Endocrine Disorders Adaptive Quizzing (Evolve) – Flashcards

2 Control postoperative pain by administering medication. 4 Assess for signs of tetany secondary to hypoparathyroidism. 5 Assess the patient every two hours for signs of bleeding or tracheal compression. Nursing interventions after a thyroidectomy are important to prevent complications, such as airway obstruction. These interventions include controlling pain with medication; assessing for signs of tetany (i.e., tingling in toes, fingers, and around the mouth, Trousseau sign, and Chvostek sign); and assessing the patient every two hours for signs of bleeding and tracheal compression. Monitoring vital signs is important, but monitoring potassium levels is not; the calcium levels should be monitored. The patient should be placed in a semi-Fowler's position, not supine, with the head supported with pillows.

1 Fatigue Activity intolerance in a patient with hypothyroidism is related to weakness and fatigue. Patients with hyperthyroidism, not hypothyroidism, experience weight loss, diarrhea, and nervousness.

2 Undetectable TSH level 4 Elevated free thyroxine (free T4) level 5 Low thyroid-stimulating hormone (TSH) level The primary laboratory findings to confirm the diagnosis of hyperthyroidism are low or undetectable TSH levels and elevated free thyroxine levels. Low free thyroxine levels and elevated TSH levels are found with hypothyroidism.

3 Assessment of Chvostek's sign A positive Chvostek's sign is a sign of life-threatening tetany, which could be caused by hypocalcemia because of accidental removal of the parathyroid glands. Hoarseness for three to four weeks postoperatively is an expected outcome of a thyroidectomy. A Babinski's reflex is not related to thyroid removal. Although it is advisable that the postoperative thyroidectomy patient exercise the neck muscles, neck flexion is contraindicated because it places tension on the suture line.

1 0600 For maximum absorption, levothyroxine should be taken first thing in the morning on an empty stomach 30 minutes before breakfast. 1200, 1600, and 2100 may not result in adequate absorption.

1 "I should take my levothyroxine every morning before eating my breakfast." A patient with a new diagnosis of hypothyroidism should be taught how to manage hypothyroidism, including taking the thyroid hormone in the morning before food. Patients with hypothyroidism need to be taught about the importance of regular follow-up care, not just when they are having abnormal symptoms. Patents with hypothyroidism should be taught to keep the environment warm and comfortable because of cold intolerance. Patients with hypothyroidism should increase the amount of fiber in their diet to prevent constipation; they should not limit the amount of fiber.

2 High thyroid-stimulating hormone level, low thyroxine level Primary hypothyroidism is caused by destruction of thyroid tissue or defective hormone synthesis. It is characterized by a high thyroid-stimulating hormone (TSH) level and a low thyroxine level. A low TSH level and low thyroxine level support secondary hypothyroidism. A low TSH level and a low basal metabolic rate (BMR) support secondary hypothyroidism. A low TSH and high BMR indicate hyperthyroidism

1 Chest pain 3 Nervousness 4 Tachycardia Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism. The signs of overtreatment, or levothyroxine toxicity, are the same as the signs of hyperthyroidism, a state of increased metabolism and increased tissue sensitivity to sympathetic nervous system stimulation. Signs of overtreatment of hypothyroidism with levothyroxine include chest pain, nervousness, and tachycardia. Weight gain, cold intolerance, and mental sluggishness are signs of hypothyroidism.

1 Apply artificial tears. 2 Tape the eyelids lightly for sleeping, if needed. 3 Ask the patient to exercise the intraocular muscles. Nursing interventions for the patient exhibiting exophthalmos include application of artificial tears to soothe and moisten conjunctival membranes, to relieve eye discomfort, and to prevent corneal ulceration. If the eyelids cannot be closed, the nurse should lightly tape them shut to help the patient sleep. To maintain flexibility, the patient must be taught to exercise the intraocular muscles several times a day by turning the eyes in the complete range of motion. The patient should sit upright as much as possible. The head must be elevated to promote fluid drainage from the periorbital area.

3 Exophthalmos Exophthalmos is the protrusion of eyeballs from the orbits; it results from increased fat deposits and fluid in orbital tissues. It is a classic clinical manifestation in Graves' disease. Gingivitis, cretinism, and muscular dystrophy are not classic clinical manifestations associated with Graves' disease.

