Many nursing schools and review courses offer structured study plans that include specific sets of NCLEX RN Practice Questions for each topic.
NCLEX Endocrine Questions - NCLEX Questions on Endocrine
Endocrine NCLEX Practice Questions
Question 1.
A 35-year-old female patient has recently been diagnosed with Addison's diseaseThe healthcare team has determined that the patient's Addison's disease is caused by hyposecretion of adrenocortical hormones. The team has prescribed hormone replacement therapy to help manage the patient's symptoms and improve her overall health.
Which of the following is a symptom of Addison's disease?
(a) Hyperglycemia
(b) Hypoglycemia
(c) Hypersecretion of adrenocortical hormones
(d) Hyposecretion of adrenocortical hormones
Answer:
(d) Hyposecretion of adrenocortical hormones
Explanation:
Addison's disease is an endocrine disorder that is caused by a deficiency of the hormones produced by the adrenal glands, including cortisol and aldosterone. This deficiency can lead to a variety of symptoms, including salt cravings, increased blood sugar levels, electrolyte imbalances, decreased sexual performance, and feelings of fatigue and weakness. Other symptoms of Addison's disease may include anorexia, weight loss, postural hypotension, gastrointestinal disturbances, and bronze pigmentation of the skin and loss of pubic and auxiliary hairs.
Cushing's syndrome, on the other hand, is an endocrine disorder that is caused by an excess of cortisol in the body'. This excess can lead to a variety of symptoms, including weight gain, particularly in the face and trunk, thinning of the skin, easy bruising, and muscle weakness. Other symptoms of Cushing's syndrome may include increased appetite, fatigue, irritability, restlessness, tremors, tachycardia, diaphoresis, and depression. It is important to distinguish between these two endocrine disorders, as they have different causes and require different treatment approaches.
Rationale:
To solve this problem, it is important to understand the definition and symptoms of Addison's disease. In this case, the patient has been diagnosed with Addison's disease and is experiencing several specific symptoms.
Option (d) is the correct answer because it accurately describes the cause of Addison's disease, which is hyposecretion of adrenocortical hormones. Option (c)s incorrect because it describes the opposite of the cause of Addison's disease, which is hypersecretion of adrenocortical hormones. This is a symptom of Cushing's syndrome, which is a different endocrine disorder.
Question 2.
A 35-year-old male presents to the clinic with a 3-month history of fatigue, weakness, and salt cravings. He reports experiencing irregular menstrual cycles and erectile dysfunction. He has also noticed an increase in his blood sugar levels and has developed bronze pigmentation of his skin. Physical examination reveals postural hypotension and loss of pubic and axillary hair. Laboratory tests show' electrolyte imbalances, Based on the patient's symptoms and lab results, the most likely diagnosis is Addison's disease.
Which of the following is a symptom of Addison's disease?
(a) Hyperglycemia
(b) Hypoglycemia
(c) Hyperkalemia
(d) Hyponatremia
Answer:
(d) Hyponatremia
Explanation:
To solve this problem, it is important to recall the symptoms of Addison's disease, which include electrolyte imbalances and metabolic disturbances such as low levels of cortisol and salt cravings. Option (d). hyponatremia, is a specific type of electrolyte imbalance that is characterized by low levels of sodium in the blood.
Rationale:
Option (a), hyperglycemia, refers to high levels of blood sugar, which is not a symptom of Addison's disease. Option (b). hypoglycemia, refers to low levels of blood sugar, which is a symptom of Addison's disease, but it is not the most specific or relevant to the patient's symptoms and lab results. Option (c), hyperkalemia, refers to high levels of potassium in the blood, which is a symptom of Addison's disease.
Question 3.
Mrs. Agrima is a 45-year-old woman who has recently been diagnosed with Addison's disease. Mrs. Agrima's medical history includes a history of autoimmune disorders and she is currently taking corticosteroid medications for her autoimmune conditions.
Which of the following is NOT a symptom of Addison's disease?
(a) Salt craving
(b) Increased blood sugar
(c) Electrolyte imbalances including high potassium and calcium and low sodium
(d) Increased sexual performance
(e) Fatigue and weakness
Answer:
(d) Increased sexual performance
Explanation:
In comparison, Cushing syndrome is characterized by hypersecretion of adrenocortical hormones and symptoms that are opposite of those seen in Addison's disease. Symptoms of Cushing syndrome include weight gain, round face, thin skin that bruises easily, purple stretch marks, and excess hair growth.
Rationale:
Option (a), (b), (c). and (e) all match the symptoms of Addison’s disease. It is important to note that Addison's disease is characterized by decreased sexual performance, not increased sexual performance.
Question 4.
A patient is experiencing irritability, restlessness, fatigue, tremors, tachycardia, diaphoresis, and depression. They also have increased hunger, urination, and appetite, as well as signs of dehydration, weight loss, and hypotension. The patient also has a high potassium level, which is causing diarrhea and irritability.
Based on the symptoms and laboratory findings, the patient is likely suffering from Addison's disease.
What is the main predisposing factor for Addison's disease?
(a) Hyperplasia of the adrenal gland
(b) Tubercular infection
(c) Atrophy of the adrenal gland
(d) Miliary TB
Answer:
(c) Atrophy of the adrenal gland
Explanation:
The patient is experiencing symptoms consistent with Addison's disease, including hyponatremia, hypokalemia, and low cortisol levels. The main predisposing factor for Addison's disease is atrophy of the adrenal gland, which is responsible for producing hormones that regulate electrolyte balance and metabolism.
Rationale:
Option (a) is incorrect because hyperplasia of the adrenal gland is a predisposing factor for Cushing's syndrome, not Addison's disease. Option (b) is incorrect because tubercular infection is not taken as a predisposing factor for Addison's disease. Option (d) is incorrect because miliary TB is not taken as a predisposing factor for either Addison's disease or Cushing's syndrome in the case study.
Option (c) is the correct answer because atrophy of the adrenal gland is specifically taken as the main predisposing factor for Addison's disease. This is consistent with the patient's symptoms, which include hyponatremia, hypokalemia, and low cortisol levels. Atrophy of the adrenal gland can lead to decreased production of hormones that regulate electrolyte balance and metabolism.
Question 5.
A 35-year-old female patient is experiencing unusual weight gain, acne, and hirsutism. She also reports feeling tired and weak, and has constipation and a u-wave on her ECG tracing. She has a moon-face appearance, buffalo hump, and an obese trunk with a pendulous abdomen and thin extremities. Based on the symptoms and diagnostic information provided, the patient is likely suffering from Cushing syndrome.
Which of the following is a predisposing factor for Cushing syndrome?
