Quiz
Saturday, March 22, 2008
Nursing Care of Clients with Endocrine Disorders
1. 1. A client is being treated with supplemental calcium for hypoparathyroidism. The nurse caring for the client knows that which of the following calcium levels indicates that a therapeutic effect of the calcium supplement has been achieved?
a. 9.2 mg/dL
b. 5.7 mg/dL
c. 12.0 mg/dL
d. 7.9 mg/dL
Normal serum calcium level is 8.8 to 10 mg/dl. The therapeutic response of supplemental calcium is demonstrated by serum calcium levels within normal limits.
2. The nurse is admitting a client status post subtotal thyroidectomy for the treatment of hyperthyroidism. Which of the following is the immediate priority?
a. Assess for respiratory distress
b. Assess for pain
c. Assess fluid volume status
d. Assess neurological status
The immediate priority for the postoperative thyroidectomy is airway management as respiratory distress may occur from laryngeal damage, hemorrhage, edema, or tetany. Assessment should include rate, rhythm, depth, and effort of excursion.
3. A nurse is implementing discharge instructions regarding medication therapy of propylthiouracil (PTU, Propyl-Thracil) to a client newly diagnosed with hyperthyroidism. Which of the following statements made by the client indicates to the nurse that further instructions are necessary?
a. "I will report any unusual bleeding, nausea, or epigastric pain to my physician."
b. "I will begin to feel better immediately after starting the medication."
c. "I will take my medication at the same time everyday."
d. "I will return to the physician for follow-up lab reports as instructed."
Antithyroid medications, such as propylthiouracil, may take up to 12 weeks before the full effects of the drug are experienced. The client should be informed of this in order to promote compliance with therapy. Side effects of antithyroid medications include unusual bleeding, nausea, epigastric pain, and loss of taste. In order to maintain stable blood levels, the medication should be taken at the same time each day. Routine evaluation of serum blood levels will be performed to monitor therapy.
4. The nurse is establishing a plan of care for a client admitted with Cushing's syndrome. Which of the following is the priority nursing diagnosis for this client?
a. Knowledge Deficit
b. Risk for Injury
c. Fluid Volume Deficit
d. Fluid Volume Excess
Sodium retention in Cushing's syndrome leads to edema and hypertension. Fluid Volume Excess is the priority nursing diagnosis and treatment is aimed at restoring normal body fluid balance. Risk for Injury and Knowledge Deficit are applicable to the client, but Fluid Volume Excess is the priority.
5. A client with a history of Addison's disease presents with weakness, abdominal pain, high fever, and hypotension, and is diagnosed with Addisonian Crisis. Which of the following represents the nurse's most appropriate immediate action?
a. Assess client for presence of infection
b. Assess client for compliance with medication therapy
c. Establish an intravenous access
d. Prepare for nasotracheal intubation
Addisonian Crisis is life threatening. Treatment is rapid intravenous replacement of fluids and glucocorticoids. Delay in treatment could result in circulatory collapse, shock, and coma. Assessing the client for presence of infection and compliance with medication therapy is important and should be assessed after the initiation of fluids and glucocorticoids. The client may experience shock and require intubation if treatment is not initiated.
6. The nurse establishes which of the following as the priority nursing assessment of a client admitted with pheochromocytoma?
a. Blood pressure
b. Neurological status
c. Urine output
d. Presence of edema
Pheochromocytoma is a catecholamine-producing tumor of the adrenal medulla. The most dangerous effects are peripheral vasoconstriction and increased cardiac rate and contractility, resulting in paroxysmal hypertension. Systolic blood pressure may reach up to 300 mmHg, and diastolic may reach 175 mmHg, which makes this disorder life threatening. Monitoring blood pressure is the priority, followed by urine output and neurological status. Treatment of choice for this disorder is an adrenalectomy.
7. The nurse, caring for a client receiving vasopressin (Pitressin) for treatment of diabetes insipidus, implements which of the following measures for the care of client?
a. Teaching the client the purpose of NPO status
b. Teaching the client the purpose of intravenous hypertonic fluids
c. Teaching the client the purpose of monitoring urine output
d. Teaching the client the purpose of fluid restriction
Diabetes insipidus results as a deficiency in the antidiuretic hormone and is manifested by massive diuresis and dehydration. Vasopressin, the antidiuretic hormone, is administered to promote fluid retention and achieve fluid balance. Oral fluids are encouraged, and hypotonic fluids are administered. Monitoring urine output for effects of Vasopressin is the correct nursing action.
8. In establishing a plan of care for a client admitted with syndrome of inappropriate antidiuretic hormone secretion (SIADH), the nurse identifies which of the following as the priority nursing diagnosis for this client?
a. Fluid Volume Deficit
b. Fluid Volume Excess
c. Impaired Tissue Integrity related to Edema
d. Risk for Injury
Syndrome of inappropriate antidiuretic hormone secretion (SIADH) results in fluid retention and hyponatremia. Restoration of fluid and electrolyte balance is the priority. Edema usually does not occur because the water is evenly distributed between the intracellular and extracellular spaces. The potential for injury does exist and should be included in the plan of care following fluid volume excess.