1 Assessing for tetany 2 Monitoring vital signs 4 Assessing the patient every two hours on the first postoperative day Postoperative nursing interventions that are appropriate for a patient after a thyroidectomy include assessing for tetany, monitoring vital signs, and assessing the patient every two hours on the first postoperative day for hemorrhage and tracheal compression. The nurse should monitor calcium levels, not potassium levels. The nurse should place the patient in a semi-Fowler's position to reduce swelling and edema in the neck area. Sandbags or pillows may be used to support the head or neck.

1 Dyspnea 3 Cardiac hypertrophy 5 Bounding, rapid pulse Exophthalmos is a classic finding in Graves' disease, which is caused by hyperthyroidism. Clinical manifestations anticipated by the nurse upon assessment include a bounding, rapid pulse; cardiac hypertrophy; and dyspnea. Clinical symptoms such as celiac disease and distended abdomen are associated with hypothyroidism.

1 Weight loss 2 Protrusion of the eye balls 4 Elevated blood pressure Weight loss, protrusion of the eyeballs, and elevated blood pressure are clinical manifestations of hyperthyroidism. Weight loss and hypertension are due to increases in metabolic demands; protrusion of the eyeballs is due in part to accumulation of fluid in the eyes. Thick, cold, and dry skin are symptoms of hypothyroidism. Purplish red marks on the abdomen are seen in Cushing syndrome.

1 Atenolol Atenolol, a β-Adrenergic blocker, is prescribed to control the stimulation of the sympathetic nervous system that often occurs with hyperthyroidism. Atenolol manages tachycardia, nervousness, irritability, and tremors. It is considered the drug of choice for treating a patient diagnosed with hyperthyroidism, asthma, and heart disease. Methimazole is used to treat hyperthyroidism; however, it is not the drug of choice for patients with concurrent diagnoses of asthma and heart disease. Lugol's solution is an antithyroid drug that is used in treatment of thyrotoxicosis. Propylthiouracil, although appropriate for the treatment of hyperthyroidism, is not the drug of choice for a patient with concurrent diagnoses of asthma and heart disease.

3 Assess the patient for signs of hemorrhage The patient who undergoes thyroid surgery is at risk for hemorrhage. Swelling is a clinical manifestation of hemorrhage. The first nursing action is to assess the patient. Monitoring calcium levels and evaluating difficulty in speaking helps in assessing the signs of hypoparathyroidism. Placing the patient in a semi-Fowler's position helps in avoiding flexion of the neck and tension on the suture lines.

3 Preventing corneal injury The patient with exophthalmos may not be able to close the eyelids completely. This puts the patient at risk for dry eyes, for overexposure to environmental irritants, and for corneal injury. Lubricating eye drops can be used to combat drying, and dark glasses are encouraged to decrease exposure to environmental irritants. Preventing corneal injury is the priority for the patient with exophthalmos. Exophthalmos may create a function limitation in extraocular movements because of forward protrusion of the globe of the eye. The patient with exophthalmos is encouraged to move the eyes through the six cardinal fields of gaze several times a day to maintain ocular muscle flexibility. Avoiding eyestrain is not a priority for the patient with exophthalmos. Patients may suffer from decreased self-esteem because of the physical changes associated with exophthalmos. Good grooming is encouraged as a strategy to improve self-esteem. Improving self-esteem is of lower priority than preventing corneal injury. Exophthalmos is not associated with ocular nerve damage.

4 To block the sympathetic nervous system response to excess thyroid hormone Thyrotoxicosis is an acute crisis state of hyperthyroidism often precipitated by a physiologic stressor in the patient with hyperthyroidism. Thyrotoxicosis is an extreme state of hypermetabolism. Excessive amounts of thyroid hormone are present and tissue sensitivity to sympathetic nervous system stimulation is increased, resulting in a number of signs and symptoms, including severe tachycardia leading to heart failure. Propranolol is a beta-adrenergic antagonist that blocks the thyroid-hormone-induced sympathetic nervous system stimulation, resulting in a lowered heart rate and a decreased risk of heart failure. One of the priority treatment goals in the patient with thyrotoxicosis is to decrease thyroid hormone secretion. A decrease in thyroid hormone secretion is primarily accomplished through the use of either methimazole or propylthiourical. Propranolol does not suppress thyroid hormone secretion. In addition to slowing heart rate, propranolol decreases blood pressure; it is not used to prevent hypotension. Nonradioactive strong iodine solution, either in the form of saturated solution of potassium iodine or Lugol's solution, may be used to decrease size and vascularity of the thyroid gland in preparation for surgery. Potassium Iodide or Lugol's solution also may inhibit thyroid hormone synthesis. Propranolol does not decrease size or vascularity of the thyroid gland.