(a) Atrophy of the adrenal gland
(b) Fungal infections
(c) Flyperplasia of the adrenal gland
(d) Tubercular infection
Answer:
(c) Hyperplasia of the adrenal gland
Explanation:
To solve this problem, it is important to have a thorough understanding of the predisposing factors for Cushing syndrome. We can eliminate options A and B as they are predisposing factors for Addison's disease. Option (c), hyperplasia of the adrenal gland, is a predisposing factor for Cushing syndrome and is therefore the correct answer.
Cushing syndrome is characterized by an excess of the hormone cortisol in the body. This can be caused by a variety of factors, including the overproduction of cortisol by the adrenal gland or the use of certain medications. One of the predisposing factors for Cushing syndrome is hyperplasia of the adrenal gland, which is an increase in the number of cells in the gland.
This can lead to the overproduction of cortisol and the development of Cushing syndrome. In contrast, Addison's disease is characterized by a deficiency of the hormones cortisol and aldosterone, which are produced by the adrenal gland. It can be caused by atrophy of the adrenal gland or the presence of fungal infections.
Rationale:
Option (a), atrophy of the adrenal gland, is a predisposing factor for Addison's disease, not Cushing syndrome. Option (b), fungal infections, is also a predisposing factor for Addison's disease. Option (c), hyperplasia of the adrenal gland, is a predisposing factor for Cushing syndrome and is therefore the correet answer. Option (d), tubercular infection, is not listed as a predisposing factor for either Addison's disease or Cushing syndrome in the provided information.
Question 6.
A patient presents to the clinic with the following symptoms of addition's disease. Upon examination, the patient has decreased sodium levels and increased potassium levels in their blood. They also have a low fasting blood sugar and a decreased plasma cortisol level. Based on these symptoms, the patient is diagnosed with Addison's disease.
Multiple Choice Questions:
1. Which of the following is NOT a symptom of Addison's disease?
(a) Polyuria
(b) Irritability
(c) Diaphoresis
(d) Polydipsia
Answer:
(a) Polyuria
Explanation:
Polyuria, polydipsia, and polyphagia are the three Ps of diabetes and are not listed as symptoms of Addison's disease. The other options are all listed as symptoms of Addison's disease.
Question 7.
Which of the following is NOT a predisposing factor for Addison's disease?
(a) Atrophy of the Adrenal gland
(b) Hyperplasia of the Adrenal gland
(c) Fungal infections
(d) Tubercular infections
Answer:
(b) Hyperplasia of the Adrenal gland
Rationale:
Atrophy of the Adrenal gland and fungal infections are listed as predisposing factors for Addison's disease. Hyperplasia of the Adrenal gland and tubercular infections are listed as predisposing factors for Cushing's syndrome.
Question 8.
Which of the following is NOT a diagnostic criterion for Cushing's syndrome?
(a) Elevated fasting blood sugar
(b) Decreased potassium levels
(c) Elevated sodium levels
(d) Decreased cortisol levels
Answer:
(d) Decreased cortisol levels
Explanation:
Rationale: Elevated fasting blood sugar, elevated sodium levels, decreased potassium levels, and elevated cortisol levels are all listed as diagnostic criteria for Cushing's syndrome.
Question 9.
Which of the following is NOT a nursing intervention for Addison's disease?
(a) Administering corticosteroids
(b) Monitoring electrolyte levels
(c) Administering insulin
(d) Providing emotional support to the patient
Answer:
(c) Administering insulin
Rationale:
Administering corticosteroids, monitoring electrolyte levels, and providing emotional support to the patient are all listed as nursing interventions for Addison's disease. Administering insulin is not listed as a nursing intervention for either Addison's disease or Cushing's syndrome.
Question 10.
The nurse on the medical-surgical unit is caring for a patient admitted for aldosterone deficiency. Which of the following assessment findings does the nurse expect to see when caring for this patient?
(a) Vasoconstriction
(b) Serum sodium 146 mEq/L
(c) Increased urine output
(d) Blood glucose 96 mg/dL
Answer:
(c) Increased urine output
Rationale:
Aldosterone is a mineralocorticoid which maintains extracellular fluid volume. Its action stimulates reabsorption of sodium and water and excretion of potassium in the tubules of the kidney. The patient with aldosterone deficiency would, therefore, have increased urine output with sodium loss and potassium retention.
(a) is incorrect because vasoconstriction is not an effect of aldosterone.
(b) is incorrect because in aldosterone deficiency, the sodium level would be decreased.
(d) is incorrect because aldosterone does not affect blood glucose.
Question 11.
A female patient on the medical unit is admitted with decreased adrenal function. Which of the following patient statements does the nurse expect when talking with a patient with decreased adrenal function?
(a) “Tve been craving potato chips.”
(b) “My face seems to be changing, and I feel like I am starting to look like a man.”
(c) “I’m always hungry, even after eating.”
(d) “I’ve taken extra hormone replacement recently, and I still feel moody.”
Answer:
(a) “Tve been craving potato chips.”
Rationale:
Decreased adrenal function is correlated with cravings for salt. The adrenal glands are responsible for producing hormones that maintain blood pressure, regulate metabolism, and slow the immune response. Lack of these hormones leads to sodium and water wasting and potassium retention. Other symptoms include dehydration, decreased blood pressure, weight loss, alopecia, fatigue, depression, lethargy, and pathological fractures.
(b) is incorrect because masculinization in females is a characteristic of increased adrenal hormone secretion (Cushing’s), not decreased adrenal function. (c) is incorrect because hunger despite eating correlates with diabetes.
(d) is incorrect because although synthetic adrenal hormones may cause moodiness, the nurse should not expect the patient to be doubling the dose. Too much hormone replacement can cause symptoms of Cushing’s, such as excessive mood swings.
Question 12.
A patient is scheduled for a serum catecholamine test. When the nurse is collecting the sample, which is the priority action by the nurse?
(a) Draw the blood after breakfast
(b) Immediately send the blood to the lab after placing on ice
(c) Add preservatives to the specimen before sending to the lab
(d) Discard the first blood sample then collect the specimen
Answer:
(b) Immediately send the blood to the lab after placing on ice
Rationale:
A serum catecholamine test measures epinephrine, dopamine, and norepinephrine, which are all hormones found in the blood made by the adrenal glands. This test assists in diagnosing catecholamine-secreting tumors, such as those found in the adrenal medulla, and in the investigation of hypertension and pheochromocytoma. The blood specimen for a serum catecholamine test needs to be placed on ice and sent to the lab immediately.
(a) is incorrect because the patient should not eat for several hours before the sample is drawn.
(c) is incorrect because the correct blood collection tube will have the appropriate preservatives already.
(d) is incorrect because the first blood sample should not be discarded.
Question 13.
A patient in the clinic has a 24-hour urine collection ordered for hormone excretion. When the patient asks the nurse why the urine needs to be collected for 24 hours instead of random, what is the best response by the nurse?
(a) “The 24-hour sample will assess your circadian rhythm hormones.”
(b) “Hormones are dilute in urine, so a large volume is needed.”
