ENDOCRINE NCLEX MED SURG EXAM 3
Which nursing measure would be effective in preventing complications in a client
with Addison's disease?
1. Restricting fluid intake
2. Offering foods high in potassium
3. Checking family support systems
4. Monitoring the blood glucose - ANSWERS-*4. Monitoring the blood glucose*
*rationale* The decrease in cortisol secretion that characterizes Addison's disease
can result in hypoglycemia. Therefore monitoring the blood glucose would detect
the presence of hypoglycemia so that it can be treated early to prevent
complications. Fluid intake should be encouraged to compensate for dehydration.
Potassium intake should be restricted because of hyperkalemia. Option 3 is not a
priority for this client.
A nurse is collecting data on a client with a diagnosis of hypothyroidism. Which of
these behaviors, if present in the client's history, would the nurse determine as
being likely related to the manifestations of this disorder?
1. Depression
2. Nervousness
3. Irritability
4. Anxiety - ANSWERS-*1. Depression*
,*rationale* Hypothyroid clients experience a slow metabolic rate, and its
manifestation includes apathy, fatigue, sleepiness, and depression. Options 2, 3,
and 4 identify the clinical manifestations of hyperthyroidism.
While collecting data on a client being prepared for an adrenalectomy, the nurse
obtains a temperature reading of 100.8° F. The nurse analyzes this temperature
reading as:
1. Within normal limits
2. A finding that needs to be reported immediately
3. An expected finding caused by the operative stress response
4. Slightly abnormal but an insignificant finding - ANSWERS-*2. A finding that
needs to be reported immediately*
*rationale* An adrenalectomy is performed because of excess adrenal gland
function. Excess cortisol production impairs the immune response, which puts the
client at risk for infection. Because of this, the client needs to be protected from
infection, and minor variations in normal vital sign values must be reported so
that infections are detected early, before they become overwhelming. In addition,
the surgeon may elect to postpone surgery in the event of a fever because it can
be indicative of infection. Options 1, 3, and 4 are not correct interpretations.
The anticipated intended effect of fludrocortisone acetate (Florinef) for the
treatment of Addison's disease is to:
,1. Stimulate the immune response.
2. Promote electrolyte balance.
3. Stimulate thyroid production.
4. Stimulate thyrotropin production. - ANSWERS-*2. Promote electrolyte
balance.*
*rationale* Florinef is a long-acting oral medication with mineralocorticoid and
moderate glucocorticoid activity used for long-term management of Addison's
disease. Mineralocorticoids act on the renal distal tubules to enhance the
reabsorption of sodium and chloride ions and the excretion of potassium and
hydrogen ions. In small doses, fludrocortisone acetate causes sodium retention
and increased urinary potassium excretion. The client rapidly can develop
hypotension and fluid and electrolyte imbalance if the medication is discontinued
abruptly. Options 1, 3, and 4 are not associated with the effects of this
medication.
A nurse is caring for a client with hypothyroidism who is overweight. Which food
items would the nurse suggest to include in the plan?
1. Peanut butter, avocado, and red meat
2. Skim milk, apples, whole-grain bread, and cereal
3. Organ meat, carrots, and skim milk
4. Seafood, spinach, and cream cheese - ANSWERS-*2. Skim milk, apples, whole-
grain bread, and cereal*
, *rationale* Clients with hypothyroidism may have a problem with being over-
weight because of their decreased metabolic need. They should consume foods
from all food groups, which will provide them with the necessary nutrients;
however, the foods should be low in calories. Option 2 is the only option that
identifies food items that are low in calories.
In planning nutrition for the client with hypoparathyroidism, which diet would be
appropriate?
1. High in calcium and low phosphorous
2. Low in vitamins A, D, E, and K
3. High in sodium with no fluid restriction
4. Low in water and insoluble fiber - ANSWERS-*1. High in calcium and low
phosphorous*
*rationale* Hypocalcemia is the end result of hypoparathyroidism resulting from
either a lack of parathyroid hormone (PTH) secretion or ineffective PTH influence
on tissue. Calcium is the major controlling factor of PTH secretion. Because of this,
the diet needs to be high in calcium but low in phosphorus because these two
electrolytes must exist in inverse proportions in the body. The other options are
not dietary interventions with hypoparathyroidism.
A preoperative client is scheduled for adrenalectomy to remove a
pheochromocytoma. The nurse would most closely monitor which of the
following items in the preoperative period?