9. The nurse is providing education to a client with exophthalmos as a result of Graves' disease. Which of the following statements made by the client indicates to the nurse that the client understands exophthalmos?
a. "After I achieve a therapeutic blood level of the medication, I should notice a difference in my eyes."
b. "My eye changes are a temporary symptom, and will resolve gradually."
c. "After I use the eye medication for a while, I should notice a difference in my eyes."
d. "The changes in my eyes are not reversible, even after I receive treatment. I will have to learn the proper care of my eyes."
Exophthalmos occurs as a result of the accumulation of fat deposits and by-products in the retro-orbital tissues. These changes are not reversible, even with treatment of Graves' disease. The client should be instructed on measures to protect the eye.
10. A client newly diagnosed with hypothyroidism is prescribed Synthroid (levothyroxine sodium) as part of the management for this disorder. Which of the following statements made by the client indicates to the nurse a need for further teaching?
a. "I will take my Synthroid on an empty stomach."
b. "I will take my Synthroid at night."
c. "I will be on Synthroid the rest of my life."
d. "I will not skip my Synthroid medication, even if I am sick."
Synthroid is a thyroid replacement hormone used in the treatment of hypothyroidism and lifelong treatment is necessary. The medication should be taken 1 hour before meals or 2 hours after meals for best absorption. To reduce the possibility of insomnia, thyroid medications should be taken in the morning.
11. A nurse is assessing a newly admitted client with symptoms of heat intolerance, insomnia, palpitations, and increased sweating. Which of the following diagnoses may be the reason for these symptoms?
a. Pretibial myxedema
b. Hyperthroidism
c. Proptosis
d. Hypothroidism
Rationale: The client with hyperthyroidism typically has an increased appetite, yet loses weight and may have hypermotile bowels and diarrhea. Additional manifestations related to hypermetabolism include heat intolerance, insomnia, palpitations, and increased sweating. # 1 is incorrect because pretibial myxedema is a rare characteristic of Graves’ disease. It is manifested by plaques and nodule development bilaterally over the shins and dorsal surface of the feet. # 3 is incorrect because proptosis is the forward displacement of the eye. # 4 is incorrect because the symptoms in the stem describe symptoms of hyperthyroidism, and not hypothyroidism. In hypothyroidism, clients characteristically have the manifestations of goiter, fluid retention and edema, decreased appetite, weight gain, constipation, dry skin, dyspnea, pallor, hoarseness, and muscle stiffness.
12. A client presents to the emergency room with a history of Graves’ disease. The client reports having symptoms for a few days, but has not previously sought or received any additional treatment. The client also reports having had a cold a few days back. Which of the following interventions would be appropriate to implement for this client, based on the history and current symptoms? Select all that apply.
a. Administer aspirin
b. Replace intravenous fluids
c. Induce shivering
d. Relieve respiratory distress
e. Administer a cooling blanket
Rationale: Thyroid storm (also called thyroid crisis) is an extreme state of hyperthyroidism that is rare today because of improved diagnosis and treatment methods (Porth, 2005). When it does occur, those affected are usually people with untreated hyperthyroidism (most often Graves’ disease) and people with hyperthyroidism who have experienced a stressor, such as an infection, trauma. The rapid increase in metabolic rate that results from the excessive TH causes the manifestations of thyroid storm. The manifestations include hyperthermia, with body temperatures ranging from 102°F (39°C) to 106°F (41°C); tachycardia; systolic hypertension; and gastrointestinal symptoms (abdominal pain, vomiting, diarrhea). Agitation, restlessness, and tremors are common, progressing to confusion, psychosis, delirium, and seizures. The mortality rate is high. Rapid treatment of thyroid storm is essential to preserve life. Treatment includes cooling without aspirin (which increases free TH) or inducing shivering, replacing fluids, glucose, and electrolytes, relieving respiratory distress, stabilizing cardiovascular function, and reducing TH synthesis and secretion. #1 is incorrect because cooling happens without the use of aspirin. All of the other choices are correct.
13. A nursing student is studying for a test on care of the client with endocrine disorders. Which of the following statements demonstrates an understanding of the difference between hyperthyroidism and hypothyroidism?
a. “Deficient amounts of TH cause abnormalities in lipid metabolism, with decreased serum cholesterol and triglyceride levels.”
b. “Graves’ disease is the most common cause of hypothyroidism.”
c. “Decreased renal blood flow and glomerular filtration rate reduces the kidney’s ability to excrete water, which may cause hyponatremia.”
d. “Increased amounts of TH cause a decrease in cardiac output and peripheral blood flow.”
Rationale: # 1 is incorrect because deficient amounts of TH cause abnormalities in lipid metabolism with elevated serum cholesterol and triglyceride levels. # 2 is incorrect because Graves’ disease is the most common cause of hyperthyroidism, not hypothyroidism. # 4 is incorrect because increased amounts of TH cause an increase in cardiac output and peripheral blood flow.