(c) “You need to urinate multiple times for collection of the correct hormone.”
(d) “We will be evaluating urine every three hours for 24 hours to determine when certain hormones are secreted in larger amounts.”
Answer:
(a) “The 24-hour sample will assess your circadian rhythm hormones.”
Rationale:
Certain hormones are secreted according to a circadian rhythm. The 24-hour urine collection is the most accurate reflection of hormone secretion.
(b) is incorrect because hormone dilution in urine is not an indication for a 24-hour urine collection.
(c) is incorrect because collecting the correct hormone is not an indication for a 24-hour urine collection.
(d) is incorrect because a 24-hour urine specimen is collected over a full 24-hour period and then sent to the lab at one time.
Question 14.
A male patient in the clinic reports fluid secretion from the breasts. When the nurse evaluates the results of this patient’s blood tests, which hormone value would be assessed first?
(a) Posterior pituitary hormone
(b) Adrenal medulla hormone
(c) Anterior pituitary hormone
(d) Parathyroid hormone
Answer:
(c) Anterior pituitary hormone
Rationale:
Prolactin is the hormone responsible for fluid and milk production from the breast, and this hormone is secreted by the anterior pituitary gland.
(a) is incorrect because the posterior pituitary stores and releases oxytocin and vasopressin.
(b) is incorrect because the adrenal medulla converts tyrosine into epinephrine, norepinephrine, and dopamine.
(d) is incorrect because parathyroid hormone is secreted from parathyroid glands and is important for bone remodeling.
Question 15.
The nurse on the medical-surgical unit is caring for a patient admitted for excessive calcitonin. Which electrolyte imbalance does the nurse assess the patient for?
(a) Hyperkalemia
(b) Decreased sodium
(c) Decreased calcium
(d) Hypercalcemia
Answer:
(c) Decreased calcium
Rationale:
Calcitonin is produced by parafollicular cells of the parathyroid gland. This serves the purpose of reducing serum calcium levels, or preventing hypercalcemia.
(a) is incorrect because calcitonin has no effect on potassium.
(b) is incorrect because calcitonin has no effect on sodium.
(d) is incorrect because calcitonin does not cause increased serum calcium. Parathyroid hormone increases calcium levels.
Question 16.
A patient in the clinic has been taking a prescribed betai receptor stimulator. When the nurse assesses the patient, which finding would necessitate notifying the healthcare provider immediately?
(a) Heart rate 55 bpm
(b) Respiratory rate 16 bpm
(c) Pulse ox 93%
(d) Blood pressure 140/72 mmHg
Answer:
(a) Heart rate 55 bpm
Explanation:
The heart has betai receptor sites, which, when stimulated, will have positive chronotropic and positive inotropic effects. The patient should have an increased heart rate and strengthened contractility, thus a greater cardiac output. The decreased heart rate indicates the patient is not responding in the expected manner to the medication.
Rationale:
(b) is incorrect because this is a normal respiratory rate, and this medication would have no effect on breathing. (c) is incorrect because the medication would have no effect on oxygenation. Because this SpO2 is low, the nurse should further assess the patient and consider instructing the patient to cough and deep breathe or apply oxygen by nasal cannula. If the oxygen level does not rise in response to nursing interventions, the healthcare provider may need to be notified.
(d) is incorrect because the blood pressure is slightly elevated but not a primary concern. The nurse should continue to monitor blood pressure, give PRN antihypertensive medications, if ordered, and notify the healthcare provider if the hypertension worsens.
Question 17.
The nurse on the medical-surgical unit is assessing four patients. Which of the following patients are at the greatest risk for gonadotropin and growth hormone deficiency?
(a) 32-year-old female on long term oral contraceptives
(b) 45-year-old male with a history of head trauma four years ago
(c) 56-year-old female allergic to shellfish
(d) 43-year-old male with diabetes mellitus
Answer:
(b) 45-year-old male with a history of head trauma four years ago
Rationale:
Head trauma can cause hypofunction of the anterior pituitary gland. This may lead to deficiency of gonadotropin and growth hormone.
(a) is incorrect because contraceptives do not increase risk for gonadotropin and growth hormone deficiency. Oral contraceptives increase the risk for breast cancer. (c) is incorrect because shellfish allergy does not increase risk for gonadotropin and growth hormone deficiency.
Allergy to shellfish (which is high in iodine) poses a risk for a client who undergoes a dye-containing procedure, since most dyes used in diagnostic procedures contain iodine. (d) is incorrect because diabetes mellitus does not increase risk for gonadotropin and growth hormone deficiency.
Explanation 18.
A patient with acromegaly has been educated by the nurse regarding an upcoming hypophysectomy procedure. Which of the following patient statements demonstrates more teaching is needed?
(a) “I won’t need to limit fluid intake after the surgery.”
(b) “I’m glad I won’t have a visible incision.”
(c) “I hope my shoe size will go back down.”
(d) “I will wear my house slippers so I don’t have to bend over to put shoes on.”
Answer:
(c) “I hope my shoe size will go back down.”
Explanation:
Acromegaly occurs as a result of excessive growth hormone secretion from the pituitary gland, which causes enlarged body size: hands, feet, forehead, nose, and jaw. Other symptoms include poor coordination, deep voice, sexual abnormalities, and visual field changes. Growth hormone is secreted by the anterior pituitary gland, and a hypophysectomy is performed to remove the portion of the gland or a tumor that is causing excessive secretion of the hormone. After the surgery, many of the symptoms of hyperpituitarism are relieved, but skeletal changes as well as organ enlargement will not generally reverse.
Rationale:
(a) is incorrect because the statement indicates the client understands the teaching about post-op expectations. Fluid intake should be encouraged after the patient has recovered from the anesthesia after a hypophysectomy surgery. (b) is incorrect as this statement indicates understanding because the incision from hypophysectomy is not visible. (d) is incorrect because the statement indicates the client understands to avoid bending over after the hypophysectomy.
Question 19.
A female patient is in the clinic complaining of body image concerns regarding hirsutism. When assessing this patient, the nurse should ask which of the following questions?
(a) “How do you plan to cover the medical bills for your treatments?”
(b) “How do you feel when you look in the mirror?”
(c) “What are your prescribed medications?”
(d) “What measures have you taken to handle this problem?”
Answer:
Hirsutism is excessive hair growth that occurs on the face and body as a result of endocrine disorder. Especially in female patients, this causes disruption of body image. Self-perception and body image feelings of the patient should be assessed by the nurse.
Rationale:
(a) is incorrect because financial status does not address the patient’s presenting physical problem. The nurse should remain focused on the client’s here-and-now physical needs as a priority. (c) is incorrect because current medications do not address the patient’s presenting problem. Assessment of current medications is certainly an important component of the nursing assessment, but this assessment is not directly related to the body image concerns the patient is expressing.