Which nursing measure would be effective in preventing complications in a client
with Addison's disease?
1. Restricting fluid intake
2. Offering foods high in potassium
3. Checking family support systems
4. Monitoring the blood glucose - ANSWERS-*4. Monitoring the blood glucose*
*rationale* The decrease in cortisol secretion that characterizes Addison's disease
can result in hypoglycemia. Therefore monitoring the blood glucose would detect
the presence of hypoglycemia so that it can be treated early to prevent
complications. Fluid intake should be encouraged to compensate for dehydration.
Potassium intake should be restricted because of hyperkalemia. Option 3 is not a
priority for this client.
A nurse is collecting data on a client with a diagnosis of hypothyroidism. Which of
these behaviors, if present in the client's history, would the nurse determine as
being likely related to the manifestations of this disorder?
1. Depression
2. Nervousness
3. Irritability
4. Anxiety - ANSWERS-*1. Depression*
,*rationale* Hypothyroid clients experience a slow metabolic rate, and its
manifestation includes apathy, fatigue, sleepiness, and depression. Options 2, 3,
and 4 identify the clinical manifestations of hyperthyroidism.
While collecting data on a client being prepared for an adrenalectomy, the nurse
obtains a temperature reading of 100.8° F. The nurse analyzes this temperature
reading as:
1. Within normal limits
2. A finding that needs to be reported immediately
3. An expected finding caused by the operative stress response
4. Slightly abnormal but an insignificant finding - ANSWERS-*2. A finding that
needs to be reported immediately*
*rationale* An adrenalectomy is performed because of excess adrenal gland
function. Excess cortisol production impairs the immune response, which puts the
client at risk for infection. Because of this, the client needs to be protected from
infection, and minor variations in normal vital sign values must be reported so
that infections are detected early, before they become overwhelming. In addition,
the surgeon may elect to postpone surgery in the event of a fever because it can
be indicative of infection. Options 1, 3, and 4 are not correct interpretations.
The anticipated intended effect of fludrocortisone acetate (Florinef) for the
treatment of Addison's disease is to:
,1. Stimulate the immune response.
2. Promote electrolyte balance.
3. Stimulate thyroid production.
4. Stimulate thyrotropin production. - ANSWERS-*2. Promote electrolyte
balance.*
*rationale* Florinef is a long-acting oral medication with mineralocorticoid and
moderate glucocorticoid activity used for long-term management of Addison's
disease. Mineralocorticoids act on the renal distal tubules to enhance the
reabsorption of sodium and chloride ions and the excretion of potassium and
hydrogen ions. In small doses, fludrocortisone acetate causes sodium retention
and increased urinary potassium excretion. The client rapidly can develop
hypotension and fluid and electrolyte imbalance if the medication is discontinued
abruptly. Options 1, 3, and 4 are not associated with the effects of this
medication.
A nurse is caring for a client with hypothyroidism who is overweight. Which food
items would the nurse suggest to include in the plan?
1. Peanut butter, avocado, and red meat
2. Skim milk, apples, whole-grain bread, and cereal
3. Organ meat, carrots, and skim milk
4. Seafood, spinach, and cream cheese - ANSWERS-*2. Skim milk, apples, whole-
grain bread, and cereal*
, *rationale* Clients with hypothyroidism may have a problem with being over-
weight because of their decreased metabolic need. They should consume foods
from all food groups, which will provide them with the necessary nutrients;
however, the foods should be low in calories. Option 2 is the only option that
identifies food items that are low in calories.
In planning nutrition for the client with hypoparathyroidism, which diet would be
appropriate?
1. High in calcium and low phosphorous
2. Low in vitamins A, D, E, and K
3. High in sodium with no fluid restriction
4. Low in water and insoluble fiber - ANSWERS-*1. High in calcium and low
phosphorous*
*rationale* Hypocalcemia is the end result of hypoparathyroidism resulting from
either a lack of parathyroid hormone (PTH) secretion or ineffective PTH influence
on tissue. Calcium is the major controlling factor of PTH secretion. Because of this,
the diet needs to be high in calcium but low in phosphorus because these two
electrolytes must exist in inverse proportions in the body. The other options are
not dietary interventions with hypoparathyroidism.
A preoperative client is scheduled for adrenalectomy to remove a
pheochromocytoma. The nurse would most closely monitor which of the
following items in the preoperative period?