14. A Clinical Instructor is questioning a student nurse about disorders of the parathyroid glands. Which statement by the nursing student, would indicate the need for further teaching?
a. “Hyperparathyroidism results in an increased release of calcium and phosphorus by bones, with resultant bone decalcification.”
b. “Hyperparathyroidism results in deposits in soft tissues and the formation of renal calculi.”
c. “Hypoparathyroidism results in impaired renal tubular regulation of calcium and phosphate.”
d. “Hypoparathyroidism results in decreased activation of vitamin D which then results in decreased absorption of calcium by the pancreas.”
Rationale: Choices 1, 2, and 3 are all correct statements. # 4 demonstrates a need for further teaching because hypoparathyroidism results in decreased activation of vitamin D which then results in decreased absorption of calcium by the intestines, not the pancreas.
15. A nurse on a general medical-surgical unit is caring for a client with Cushing’s syndrome. Which of the following statements is correct about the medication regimen for Cushing’s syndrome?
a. Mitotane is used to treat metastatic adrenal cancer.
b. Aminogluthimide may be administered to clients with ectopic ACTH-secreting tumors before surgery is performed.
c. Ketoconazole increases cortisol synthesis by the adrenal cortex.
d. Somatostatin analog increases ACTH secretion in some clients.
Rationale: Mitotane directly suppresses activity of the adrenal cortex and decreases peripheral metabolism of corticosteroids. It is used to treat metastatic adrenal cancer. # 2 is incorrect because aminogluthimide may be administered to clients with ectopic ACTH-secreting tumors that cannot be surgically removed. # 3 is incorrect because ketoconazole inhibits, not increases, cortisol synthesis by the adrenal cortex. # 4 is incorrect because somatostatin suppresses, not increases, ACTH secretion.
16. Which of the following nursing implications is most important in a client being medicated for Addison’s disease?
a. Administer oral forms of the drug with food to minimize its ulcerogenic effect.
b. Monitor capillary blood glucose for hypoglycemia in the diabetic client.
c. Instruct the client to never abruptly discontinue the medication.
d. Teach the client to consume a diet that is high in potassium, low in sodium, and high in protein.
Rationale: The primary medical treatment of Addison’s disease is replacement of corticosteroids and mineralcorticoids, accompanied by increased sodium in the diet. The client needs to know the importance of maintaining a diet high is sodium and low in potassium. Medications should never be discontinued abruptly because crisis can ensue. Oral forms of the drug are given with food in Cushing’s disease.
17. A nurse on a surgical floor is caring for a post-operative client who has just had a subtotal thyroidectomy. Which of the following assessments should be completed first on the client?
a. Assess for signs of tetany by checking for Chvostek’s and Trousseau’s signs
b. Assess dressing (if present) and the area under the client’s neck and shoulders for drainage.
c. Administer analgesic pain medications as ordered, and monitor their effectiveness.
d. Assess respiratory rate, rhythm, depth, and effort.
Rationale: All of the above assessments have importance, but airway and breathing in a client should always be addressed first when prioritizing care. Assess for signs of latent tetany due to calcium deficiency, including tingling of toes, fingers, and lips; muscular twitches; positive Chvostek’s and Trousseau’s signs; and decreased serum calcium levels. However, tetany may occur in 1 to 7 days after thyroidectomy so # 1 is not the highest priority. Assessing for hemorrhage is always important, but the danger of hemorrhage is greatest in the first 12 to 24 hours after surgery, and as this client is immediately post operative it is not the main concern at this time. Pain medication is important but according to Maslow, pain is a psychosocial need to be addressed after a physiologic need.
18. The nurse is caring for a client who is about to undergo an adrenalectomy. Which of the following Preoperative interventions is most appropriate for this client?
a. Maintain careful use of medical and surgical asepsis when providing care and treatments.
b. Teach the client about a diet high in sodium to correct any potential sodium imbalances preoperatively.
c. Explain to the client that electrolytes and glucose levels will be measured postoperatively.
d. Teach the client how to effectively cough and deep breathe once surgery is complete.
Rationale: Use careful medical and surgical asepsis when providing care and treatments since Cortisol excess increases the risk of infection. # 2 is incorrect. Nutrition should be addressed preoperatively. Request a dietary consultation to discuss with the client about a diet high in vitamins and proteins. If hypokalemia exists, include foods high in potassium. Glucocorticoid excess increases catabolism. Vitamins and proteins are necessary for tissue repair and wound healing following surgery. # 3 is incorrect. Monitor the results of laboratory tests of electrolytes and glucose levels. Electrolyte and glucose imbalances are corrected before the client has surgery. # 4 is incorrect. Teach the client to turn, cough, and perform deep-breathing exercises. Although they are important for all surgical clients, these activities are even more important for the client who is at risk for infection. Having the client practice and demonstrate the activities increases postoperative compliance.
19. The nurse is caring for a client with pheochromocytoma. Which of the following must be included in planning the nursing care for this client ?
a. Monitor blood pressure frequently, assessing for hypertension.
b. Assess only for physical stressors present.
c. Collect a random urine sample.
d. Prepare the client for chemotherapy to shrink the tumor.