(d) is incorrect because hirsutism is not caused by any specific behaviors, and it cannot be prevented totally. Some patients may shave, wax, or use other methods for hair removal, but assessing how the patient currently feels is more important than determining past attempts to deal with the problem.
Question 20.
The nurse is caring for a 68-year-old female patient and is providing education regarding decreased estrogen production. In order to decrease risk of injury, which statement does the nurse include?
(a) “Drink up to two liters of water daily to prevent falls and accidental fractures.”
(b) “Daily exercise, such as a walk around your neighborhood, will help prevent injury.”
(c) “Bathe the perineum two times a day.”
(d) “Check your blood sugar daily so you don’t experience dizziness related to hypoglycemia.”
Answer:
(b) “Daily exercise, such as a walk around your neighborhood, will help prevent injury.”
Rationale:
Older female patients, who have decreased estrogen production, are at risk for bone density reduction as well as fractures. Daily exercise, such as walking around the neighborhood, should be encouraged by the nurse. (a) is incorrect because adequate fluid intake will decrease vaginal dryness associated with decreased estrogen production but will not prevent injury. Normal daily fluid intake for average adults is 2-2.5 liters daily.
(c) is incorrect because perineal care will decrease vaginal dryness, but not prevent injury. (d) is incorrect because abnormal blood glucose levels are not related to decreased estrogen production in older age. A 68-year-old client does not need to check blood glucose regularly unless indicated by a specific diagnosis such as diabetes.
Question 21.
The nurse on the medical unit is assessing a patient who takes levothyroxine for hypothyroidism. Which of the following findings indicates the medication is effective?
(a) The patient recognizes thirst and is drinking fluids
(b) The patient’s weight has increased 1 pound the past three weeks
(c) The patient’s white blood cell count is 7,000 cells/mm3
(d) The patient’s heart rate is 68 bpm
Answer:
(d) The patient’s heart rate is 68 bpm
Explanation:
Hypothyroidism is decreased activity of the thyroid gland, which decreases body functioning. Symptoms of hypothyroidism include bradycardia, confusion, alopecia, dry skin and hair, and constipation. The patient’s heart rate is normal at 68 which indicates the medication is working. If the dose of thyroid hormone replacement medication were too high, the heart rate would be elevated.
Rationale:
(a) is incorrect because thirst does not indicate therapeutic response to levothyroxine. (b) is incorrect because patients with hypothyroidism tend to experience weight gain and obesity. Gaining a pound in three weeks is not an indication of effectiveness of levothyroxine. Weight loss (over time) would be a sign of improvement with this medication. (c) is incorrect because decreased white blood cell count is not an intended effect of levothyroxine.
Question 22.
The nurse in the clinic is assessing four patients for potential endocrine disorder. Which patient does the nurse identify as being at the greatest risk of hyperparathyroidism?
(a) 28-year-old female who has pregnancy induced hypertension
(b) 43-year-old male on dialysis for end stage kidney disease
(c) 62-year-old female diagnosed with heart failure
(d) 75-year-old male with asthma and hypertension who uses oxygen at home
Answer:
(b) 43-year-old male on dialysis for end stage kidney disease
Explanation:
Hyperparathyroidism can be a result of disorders that cause hypocalcemia. Patients with chronic kidney disease cannot activate vitamin D and have poor absorption of calcium in the gastrointestinal tract. This puts the patient at highest risk for hyperparathyroidism.
Rationale:
(a) is incorrect because pregnancy-induced hypertension does not increase risk of hyperparathyroidism. Pregnancy-induced hypertension can cause thrombocytopenia, HELLP syndrome, and if it progresses to eclampsia, ultimately renal failure and cerebral hemorrhage.
(c) is incorrect because heart failure does not increase risk of hyperparathyroidism. Patients with heart failure are at risk for liver failure, atrial fibrillation, and other arrhythmias.
(d) is incorrect because this patient’s medical details do not indicate increased risk for hyperparathyroidism.
Question 23.
The nurse in the recovery room is caring for a patient who had a transsphenoidal hypophysectomy. What is the priority action the nurse should take?
(a) Keep the patient supine and head of bed flat
(b) Educate the patient regarding turning, coughing, and deep breathing
(c) Monitor for nasal drainage
(d) Prevent dryness of the lips by applying petroleum jelly
Answer:
(c) Monitor for nasal drainage
Explanation:
Hypophysectomy is partial or complete removal of the pituitary gland. Drainage from the nose after hypophysectomy, especially light yellow or halo effect, would indicate leaking of cerebrospinal fluid. The healthcare provider should be notified of this finding immediately.
Rationale:
(a) is incorrect because the patient should have the head of bed elevated after hypophysectomy.
(b) is incorrect because the patient should not be coughing postoperatively as this can increase the risk for a CSF leak.
(d) is incorrect because petroleum jelly can be applied to the lips, but this is not as important as drainage from the nose.
Question 24.
A patient is admitted to the medical-surgical unit for excessive catecholamine release. Which of the following assessment findings does the nurse correlate with the patient’s diagnosis?
(a) Blood pressure 110/72 mmHg
(b) Pulse 112 beats per minute
(c) Respirations 8 per minute
(d) Urine output 200 ml/hour
Answer:
(b) Pulse 112 beats per minute
Explanation:
Catecholamines, or epinephrine and norepinephrine, are released from the adrenal medulla of the adrenal glands when the sympathetic nervous system is activated. This is part of the fight or flight stress response. Characteristic findings include an increased pulse, increased blood pressure, and increased blood glucose.
Rationale:
(a) is incorrect because catecholamines increase blood pressure.
(c) is incorrect because catecholamines increase respirations.
(d) is incorrect because catecholamines do not increase urine output. Normal urine output is 30-60 ml/hr.
Question 25.
The nurse is caring for an adult patient hospitalized for an upper respiratory tract infection (URI) and a history of growth hormone deficiency. Which of the following actions should the nurse include?
(a) Avoid subcutaneous injections
(b) Put the patient in isolation
(c) Reposition the patient with a lift sheet
(d) Have the patient dangle the lower extremities before standing
Answer:
(c) Reposition the patient with a lift sheet
Explanation:
Growth hormone helps maintain bone strength and density, so patients with growth hormone deficiency (hypopituitarism, or dwarfism) often have fragile, thin bones. A lift sheet is a safety measure to prevent fractures when repositioning in the bed.
Rationale:
(a) is incorrect because avoiding subcutaneous injections is not a safety measure for a patient with growth hormone deficiency. Some patients with human growth hormone deficiency are treated routinely with subcutaneous human chorionic gonadotropin (HcG) injections.
(b) is incorrect because isolation is not necessary for a patient with growth hormone deficiency. A patient with an URI can share a semi-private room with another patient infected with the same bacteria or can be placed in a private room, but isolation is not necessary.
