sex hormones/steroids (androgens)

causes of adrenocortical insufficiency

Adrenal cortex destruction possibly due to: -Tumors – Infection such as tuberculosis, histoplasmosis, etc. – Addison’s disease -an auto immune disease (the most common cause) and is more common in women than in men – Could also be due to the inability to synthesize hormones (Congenital adrenal hyperplasia) -inherited genetic defect that limits production of one of the many enzymes the adrenal glands use to make cortisol

Acute Adrenal Crisis:Addisonian Crisis

– It is life threatening – Characterized by cyanosis and classic signs of circulatory shock such as pallor, tachypnea, hypotension, etc. – Patient may c/o headache, abdominal pain, nausea, diarrhea – Precipitated by stressors – Severe fluid loss – The stress of surgery -possibly hypophysectomy and adrenalectomy or dehydration resulting from preparation for tests or surgery may precipitate Addisonian Crisis

treatment for addisonian crisis

– Treatment is directed toward combating circulatory shock, restoring blood circulation – Lifelong hormone replacement if adrenal gland does not regain function (to prevent recurrence of adrenal insufficiency) – Never stop taking medications or skip doses – Identify other factors, stressors or illnesses that led to the acute episode

cortisol replacement

– Cortisone, hydrocotisone, prednisolone, prednisone – Taken BID -larger doses in a.m. and smaller doses in p.m. – Increase dose of therapy during stressful procedures or significant illnesss – May need to supplement dietary intake with added salt during GI losses of fluids during vomiting and diarrhea – Advise to carry an emergency kit with Solu-cortef and a syringe

Aldosterone Replacement

– Need to increase salt intake – Fludrocortisone acetate (florinef) -0.5-2 mg po once daily – Desoxycorticosterone acetate (DOCA) . 1-2 mg IM daily . Subcutaneous implants -last 9 to 12 months

Care for Acute Adrenal Crisis

– Medical emergency -restore BP, replace hormone therapy – Fluid replacement with D5 NS, albumin and whole blood for volume – Administer steroids -Solu-cortef 100-200 mg bolus IV, then 100 mg IVPB every 6 hours as ordered – Monitor for hypoglycemia -give 50% dextrose bolus IV, high carbohydrate diet – Minimize stressors STRICT BEDREST: – Provide periods of rest in a quiet environment – Minimize physical and psychological stressors such as cold exposure , overexertion as much as possible – Encourage to increase activity gradually as tolerated – Treat underlying cause – Protect from infection – Offer emotional support

Cushing’s Disease

Due/secondary to ACTH excess/adrenocortical activity – Ectopic ACTH secretion by the lung or pancreatic tumors

Cushing’s Syndrome

– Primary hyperfunction due adrenal nodules or hyperplasia – More common in women than in men

Iatrogenic Cushing’s Syndrome

– Treatment with glucocorticoids for conditions other than hormone deficit

assessment findings for cushings

– Cortisol excess . Increased protein breakdown . Alteration in carbohydrate metabolism producing muscle wasting and osteoporosis . Abdominal pain, gastritis, ulcers . Immnunosuppression -slow healing of minor cuts and bruises, thin, fragile skin; easily traumatized, ecchymosis, strae . Mood swings/disturbances, psychosis . "Moon-faced" appearance – Aldosterone excess: . Weight gain, edema . Hypernatremia, hypokalemia . Hypertension – Sex steroid excess: . In female -acne, hirsutism,amenorrhea, breast atrophy, thinning of scalp hair . In male -gynecomastia, decreased libido

diagnostics for cushings

– Elevated cortisol level in a.m. and p.m. – Metabolic alkalosis, decreased chloride – Elevated 17-OHCS – Elevated 17-KS

treatment and nursing care for cushings

– Reduction of hormone levels – Pituitary surgery for ACTH secreting tumor – Adrenalectomy:Either both glands, 1 gland or resection/removal of the tumor (if 1 adrenal gland is removed; replacement therapy may be temporary necessary, if both glands are removed then replacement of corticosteroids will be lifelong) . Laparoscopic approach for single nodules . Convertional surgery:Risk for adrenal crisis, care similar for adrenal crisis. May require hormone replacement Drugs to Block Synthesis of Cortisol: -Metyrapone, mititane, aminoglultethamide -Will cause hormone deficit, replacement required

PRIMARY ALDOSTERONISM

– Aldosterone secreting tumor – patient exhibits profound alkalosis and hypokalemia – Hypertension is the most prominent and almost a universal sign of aldosterorism – Hypokalemic alkalosis may decrease serum calcium level resulting in tetany and paresthesia – – Glucose intolerance may occur leading to hyperglycemia – The urine volume is excessive, leading to polyuria – Serum by contrast becomes concentrated leading to polydipsia

treatment for aldosteronism

– Surgical removal/resection of the tumor – Encourage low sodium and high potassium diet -may need potassium supplements – Administer spiranolactone (aldactone) -potassium sparing diuretic – Monitor vital signs especially BP, daily weight, and strict I/O’s

Pheochromocytoma

. Catecholamine secreting tumor -excess epinephrine and norepinephrine . Tumor is located in the medulla, abdominal cavity, or the sympathetic nervous system . Usually benign . Mostly seen in adults 40-60 years of age . Hypertensive child needs to be screened for pheochromocytoma

diagnostics Pheochromocytoma

– Elevated urinary catecholamines and vanillymandelic acid (VMA) – Regitine test: Measures BP before and after administration of regitine (phentolamine) – Immediate decrease of 35mmHg systolic and 25mmHg diastolic indicates positive test – CT scan and MRI – MIBG (metaiodobenzylguanidine): Radioactive dye concentrates in tumor only is vidualized on xray i.e this imaging test uses a radioactive substance (called a tracer) and a special scanner to find or confirm the presence of pheochromocytoma and neuroblastoma

assessment findings Pheochromocytoma

– hypertension – Episodic Paroxysmal attacks: Severe headache, palpitations, tachycardia, visual disturbances, tremors, anxiety,, chest, abdominal pain dizziness, diaphoresis, nausea, etc. – Attacks increase in frequency – High risk of ventricular fibrillation (VF), heart failure, stroke and even death

treatment and nursing care for Pheochromocytoma

– Very crucial to stabilize the BP and remove the tumor WATER: Increased cardiac output – Patient need intensive care and monitoring of BP and other vital signs – Administer IV nitroprusside titrated to reduce the BP or use of regitine IV – Change to dibenzyline po or regitine po once patient is stabilized – Administer propanolol (beta blocker) ACTIVITY AND REST: – Maintain bedrest with HOB elevated – Provide a quiet and semi-darkened room – Conserve energy as much as possible – Reassure patient and offer emotional support *Surgical Treatment: Important to stabilize the BP first – No atropine pre-operatively – Possible laparoscopic approach -not as invasive – BP very labile post-operatively – Life long hormone replacement therapy required if both adrenal glands are removed