Rationale: Pheochromocytomas are tumors of chromaffin tissues in the adrenal medulla. These tumors which are usually benign produce catecholamines (epinephrine or norepinephrine) that stimulate the sympathetic nervous system. Although many organs are affected, the most dangerous effects are peripheral vasoconstriction and increased cardiac rate and contractility with resultant paroxysmal hypertension. Systolic blood pressure may rise to 200 to 300 mmHg, the diastolic to 150 to 175 mmHg. # 1 is correct because the careful monitoring of blood pressure is essential. Attacks are often precipitated by physical, emotional, or environmental stimuli, so # 2 is incorrect because more than physical stressors are considered. This condition is life threatening and is usually treated with surgery as the preferred treatment. # 3 is incorrect because it is a random sample and not a 24 hour urine collection. Because catecholamine secretion is episodic, a 24-hour urine is a better surveillance method than serum catecholamines. (Pagana & Pagana, 2002). Surgical removal of the tumor(s) by adrenalectomy is the treatment of choice. # 4 is incorrect because surgery would be the treatment usually completed.
20. A client newly diagnosed with Addison’s disease is giving a return explanation of teaching done by the primary nurse. Which of the following statements indicates that further teaching is necessary?
a. “I need to increase how much I drink each day.”
b. “I need to weigh myself if I think I am losing or gaining weight.”
c. “I need to maintain a diet high in sodium and low in potassium.”
d. “I need to take my medications each day.”
Rationale: The client is at risk for ineffective therapeutic regimen management. Clients with Addison’s disease must learn to provide lifelong self-care that involves varied components: medications, diet, and recognizing and responding to stress. Changes in lifestyle are difficult to maintain permanently. The client needs to take the medications on a daily basis. The client needs to perform daily weights to monitor for signs of dehydration. The client needs to maintain a diet high in sodium and low in potassium, as well as maintain an increased fluid intake. # 2 is incorrect because daily weights need to be performed instead of weighing when a problem is suspected.
Thursday, March 20, 2008
Assessing Clients with Endocrine Disorders
1 . A client in the health department asks what purpose the pituitary gland serves. The nurse plans to provide the client information based on the knowledge that the function of the pituitary gland is which of the following?
a. The pituitary gland secretes the hormones thyroxine (T4) and triiodothyronine (T3).
b. The pituitary gland serves as the body's "master gland" because its hormones regulate many body functions.
c. The pituitary gland secretes hormones which are not essential to life.
d. The pituitary gland secretes mineralcorticoids and glucocorticoids.
The pituitary gland is the body's master gland because its hormones regulate many body functions. The anterior pituitary secretes the growth hormone (GH), prolactin (PRL), thyroid stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), gonadotropin hormones, follicle-stimulating hormone (FSH) and luteinizing hormone (LH). The posterior pituitary secretes the antidiuretic hormone (ADH) and oxytocin.
Thyroxine (T4) and triiodothyronine (T3) are secreted by the thyroid gland, mineralcorticoids and glucocorticoids are secreted by the adrenal cortex.
Planning; Health Promotion and Maintenance; Analysis
a. Thyroid gland
b. Adrenal glands
c. Pancreas
d. Pituitary gland
The thyroid gland is responsible for growth and development in children as well as increasing metabolism. The adrenal medulla produces catecholamines, the adrenal cortex produces mineralcorticoids and glucocorticoids, and the pancreas produces hormones that regulate carbohydrate metabolism.
Implementation; Physiological Integrity; Application
a. Secretes aldosterone for regulation of water and sodium
b. Secretes the steroid sex hormones
c. Regulates metabolism
d. Secretes hormones such as insulin necessary for carbohydrate metabolism
The pancreas has endocrine functions (produces hormones) and exocrine functions (produces digestive enzymes). The islets of Langerhans, located throughout the pancreas, secrete glucagon, insulin, and somatostatin, all necessary for carbohydrate metabolism. The adrenal cortex secretes aldosterone, the Gonads secrete steroid sex hormones, and the thyroid regulates metabolism.
Planning; Physiological Integrity; Application
a. "When my body detects a change in hormone levels, the hormones adjust secretion to maintain stable levels."
b. "When one hormone level increases, they all increase."
c. "If there is a decrease of a certain hormone in my body, nothing can be done to increase the hormone."
d. "If a hormone stops producing in my body, another hormone will take its place."
In negative feedback, endocrine system sensors detect changes in hormone levels and adjust the hormone secretion to maintain normal body levels. If there is an increase in the hormone levels, the hormones decrease in production and release, and if there is a decrease in hormone levels, there is an increase release of hormones.
Evaluation; Health Promotion and Maintenance; Analysis
a. Ask the client how much weight she has gained
b. Assess the client's thyroid gland
c. Assess the client's throat and tonsils
d. Assess the client's history of smoking
Often clients with enlarged thyroid glands will complain of tightening of clothing, collars, and jewelry around the neck. Clients also describe a swelling in the front of their neck. The other assessments are important; however, establishing the presence of an enlarged thyroid gland is the priority.
Assessment; Health Promotion and Maintenance; Application
a. Maternal history of diabetes
b. Obesity
c. Age
d. Race
The client has numerous risk factors, including family history, race and age. However, the only modifiable risk factor is obesity, which is linked to Type II diabetes.