(d) is incorrect because having the patient dangle the lower extremities before standing is not a necessary safety measure for a patient with growth hormone deficiency.
Question 26.
The nurse is caring for a patient recovering after endoscopic trans-nasal hypophysectomy. When the nurse teaches the patient regarding the procedure, which patient statement demonstrates correct understanding?
(a) “I will wear sunglasses to decrease sun exposure.”
(b) “I will keep food in upper cabinets to prevent having to bend over.”
(c) “I will wash my incision daily with half-strength hydrogen peroxide and apply a new dressing.”
(d) “While awake, I will cough and deep breathe every two hours.”
Answer:
(b) “I will keep food in upper cabinets to prevent having to bend over.”
Explanation:
Endoscopic trans-nasal hypophysectomy is performed to remove the portion of the gland or a tumor that is causing excessive secretion of growth hormone. Following the surgery, the patient is advised to avoid bending over and any other activities that may increase intracranial pressure. Other important components of post-hypophysectomy nursing care include monitor I/O, observe for hypoglycemia, check neurological status frequently, and teach the client to avoid toothbrushing for two weeks.
Rationale:
(a) is incorrect because decreasing sun exposure is not necessary after endoscopic trans-nasal hypophysectomy.
(c) is incorrect because there is no visible incision with endoscopic trans-nasal hypophysectomy.
(d) is incorrect because coughing and deep breathing will increase intracranial pressure, which is not desired after this surgical procedure.
Question 27.
A 72-year-old patient is admitted to the medical unit for pneumonia. The patient has no significant health history and no known allergies. When planning this patient’s care, which of the following should the nurse include?
(a) Airborne precautions
(b) PO fluids eveiy 1-2 hours
(c) Indwelling urinary catheter
(d) Palpate thyroid gland
Answer:
(b) PO fluids eveiy 1-2 hours
Explanation:
Older adults can experience decreased antidiuretic hormone (ADH) production as a normal part of the aging process. Decreased ADH leads to dilute urine with excessive fluid loss, which can lead to dehydration. The patient should be offered PO fluids every 1-2 hours and fluid intake should be encouraged up to 3L daily with pneumonia.
Rationale:
(a) is incorrect because pneumonia is not an indication for airborne precautions. Airborne precautions are required for tuberculosis, active varicella, rubeola, and disseminated zoster (shingles).
(c) is incorrect because although assessing I&O is necessary, an indwelling urinary catheter is not indicated for a diagnosis of pneumonia.
(d) is incorrect because assessing the thyroid gland is not indicated.
Question 28.
A patient is prescribed spironolactone before surgery for hyperaldosteronism. The nurse will teach the patient about which precautions?
(a) “Read labels of salt substitutes.”
(b) “Don’t add salt to food.”
(c) “Avoid the sun.”
(d) “Take acetaminophen for pain, not aspirin.”
Answer:
(a) “Read labels of salt substitutes.”
Explanation:
Salt substitutes frequently contain potassium and using spironolactone can lead to hyperkalemia as it is a potassium-sparing diuretic. Use of spironolactone is indicated to maintain or increase potassium levels and use of salt substitutes can be dangerous.
Rationale:
(b) is incorrect because spironolactone can cause hyponatremia and hyperkalemia, and avoiding salt is not necessary.
(c) is incorrect because spironolactone does not cause photosensitivity, so avoiding the sun is not necessary.
(d) is incorrect because avoiding aspirin is not necessary.
Question 29.
The nurse in the clinic needs to assess a patient’s thyroid gland. When palpating the thyroid, which action should the nurse take?
(a) Face the patient to palpate the thyroid gland
(b) Have the patient swallow after palpation
(c) Palpate the right lobe of the thyroid gland with the left hand
(d) Have the patient sit with the chin tucked downward
Answer:
(d) Have the patient sit with the chin tucked downward
Rationale:
The nurse has the patient sit down and tuck their chin downward and stands behind the patient to palpate the thyroid gland.
(a) is incorrect because the proper technique for palpating the thyroid gland is standing behind the patient.
(b) is incorrect because the proper way to assess the thyroid gland is to palpate while the patient swallows.
(c) is incorrect because the nurse palpates the right side for the isthmus while the patient swallows and turns the head to the right.
Question 30.
The nurse is caring for a patient on the medical unit. Which patient statement would alert the nurse that the patient may have hypothyroidism?
(a) “My sister has problems with her thyroid.”
(b) “I’m much more sensitive to heat than others.”
(c) “I have to add quite a bit of salt to my food to make it taste good.”
(d) “I could sleep 12 hours and still be tired.”
Answer:
(d) “I could sleep 12 hours and still be tired.”
Explanation:
Hypothyroidism is characterized by decreased production of thyroid hormone and happens more often in older adult females. Feeling tired after adequate sleep is common in hypothyroidism. Other symptoms include decreased activity level, weight gain, constipation, alopecia, bradycardia, and decreased ability to perspire.
Rationale:
(a) is incorrect because hypothyroidism is not genetic or inherited.
(b) is incorrect because hypothyroidism causes intolerance to cold. Hyperthyroidism causes sensitivity to heat.
(c) is incorrect because taste loss is not indicative of hypothyroidism.
Question 31.
A patient is admitted to the medical-surgical unit with a diagnosis of Hashimoto’s thyroiditis and hypothyroidism. When the patient asks the nurse how long the thyroid medication will need to be taken, what is the best response by the nurse?
(a) “The medication will need to be taken until the goiter is gone completely.”
(b) “Thyroiditis is cured by treatment with antibiotics. Once that is resolved you won’t require thyroid medication.”
(c) “Your thyroid will not work again, so you will take thyroid replacement for the rest of your life.”
(d) “We will test your thyroid function with blood tests, and when your thyroid function returns to normal, the medication can be stopped.”
Answer:
(c) “Your thyroid will not work again, so you will take thyroid replacement for the rest of your life.”
Explanation:
Hashimoto’s thyroiditis or Hashimoto’s disease is the result of an autoimmune process. The immune system attacks and damages the thyroid which leads to hypothyroidism. Thyroid function is permanently lost, so lifelong thyroid replacement therapy is necessary.
Rationale:
(a) is incorrect because even if the goiter is reduced or eliminated, the patient cannot stop taking the thyroid medication.
(b) is incorrect because antibiotics will not cure the thyroiditis and the patient cannot stop taking the thyroid medication.
(d) is incorrect because the patient cannot stop taking the thyroid medication.
Question 32.
The nurse on the medical unit is caring for a child newly diagnosed with Graves’ disease. How should the nurse respond when the patient’s mother asks, “Is my daughter’s new diagnosis disease due to my type 1 diabetes?”
(a) “Your diabetes did not cause your daughter’s Graves’ disease. There is no known connection between diabetes and Graves’ disease.”
(b) “There is a connection between diabetes and Graves’ disease, but your diabetes did not likely cause your daughter’s Graves’ disease.”