Implementation; Health Promotion and Maintenance; Application
a. Standing behind the client and placing fingers on either side of the trachea below the thyroid cartilage
b. Standing in front of the client and placing fingers on either side of the trachea below the thyroid cartilage
c. Standing behind the client and placing fingers on either side of the trachea above the thyroid cartilage
d. Standing in front of the client and placing fingers on either side of the trachea above the thyroid cartilage
The appropriate technique for assessing the client's thyroid is to stand behind the client, place your fingers on either side of the trachea below the thyroid cartilage. The client should tilt the head to the right and swallow, as the client swallows, displace the left lobe while palpating the right lobe. Repeat the process to palpate the left lobe.
Assessment; Health Promotion and Maintenance; Application
a. Dry, brittle nails
b. Dry coarse hair
c. Exophthalmos (protruding eyes)
d. Yellow cast to skin
Exophthalmos (protruding eyes) may be seen in hyperthyroidism. Dry, brittle nails, dry hair, and a yellowish cast to the skin may be indications of hypothyroidism.
Assessment; Health Promotion and Maintenance; Application
a. Place a rubber band in the client's hand and ask to the client to identify the object
b. Use the blunt end of a safety pin and prick the client's finger
c. Use a tuning fork over the client's fingers
d. Use a cup of cold water placed in the client's hand
Stereognosis is the ability to identify an object merely by touch. The use of rubber bands, buttons, cotton balls or other common items are recommended. The pinprick tests pain; the cold water tests temperature; and the tuning fork tests vibration.
Assessment; Health Promotion and Maintenance; Application
a. "I will inform the physician and she may want to run some lab tests on you."
b. "Those are normal changes experienced as one ages."
c. "There is nothing to worry about at this time, if you notice any other changes, let us know."
d. "You might want to mention that to the physician when you see her."
Changes in memory and ability to concentration, changes in hair texture, sleep disturbances, and changes in appetite and thirst may indicate endocrine disorders. These symptoms do not necessarily occur with aging. Informing the physician assures she has all of the assessment data.
Implementation; Physiological Integrity; Application
11. When the nurse is performing assessment of the client and notes that the client had demonstrated a negative Chovostek’s sign, the nurse will be able to document the same finding if the nurse performs the Chovostek’s assessment with which of the following results?
a. No contraction of the client’s hand and fingers when the nurse inflates a pressure cuff above the antecubital space to occlude the blood supply to the arm.
b. Minimal knee reaction to reflex hammer assessment.
c. Ability to identify a cotton ball when the cotton ball is placed in the client’s hand while the client keeps eyes closed.
d. No contraction of the lateral facial muscles when the nurse taps the nurse’s finger in front of the client’s ear at the angle of the jaw.
Rationale: Chvostek’s sign is positive for decreased calcium level when the client’s lateral facial muscles contract when the nurse taps the nurse’s finger in front of the client’s ear at the angle of the jaw. Trousseau’s sign is positive (indicating deceased calcium levels) when the nurse applies a pressure cuff above the antecubital space resulting in carpal spasm. Increased reflexes may be seen in hyperthyroidism while decreased reflexes may be seen in hypothyroidism. Stereognosis is tested by placing a familiar object in the client’s palm and asking the client to identify the object by touch.
Nursing Process: Assessment
Client Need: Physiological Integrity
Cognitive Level: Analysis
Objective: Identify abnormal findings that may indicate malfunction of the glands of the endocrine system.
Strategy: Use knowledge of pathophysiology and the process of elimination to make the correct choice.
12. Which of the following statements, if made by the client to the nurse during the performance of the physical assessment, would indicate to the nurse that the client may be developing Cushing’s syndrome?
a. “My abdomen has gotten so large so quickly that I have stretch marks and what looks like bruising – can you see it?”
b. “I just can’t seem to use enough lotion to keep my skin smooth and moist.”
c. “My eyes look like their going to pop out of my head, don’t they?”
d. “I know I’m getting older, but what in the world is this bulge on the front of my neck?"
Rationale: When individuals develop Cushing’s syndrome, one of the most distressing physical changes for them is the development of purple striae (stretch marks) and bruising on the abdomen. Dry, rough skin is often seen in clients with hypothyroidism. Exophthalmos is associated with hyperthyroidism. A goiter is an enlargement of the thyroid gland and is associated with thyroid dysfunction.
Nursing Process: Assessment
Client Need: Physiologic Integrity
Cognitive Level: Application
Objective: Conduct and document a physical assessment of the structure of the thyroid gland and the effects of altered endocrine function on other body structures and functions.
Strategy: Use knowledge of pathophysiology and the process of elimination to make the correct choice.
13. The nurse on evening shift is providing acute inpatient care to a 72 year old client who had undergone total knee replacement surgery two days earlier and the physician suspects that the client may have hypothyroidsm? The nurse reviews the blood values for the client from blood samples taken earlier that day (10:00 a.m.) to measure: non-fasting blood sugar (NFBS), thyroid stimulating hormone (TSH), and thyroxine (T4). Results: NFBS slightly elevated; decreased T4; and, normal TSH level. From which of the lab values will the nurse discern that the client’s thyroid gland does not show a disorder of functioning?
a. All of them
b. Normal TSH and decreased T4
c. Elevated NFBS and decreased T4
d. Elevated NFBS
Rationale: A decreased T4 level and a normal or increased TSH level can indicate a thyroid disorder. These labs are drawn in combination to differentiate pituitary from thyroid causes of hypothyroidsm. Age-related endocrine changes of the pancreas gland causes delayed and decreased insulin release. Hence, aged clients have decreased ability to metabolize glucose with higher and more prolonged blood glucose levels. For a non-fasting blood sugar to be slightly elevated in an aged client is an expected abnormal.
Nursing Process: Assessment
Client Need: Physiologic Integrity
Cognitive Level: Application
Objective: Monitor the results of diagnostic tests and report abnormal findings.
Strategy: Use nursing knowledge and the process of elimination to make the correct selection.
14. Which of the following statements, if made by the client, would indicate to the nurse that the client understands the instructions the client must follow prior to the client’s blood draw for measurement of serum cortisol?
a. “I’ll plan to stop at the lab on my way home from work and I’ll not eat or drink anything after lunch.”
b. “I should have the blood drawn first thing in the morning after a good night’s sleep and before breakfast and my morning coffee.”
c. “I’ll plan to visit the lab on my lunch break from work before having anything to eat.”
d. “Thank goodness I don’t have to have enemas.”
Rationale: The client should not eat or drink and should rest for 2 hours before the test. To stop on the way home or to have the test during a worktime lunch break would preclude the client from resting for 2 hours prior to the test. Further, client makes no mention of the need to abstain from fluids as well as food prior to the test. To have the blood drawn early in the morning, upon awakening and before breakfast and morning coffee would indicate complete understanding of the instructions.
Nursing Process: Evaluation
Client Need: Physiologic Integrity
Cognitive Level: Application
Objective: Monitor the results of diagnostic tests and report abnormal findings.
Strategy: Identify key words in the question or stem to select the right answer.
15. Which of the following methods would be the preferred method to use when performing physical assessment (palpation) of the thyroid gland?
a. Stand in front of the client, place fingers above the trachea, have the client flex the head, and ask the client to swallow.
b. Stand in front of the client, place fingers slightly above the thyroid cartilage, have the client extend the head and swallow.
c. Stand behind the client, place the fingers on either side of the trachea below the thyroid cartilage, have the client tilt the head to the right and swallow.
d. Stand behind the client, place the fingers above the jugular notch, have the client extend the head and swallow.
Rationale: The nurse stands behind the client, places the fingers on either side of the trachea below the thyroid cartilage, asks the client to tilt the head to the right and swallow. As the client swallows, the nurse displaces the left lobe while palpating the right lobe. The nurse repeats the process as stated, but displaces the right lob while palpating the left lobe. The thyroid gland is not usually palpable.
Nursing Process: Assessment
Client Need: Physiologic Integrity
Cognitive Level: Application
Objective: Conduct and document a physical assessment of the structure of the thyroid gland and the effects of altered endocrine function on other body structures and functions.
Strategy: Use knowledge of the nursing process and critical indicators to make the correct selection.
16. When the client demonstrating polydipsia is scheduled for a water (fluid) deprivation test, the nurse knows that additional teaching regarding preparation before the test is needed when the client states:
a. “I cannot go without my cigarettes.”
b. “You’ll be drawing blood and taking urine samples every hour, right?”
c. “I’ll just plan on taking a vacation day since the test could take 8 hours.”
d. “I’ll need to drink a fair amount before midnight in order to give all those urine specimens.”
Rationale: The client should be instructed not to smoke, eat, or drink after midnight and that the test will take up to 8 hours. Every hour for the duration of the test, the client’s weight and blood pressure (lying and standing) will be measured. Finally, every hour the client will be asked for a urine sample and blood samples will be drawn when urine samples are collected.
Nursing Process: Evaluation
Client Need: Physiologic Integrity
Cognitive Level: Application
Objective: Identify specific topics to consider during a health history interview of the client with health problems involving endocrine function.
Strategy: Apply knowledge of the nursing process to the clinical scenario to select the correct interventions.
17. When the client who is suspected of having hypothyroidism asks the nurse “What all does the thyroid gland produce?”, the nurse’s best response is that the thyroid gland is responsible for producing which of the following combinations of hormones?
a. Thyroid hormone, thyroid stimulating hormone, and vasopressin
b. Thyroid stimulating hormone, thyroid hormone, parathormone
c. Thyroid hormones, vasopressin, oxytocin
d. Thyroxine, triiodothyronine, calcitonin
Rationale: The thyroid gland produces thyroid hormone which serves as a general name for two similar hormones, thyroxine and triiodothyronine. Additionally, the thyroid gland produces calcitonin. Thyroid stimulating hormone is secreted by the posterior pituitary gland. Vasopressin and oxytocin are produced by the posterior pituitary, and parathormone is produced by the parathyroid glands.
Nursing Process: Implementation
Client Need: Physiologic Integrity
Cognitive Level: Application
Objective: Describe the anatomy and physiology of the endocrine glands.
Strategy: Use knowledge of pathophysiology and the process of elimination to make the correct choice.