(c) “There is an association between Graves’ disease and autoimmune diseases such as rheumatoid arthritis, but not with diabetes.”
(d) “Diabetes can cause hypothyroidism, so yes, that is a possibility.”
Answer:
(b) “There is a connection between diabetes and Graves’ disease, but your diabetes did not likely cause your daughter’s Graves’ disease.”
Explanation:
Graves’ disease is over-activity of the thyroid gland as a whole, or hyperthyroidism. Also, termed “toxic diffuse goiter,” it is the result of an autoimmune process with symptoms including sleeping problems, tachycardia, poor heat tolerance, irritability, and exophthalmos. Research shows an association between Graves’ disease and other autoimmune diseases, such as type l diabetes, but predisposition is most likely polygenic and not caused by the mother’s diabetes.
Rationale:
(a) is incorrect because there is a known connection between diabetes and Graves’ disease.
(c) is incorrect because there is a known connection between diabetes and Graves’ disease.
(d) is incorrect because diabetes does not cause hypothyroidism, and the daughter has hyperthyroidism, not hypothyroidism.
Question 33.
The nurse on the surgical unit is caring for a patient after recovery from complete thyroidectomy. When the nurse is reinforcing postoperative teaching, which of the following patient statements demonstrates more education is needed?
(a) “I might need calcium replacement after this surgery.”
(b) “I won’t need to take my thyroid medication anymore.”
(c) “I will be on thyroid hormones for life.”
(d) “If I need it, I can take pain medication.”
Answer:
(b) “I won’t need to take my thyroid medication anymore.”
Explanation:
Complete thyroidectomy may be carried out as a primary7 treatment for thyroid carcinoma hyperthyroidism. Because the thyroid has been removed completely, the patient will need to take thyroid medication for life to return thyroid hormone levels and metabolic rate to normal.
Rationale:
(a) is incorrect because calcium needs aren’t determined until after the patient has been evaluated for parathyroid damage, which is a potential complication after thyroidectomy. If calcium levels fall, the nurse may note hyperirritability of the nerves, twitching hands and feet, and rarely, laryngospasm. The patient’s statement indicates that calcium supplementation may be needed.
(c) is incorrect because the patient will need to take thyroid medication for life, indicating correct understanding.
(d) is incorrect because the patient can have pain medication after surgery, indicating correct understanding. Managing pain, avoiding stress on suture lines, increasing humidity, and encouraging rest, relaxation, and nutrition are important components of the postoperative care.
Question 34.
The nurse is planning care for a patient admitted with hyperparathyroidism. Which of the following interventions does the nurse include?
(a) Keep the patient on bed rest to prevent stress on bones
(b) Encourage PO fluids of 2L/day or more
(c) Brush teeth with a soft toothbrush
(d) Administer thiazide diuretics to prevent fluid volume overload
Answer:
(b) Encourage PO fluids of 2L/day or more
Explanation:
The parathyroid gland controls calcium levels in the blood and bones, and hyperparathyroidism causes resorption of calcium from bones to increase. This puts the patient at risk for renal calculi. Fluids intake of 2L or more daily helps decrease formation of kidney stones. Cranberry juice is suggested because it can lower urinary pH. The patient is instructed to report abdominal pain and hematuria, which are signs of renal calculi.
Rationale:
(a) is incorrect because bed rest increases calcium excretion and risk for renal calculi. Mobility with the use of a rocking chair or ambulation is encouraged as much as possible because bones subjected to normal stress give up less calcium.
(c) is incorrect because using a soft toothbrush is not specific to hyperparathyroidism.
(d) is incorrect because thiazide diuretics are contraindicated in a patient with hyperparathyroidism. These medications decrease renal excretion of calcium and increase the risk for hypercalcemic crisis.
Question 35.
The nurse is monitoring a patient after parathyroidectomy. The nurse notes flexion contractions of the patient’s hand when the blood pressure is taken. Which of the following lab results would the nurse associate with this finding?
(a) Serum potassium 2.8 mEq/L
(b) Serum magnesium 1.6 mEq/L
(c) Serum sodium 124 mEq/L
(d) Serum calcium 5.7 mg/dL
Answer:
(d) Serum calcium 5.7 mg/dL
Explanation:
The parathyroid gland controls calcium levels in the blood and bones. Once the parathyroid gland is removed with surgery, hypocalcemia may occur. This leads to muscle twitches, muscle spasms, and tetany. This is worsened if tissue hypoxia is present. Trousseau’s sign is carpal spasm when the blood pressure cuff is applied for three minutes, which indicates hypocalcemia. The nurse may also see Chvostek’s sign, twitching of the eye, cheek, nose, or mouth when the facial nerve is tapped.
Rationale:
(a) is incorrect because hypokalemia is not associated with parathyroidectomy.
(b) is incorrect because hypomagnesemia is not associated with parathyroidectomy.
(c) is incorrect because hyponatremia is not associated with parathyroidectomy.
Question 36.
The nurse on the medical-surgical unit is assessing a patient admitted with Graves’ disease. When vital signs are taken, it is noted the temperature has risen by i°F (o.56°C) in the last hour. What is the first action the nurse should take?
(a) Turn down the room lights and shut the door
(b) Call for a STAT electrocardiogram (ECG)
(c) Calculate apical-radial pulse deficit
(d) Administer acetaminophen 650 mg PO
Answer:
(a) Turn down the room lights and shut the door
Explanation:
Graves’ disease is overactive thyroid gland as a whole, or hyperthyroidism. Also termed “toxic diffuse goiter,” it is the result of autoimmune disease with symptoms including sleeping problems, tachycardia, poor heat tolerance, irritability, and exophthalmos. The temperature increase could indicate thyroid storm is developing, and the nurse needs to notify the healthcare provider after reducing environmental stimuli which could lead to cardiac complications.
Rationale:
(b) is incorrect because environmental stimuli need to be minimized first.
(c) is incorrect because calculating apical-radial pulse deficit is unnecessary.
(d) is incorrect because acetaminophen is not indicated as thyroid activity is responsible for temperature increase. Acetaminophen may reduce the temperature because it is an antipyretic, but it will not treat the overactive thyroid or prevent thyroid storm.
Question 37.
A patient is admitted to the cardiac unit for bradycardia due to hypothyroidism. Which of the following medications does the nurse anticipate administering to this patient?
(a) Atropine sulfate
(b) Levothyroxine sodium
(c) Propranolol
(d) Epinephrine
Answer:
(b) Levothyroxine sodium
Explanation:
The cause of this patient’s bradycardia is hypothyroidism, so the nurse anticipates administering levothyroxine sodium. If the patient becomes symptomatic from the bradycardia, atropine or epinephrine could be administered as short-term treatment.
Rationale:
(a) is incorrect because atropine sulfate is only indicated if the patient is experiencing symptomatic bradycardia. When bradycardia is present due to hypothyroidism, the initial medication to increase the heartrate is a thyroid replacement medication, such as levothyroxine sodium.
(c) is incorrect because propranolol is a beta blocker and contraindicated for bradycardia as it will cause a further decrease in the patient’s heartrate.
(d) is incorrect because epinephrine is only indicated if the patient is symptomatic.
Question 38.
The nurse on the medical unit is planning care for a patient admitted for hypothyroidism. Which of the following is a priority problem that should be addressed first by the nurse?
(a) Intolerance to heat
(b) Body image problems
(c) Depression and withdrawal
(d) Depressed ventilation
Answer:
(d) Depressed ventilation
Explanation:
Hypothyroid patients may have ineffective breathing patterns related to depressed ventilation. The nurse must monitor respiratory rate, depth, and pattern. Pulse oximetry and arterial blood gases may be used to determine of oxygenation is adequate. Deep breathing, coughing, and incentive spirometry should be encouraged, and sedative medications should be avoided or used with caution.
Rationale:
(a) is incorrect because intolerance to heat is characteristic of hyperthyroidism, not hypothyroidism.
(b) is incorrect because body image problems are psychosocial and not a greater priority than other concerns which may have a detrimental physical effect on the patient.
(c) is incorrect because a depressed respiratory system is a greater priority than psychosocial issues, such as depression and withdrawal. The depressed patient may have a lack of motivation for self-care, but the nurse must address the respiratory system first.
Question 39.
A patient on the medical-surgical unit with adrenal hyperfunction screamed at her husband, threw a water pitcher across the room, then started crying uncontrollably. When the patient tells the nurse she feels like she is losing her mind, what is the best response by the nurse?
(a) “I will notify the healthcare provider for a psychiatric consult.”
(b) “Your hormone levels are causing this.”
(c) “I can bring you some pamphlets regarding support groups.”
(d) “I will post a sign on your room restricting visitors and close the door.”
Answer:
(b) “Your hormone levels are causing this.”
Explanation:
The adrenal glands are responsible for secreting cortisol, and the patient with adrenal hyperfunction has hypercortisolism. This can lead to changes in mood and mental behavior, psychosis, or neurotic behavior. The patient must be educated about behavior changes that are not psychiatric in nature and which often improve with blood cortisol level stabilization.
Rationale:
(a) is incorrect because the behavior is not psychiatric in nature.
(c) is incorrect because providing factual information about the physical changes taking place in the body is more appropriate than support groups.
(d) is incorrect because restricting visitors is not needed.
Question 40.
The nurse on the medical-surgical unit is caring for a patient admitted with pneumonia and a history of hypothyroidism. What is the priority intervention the nurse should include when planning care?
(a) Monitor IV site every shift
(b) Administer acetaminophen for fever
(c) Ensure suction equipment is working
(d) Limit PO fluids to prevent fluid volume overload
Answer:
(c) Ensure suction equipment is working
Explanation:
Patients with hypothyroidism who are diagnosed with another illness such as pneumonia are at risk for myxedema coma. Myxedema coma is severe hypothyroidism that can present with hypothermia, decreased mental status, and decreased respiratory rate, pulse, and blood pressure. This is an emergency situation in which maintaining airway is priority. Suction equipment must be available in the room and checked for function routinely if the patient should develop myxedema coma.
Rationale:
(a) is incorrect because monitoring IV site is necessary but not priority.
(b) is incorrect because acetaminophen administration for fever is necessary but not priority.
(d) is incorrect because PO fluids should be encouraged for the patient with hypothyroidism because they are at increased risk for constipation.
Question 41.
The nurse is teaching a patient about a prescription for prednisone for cortisol deficiency. Which of the following statements does the nurse include in the teaching?
(a) “You will need to rotate injection sites.”
(b) “You will need another drug if you work in the heat outside.”
(c) “Your diet will need strict sodium restrictions.”
(d) “Take one pill when you wake up and two pills before bed.”
Answer:
(b) “You will need another drug if you work in the heat outside.”
Explanation:
Working outside in the heat necessitates adjustment of steroid dosage, as the patient will sweat more than normal.
Rationale:
(a) is incorrect because prednisone is taken orally for cortisol deficiency.
(c) is incorrect because sodium restriction is not required when taking prednisone.
(d) is incorrect because dosage is usually two pills in the morning and one pill at night.
Question 42.
A patient with chronic hypercortisolism is admitted to the medical unit. Which of the following actions does the nurse take?
(a) Wash hands upon entering the room
(b) Place patient in airborne isolation
(c) Observe for signs of infection
(d) Assess daily chest X-ray
Answer:
(a) Wash hands upon entering the room
Explanation:
Washing hands when entering patient rooms is always appropriate but specifically for the patient who has hypercortisolism. Increased levels of cortisol will decrease lymphocytes, inhibit macrophage maturation, decrease antibody synthesis, and inhibit cytokine and inflammatory chemical synthesis. This causes increased risk of infection, so handwashing is vital to prevent bringing unwanted bacteria into the patient’s room.
Rationale:
(b) is incorrect because the patient with chronic hypercortisolism does not need airborne isolation.
(c) is incorrect because the patient will not display the usual signs of infection due to hypercortisolism.
(d) is incorrect because the patient does not require daily chest X-rays.
Question 43.
The nurse is teaching a patient newly diagnosed with diabetes mellitus. When the patient asks why blood glucose levels should be maintained at greater than 60 mg/dL, what is the best response by the nurse?
(a) “Glucose is the only fuel the body uses for energy production.”
(b) “The brain constantly requires glucose supply as it is unable to store glucose.”
(c) “When minimum blood glucose is not maintained, the body does not produce red blood cells.”
(d) “Maintaining blood glucose levels prevents lactic acid buildup and acidosis.”
Answer:
(b) “The brain constantly requires glucose supply as it is unable to store glucose.”
Explanation:
The brain does not synthesize or store glucose, so a constant supply from blood circulation is required for meeting central nervous system needs. The patient needs to be taught about maintaining minimum blood glucose to prevent a hypoglycemia prevention.
Rationale:
(a) is incorrect because fat and protein are also used as fuel by the body.
(c) is incorrect because red blood cell production and glucose are unrelated. Erythropoietin, a hormone secreted by the kidney, stimulates the production of red blood cells.
(d) is incorrect because blood glucose levels are not responsible for formation of lactic acid. Insufficient oxygen supply to muscles is the cause of lactic acid formation.
Question 44.
The nurse in the emergency room is caring for a patient experiencing acute adrenal crisis. What is the first action the nurse should take?