18. When the nurse reviews the client’s medical record prior to performing a nursing assessment, the nurse notes that the client has been diagnosed with Cushing’s syndrome. The nurse anticipates which of the following potential client comments regarding body image as being an expected comment for client’s with Cushing’s syndrome?
a. “This huge goiter makes me look deformed.”
b. “I never realized that nails could be so dry, and thick, and brittle.”
c. “All of this excessive hair on my face makes me feel ugly.”
d. “These long arms make it easier to reach things in the supermarket.”
Rationale: The nurse should anticipate that the client with Cushing’s syndrome may make statements regarding the client’s hirsuitism. Dry, thick, brittle nails are characteristic of client’s with have been diagnosed with hypothyroidism. Goiter is associated with thyroid gland disorders. Long limbs may be associated with acromegaly, a growth hormone disorder.
Nursing Process: Planning
Client Need: Physiologic Integrity
Cognitive Level: Application
Objective: Identify abnormal findings that may indicate malfunction of the glands of the endocrine system.
Strategy: Use knowledge of pathophysiology and the process of elimination to make the correct choice.
19. From the following list, select those hormones that are secreted by the posterior pituitary gland. Select all that apply.
a. somatotropin
b. calcitonin
c. vasopressin
d. oxytocin
e. luteinizing hormone
Rationale: Antidiuretic hormone (vasopressin) and oxytocin are released by the posterior pituitary. Calcitonin is released by the thyroid gland. Somatotropin and luteinizing hormones are secreted by the anterior pituitary.
Nursing Process: Assessment
Client Need: Physiologic Integrity
Cognitive Level: Application
Objective: Explain the functions of the hormones secreted by the endocrine glands.
Strategy: Use nursing knowledge and the process of elimination to make the correct selection.
Wednesday, March 19, 2008
Saturday, March 15, 2008
Tuesday, March 11, 2008
Friday, February 29, 2008
NCLEX TIPS
1. Arrive early to the testing center.
2. Bring multiple forms of idea.
3. Wear layered clothing.
4. Get a good night’s sleep before the test. (Don’t cram)
5. Use a study partner when preparing for the exam.
6. Be familiar with the format of the exam.
7. Know your medical terminology.
8. Limit your distractions preparing for the exam.
9. Take time to unwind and reduce stress as you prepare.
10. Remember if you don’t pass, you can retake the exam.
Tuesday, February 26, 2008
NLE Reviewer
Situation1: Hygienic care is an activity that must be attended by the nurse in the care of her patients either at home or in the hospital primarily to prevent infection.
1. In taking care of a child with hepatitis A, the nurse teaches the mother that best way to avoid spread of infection is
a. Regular hand washing c.Wearing a protective gown
b. Wearing gloves d. Wearing a mask
2. A public health nurse is administering nebulizer treatment to an asthmatic body at home.Which of the following is most important to be part of her health to the family?
a. Wash equipment with soap and water after use
b. Have the equipment sterilized
c. Wash client's hand after use
d. Wear a mask while giving the treatment
3. Circumcision of the male infants has become common now a days, which nursing would be INAPROPRIATE care for the infant after circumcision?
a. Thorough cleansing of the anal area bowel movement.
b. Gentle removal of blood with clear, moistened cotton balls
c. Frequent tub baths to reduce inflammation
d. Loose application of the diaper
4. Excessive or impacted cerumen is most effectively removed by which of the following?
a. Mineral oil drop and tepid H2O irrigation
b. Water irrigation with cold H2O
c. Gentle use of cotton tipped applicator
d. Bulb syringe irrigation with hot H2O
5. When caring for a diabetic patient's feet and nails, which of the following is a routine procedure for the nurse?
a. Trim away calluses with a sterile blade or scissors
b. Cuts the nails straight across
c. Check the femoral pulses
d. Soaks the client's feet for 10-20 minutes before trimming nails.
Situation 2: In order to meet the nutritional needs of the patients, nurses must have very good background of the digestive and metabolic processes of the body.
1. The major portion of digestion occurs in which of the following parts?
a. large intestine c. stomach
b. mouth d. small intestine
2. Which of the following primary nutrients is absorb in the large intestines?
a. bile c. iron
b. water d. vitamins
3. Which of the following primary metabolic processes is responsible for the breakdown of chemical substances into simpler substances?
a. anabolism c. catabolism
b. digestion d. diffusion
4. a fully breast-fed infant is one who is given:
a: breast milk plus 2 table spoon of calamansi juice daily after month
b. breast milk plus sterile water in between feeding
c. breast milk only
d. breast milk plus 4 ounces of cerelac daily after the third months
5. At what age are solid food best introduced in a fuly breast-fed infant?
a. 9 months c. 3 months
b. 6 months d. 13 months
Situation 3: Rape is the most tragic thing that could happen to anyone especially with young girls. Incidence such as these could into a crisis situation involving not only the rape victims but also their families.
1. This type of crisis could be an example of which of the following?
a, Combination of developmental and situational
b. Stiuational
c. Emotional
d. Developmental
2. Rose, a staff nurse in the emergency room, realizes that she has an important role to play as a patient advocate to rape victims. To demonstrate this role, she takes note which of the following responsibilities?
a. Since this is legal case, call press about the incidence of rape
b. Performance through physical assessment and documenting objectively all the evidence of rape.
c. Ask the patient to stay in one isolated room first to provide privacy while attending to other patients.
d. Provide emotional support first and postpone physical assessment when patient is already calm.