(a) Start a peripheral IV
(b) Administer hydrocortisone succinate
(c) Check blood glucose
(d) Administer dextrose and insulin
Answer:
(a) Start a peripheral IV
Explanation:
Acute adrenal crisis is adrenal insufficiency with decreased levels of cortisol. Signs and symptoms include abdominal pain, confusion, fatigue, hypotension, tachycardia, tachypnea, muscle weakness, dark pigmentation, and high fever. Patients may also experience low serum sodium and hyperkalemia. Therapy for acute adrenal crisis is administered intravenously, so the first action is starting an IV.
Rationale:
(b) is incorrect because the drug cannot be administered until IV access has been established.
(c) is incorrect because blood glucose is checked hourly as glucose tends to drop in adrenal crisis but establishing IV access is a greater priority.
(d) is incorrect because dextrose and insulin are administered for hyperkalemia, which may be present with adrenal crisis, but starting an IV is the greater priority.
Question 45.
The emergency room nurse is monitoring a patient with possible syndrome of inappropriate antidiuretic hormone (SLADH). The patient has an IV of 0.9% NaCl running at 100 ml/hr. The lab results reflect a sodium level of 112 mEq/L. What is the first action the nurse should take?
(a) Consult the dietitian regarding dietary sodium supplementation
(b) Restrict fluid intake to 500 mL/day
(c) Reposition the patient with a lift sheet
(d) Delegate hourly intake and output to the unlicensed assistive personnel (UAP)
Answer:
(b) Restrict fluid intake to 500 mL/day
Explanation:
SIADH is the production of too much antidiuretic hormone from the pituitary gland, leading to small amounts of highly concentrated urine excretion and fluid retention. This will lead to dilutional hyponatremia. Treatment includes removing the underlying cause (lung cancer, brain tumor, central nervous system infection) and fluid restriction. The patient currently has an IV running at 100 ml/hr, which will total 2400 mL/24hrs (this is too high). Fluid must be restricted to 500-600 ml/24hrs with SIADH. Retained water will slowly be excreted through the kidneys and serum sodium will slowly return to normal. Diuretics may also be used.
Rationale:
(a) is incorrect because supplementation of sodium in the diet is not helpful as it may worsen fluid retention.
(c) is incorrect because the patient is not at risk for fractures, and a lift sheet does not address sodium needs.
(d) is incorrect because measuring intake and output is necessary, but the priority action is to reduce fluid intake.
Question 46.
A patient is admitted to the medical-surgical unit with Cushing’s disease. In order to prevent injury, which action does the nurse include when planning care?
(a) Prepare the client for adrenalectomy
(b) Limit vitamin D to prevent hypercalcemia
(c) Reposition the patient with a lift sheet
(d) Ensure suction equipment is working
Answer:
(c) Reposition the patient with a lift sheet
Explanation:
Cushing’s disease leads to increased cortisol levels in the blood, which causes bone demineralization. This condition increases risk of pathologic bone fractures, so the patient should be repositioned with a lift sheet rather than pulling on the patient. A protective environment is necessary to prevent falls, fractures, and injuries to bones and soft tissues. The patient may also require the nurse’s assistance with ambulation to prevent bumping into corners of furniture.
Rationale:
(a) is incorrect because adrenalectomy may be required as a surgical treatment option for Cushing’s disease, but this does not address safety needs.
(b) is incorrect because patients with Cushing’s disease specifically need adequate amounts of vitamin D in their diet, along with protein and calcium to minimize muscle wasting and osteoporosis.
(d) is incorrect because the patient with Cushing’s disease doesn’t often require suctioning, and this nursing implementation does not prevent injury.
Question 47.
The nurse is caring for a patient who has 24-hour urine collection ordered. When delegating this task to the unlicensed assistive personnel (UAP), which statement does the nurse include?
(a) “Document time of the patient’s first void of the day and collect the urine specimen for 24 hours.”
(b) “Preservatives must be added to the specimen container at the end of 24 hours.”
(c) “The collection will start with first void in the morning.”
(d) “It is important that no more than one urine collection is missed in the 24 hours.”
Answer:
(a) “Document time of the patient’s first void of the day and collect the urine specimen for 24 hours.”
Explanation:
The 24-hour urine collection is the most accurate reflection of hormone secretion. It is appropriate to delegate this task to UAP because it does not require critical thinking. It is performed according to a sequence of steps, and the task does not vary much from one patient situation to another. The nurse is responsible for assuring that the collection process is understood. The collection starts after the first morning void, as the first void is discarded due to length of time in the bladder. The time is documented as start time.
Rationale:
(b) is incorrect because preservatives should be added at the beginning of collection.
(c) is incorrect because the first void is discarded.
(d) is incorrect because for accuracy, all voids must be collected within the 24-hour period.
Question 48.
The unlicensed assistive personnel (UAP) reports to the nurse that while collecting a 24-hour urine specimen, some of the urine was splashed on her hand. What is the next action the nurse should take?
(a) Ask the UAP if they washed their hands after the splash
(b) Cell the UAP to complete an incident report
(c) Call the lab and ask about the presence of preservatives in the urine collection container
(d) Have the UAP report to employee health services immediately
Answer:
(a) Ask the UAP if they washed their hands after the splash
Explanation:
The priority is to determine if the hands have been washed yet. Standard precautions are in place to protect staff and patients from exposure to contaminated fluids and prevent injury. The UAP may need education on Standard Precautions and the importance of wearing gloves.
Rationale:
(b) is incorrect because an incident report should be completed after the hands are washed. (c) is incorrect because although preservatives used in some 24-hr urine collection containers can cause the skin to burn, the lab can be called after the hands have been washed. (d) is incorrect because washing the hands is the priority, and the UAP may not need to report to employee health.
Question 49.
A 11-year-old male patient is diagnosed with hypopituitarism and has a new prescription for testosterone replacement therapy. When the patient asks the nurse how long the medication should be taken, what is the best response by the nurse?
(a) “Therapy will be discontinued once your blood testosterone levels return to normal.”
(b) “When your voice gets deeper and your beard gets thicker, the dose will be decreased, but you will require medication for life.”
(c) “Once your sperm count is within normal, the treatment will not be needed anymore.”
(d) “Testosterone levels decrease with age, so your treatment will stop when you reach 50 years of age.”
Answer:
(b) “When your voice gets deeper and your beard gets thicker, the dose will be decreased, but you will require medication for life.”
Explanation:
Hypopituitarism (dwarfism) occurs before puberty and causes height below normal with normal body proportions. Bone and tooth growth can be delayed and sexual maturity may be slow. Testosterone replacement therapy is begun with high dose until the patient achieves virility, then the dosage is decreased. The treatment is taken for life.
Rationale:
(a) is incorrect because testosterone replacement is not discontinued when blood testosterone levels are normal. Discontinuing the hormone replacement would lead to a drop in serum levels. (c) is incorrect because testosterone replacement is not discontinued based on when sperm count is increased. (d) is incorrect because testosterone replacement is not discontinued when the patient reaches 50 years of age.
Also Read: Endocrine Health Problems