3. Which of the following is a form of active, focused, emotional environmental first aid for the patient in crisis?
a. Attituted Therapy c. Psychotherapy
b. Crisis Intervention d. Remotivation technique
4. Which of the following is True with regards to crisis?
a. Crisis is self-limiting
b. After crisis, the individual always return to a pre-crisis state or condition
c. Crisis always result in adaptive behavior
d. The person in crisis not susceptible for any help
5. If help is Not provided in a crisis situation, an individual may spontaneously resolve it negatively or positively returning to pre-crisis state, usually within of the following duration?
a. 2-3 weeks c. 1-2 weeks
b. 3-4 weeks d. 4-5 weeks
Situation 4: The scope of nursing practice provides that the nurse render nursing care to her client through the application of nursing process.
1. Nursing process is a problem solving technique that utilized which of the following sequential problem?
a. Planning, assessment, implementation, evaluation
b. Assessment, implementation, planning, and evaluation.
c. Problem identification, planning, implementation and evaluation
d. Planning, implementation, assessment and evaluation
2. which of the following is included in psycho-social assessment of patient:
a. Doing the examination using the cephalo-caudal approach.
b. Gathering information on the personal, social, and environmental history of the patient.
c. Getting the general data and chief complaints of her patient.
d. Obtaining the past medical history of her patient.
3.Which of the following is the main purpose of doing pychosocial and physical assessment?
a. Formulate a nursing diagnosis for the plan of care.
b. Identify past potential and probable health problems of the patient.
c. Ascertain the reason why the patient is brought to the hospital.
d. Know the patient and his family at the time of admission.
4. Which of the following information about patient care is provided by evaluation as part of the nursing process?
a. The patient has agreed with the plan of care.
b. Nursing assessment was properly done.
c. Nursing goal is met through the use of certain nursing interventions.
d. The competence of the nurse is determined in managing patient care.
5. The general appearance and emotional disposition of a client is best observed initially during which of the following situations?
a. taking of vital signs
b. interview
c. implementation of initial care
d. actual physical examination
Situation 5: One important fact will guide the nurse in the practice of the profession is her knowledge of the nursing law.
1. The nurse practice Act of 1991 regulates the practice of nursing in the Philippines. Which of the following statements about this Act is Not true.
a. This Act delineates the practice of nursing and midwifery.
b. It was enacted in November 1991
c. The primary purpose is to protect the public
d. This Act defines the practice of nursing in the Philippines.
2. when a nurse starts working in a hospital but without a written contract, which of the following is expected of her?
a. She is not bound to perform according to the standards of nursing practice.
b. Provides nursing care within the acceptable standards of nursing practice.
c. She is not obligated to provide professional service.
d. The employer does not hold the nurse responsible for action.
3. A patient, G8P%, refused to injected with her 3rd dose of Depo-Provera. The nurse insisted despite of the patient's refusal and forcibly injected the contraceptive. She can be sued for which of the following?
a. misrepresentation c. malpractice
b. assault d. negligence
4. a patient has been in the ICU for 2 weeks. the relatives have consented to a "Do not Resuscitate" order. When the patient develops a cardiac arrest, the nurse will carryout which of the following actions:
a. only medication will be given
b. all ordinary measures will be stopped
c. basic and advance life support will not be given
d. mechanical ventilation and NGT will be be stopped
5. When a patient falls from bed, which of the following is yur most immediate action?
a. Report to the head nurse and call someone for help.
b. Determine any injury or harm
c. Refer to the resident on duty.
d. Put back patient to bed
Situation 6: Epidemiology and Vital statistics is a very important tool that a nurse could use in controlling the spread of disease in the community and at the same time, surveying the impact of the disease on the population and prevent it’s future occurrence.
1. It is concerned with the study of factors that influence the occurrence and distribution of diseases, defects, disability or death which occurs in groups or aggregation of individuals.
A. Epidemiology
B. Demographics
C. Vital Statistics
D. Health Statistics
2. Which of the following is the backbone in disease prevention?
A. Epidemiology
B. Demographics
C. Vital Statistics
D. Health Statistics
3. Which of the following type of research could show how community expectations can result in the actual provision of services?
A. Basic Research
B. Operational Research
C. Action Research
D. Applied Research
4. An outbreak of measles has been reported in Community A. As a nurse, which of the following is your first action for an Epidemiological investigation?
A. Classify if the outbreak of measles is epidemic or just sporadic
B. Report the incidence into the RHU
C. Determine the first day when the outbreak occurred
D. Identify if it is the disease which it is reported to be
5. After the epidemiological investigation produced final conclusions, which of the following is your initial step in your operational procedure during disease outbreak?
A. Coordinate personnel from Municipal to the National level
B. Collect pertinent laboratory specimen to confirm disease causation
C. Immunize nearby communities with Measles
D. Educate the community in future prevention of similar outbreaks
Sunday, February 24, 2008
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