2 Consume a high-calorie diet. 3 Eat snacks high in protein. 4 Avoid caffeinated beverages. A diet high in calories and protein is encouraged. Caffeinated beverages should be avoided. High-fiber foods should be avoided, not encouraged, because they can further stimulate the already hyperactive gastrointestinal tract. The patient should increase intake of carbohydrate-rich foods to compensate for the increased metabolism. This provides energy and decreases the use of body-stored protein.

3 Anaplastic thyroid cancer The patient with anaplastic thyroid cancer has a poor prognosis because the cancer is aggressive and resistant to therapy. Papillary, follicular, and medullary thyroid cancers are treated successfully when compared to anaplastic thyroid cancer.

2 "If I begin to gain weight I should stop taking my medication." Corticosteroids should be gradually tapered and not stopped suddenly to avoid life-threatening adrenal insufficiency. Corticosteroids may lead to insulin resistance and increased gluconeogenesis by the liver, and therefore the patient may need to monitor for blood sugar increase. Corticosteroids decrease the inflammatory response and delay healing, and therefore the patient is more susceptible to infections. Adipose tissue accumulates in the trunk, face, and cervical spine as a result of corticosteroid therapy.

1 Hypocalcemia Hypocalcemia is a low serum calcium level. Surgical removal of the thyroid gland may also include removal of the parathyroid gland. This results in a deficiency of parathyroid hormone, which controls serum calcium by regulating absorption of calcium from the gastrointestinal tract, mobilizing calcium in bones, and excreting calcium in breast milk, feces, sweat, and urine. The normal serum calcium level ranges from 9.0 to 11.5 mg/dL. Potassium is within normal limits (3.5 to 5 mEq/L), and phosphorus is also within normal limits (2.8 to 4.5 mg/dL).

4 Life-long hormone replacement will be needed. This patient will need life-long thyroid hormone replacement with levothyroxine because the entire thyroid gland will be missing after surgery. Exercise will not be restricted for six months. Lengthy exercise restriction or physical therapy generally is not indicated following a thyroidectomy. A sodium-restricted diet would not ordinarily be necessary.

3 "It may take several weeks to see the full benefits of the treatment." Radioactive iodine has a delayed response, and the maximum effect may not be seen for up to three months. For this reason, it would not be necessary to contact the primary health care provider immediately, or for the patient to have the thyroid gland removed sooner. Asking the patient to sit and talk about it demonstrates that the nurse is being responsive to psychosocial/emotional needs, but is not the best nursing response at this time.

4 Decreased serum calcium During thyroid surgery the parathyroid glands are often unavoidably removed. The result is an inability to regulate serum calcium, stemming from a lack of parathyroid hormone. In hypoparathyroidism there is a decrease in parathyroid hormone, which results in decreased serum calcium and increased phosphorus levels. An increase in thyroxine is not seen after thyroidectomy; the thyroxine level may actually drop below normal. Decreased phosphorus and increased serum calcium levels may occur initially after a thyroidectomy because of manipulation of the thyroid gland during surgery. This causes a surge of parathormone, but the level does decrease if the parathyroid glands are removed.

2 Monitor vital signs and calcium levels. 3 Check for muscular twitching or tingling in the toes. 5 Assess the patient for irregular breathing or neck swelling. The nurse should monitor the patient's vital signs and calcium levels. The patient should be assessed for muscular twitching or tingling in the toes, which are signs of tetany secondary to hypoparathyroidism. The nurse should assess the patient every 2 hours for 24 hours for signs of hemorrhage or tracheal compression such as irregular breathing, neck swelling, frequent swallowing, sensations of fullness at the incision site, choking, and blood on the anterior or posterior dressings. The patient should be placed in semi-Fowler's position and the head should be supported with pillows.

3 "This medication will decrease the vascularity of the thyroid gland." When a patient is to undergo a thyroidectomy, before surgery antithyroid drugs, iodine, and adrenergic blockers may be administered to achieve a euthyroid state. Iodine reduces vascularization of the thyroid gland, reducing the risk of hemorrhage. Potassium iodide does not promote thyroid hormone synthesis, inhibit the production of parathyroid hormone, or enhance healing and electrolyte balance postoperatively.

4 Jugular vein distention The patient is at risk for thyrotoxicosis because of a medical history of hyperthyroidism and a current diagnosis of infection. Jugular vein distention is a sign of congestive heart failure, which is a manifestation of thyrotoxicosis. Early treatment is essential to prevent further complications. Flank pain and frequent voiding are non-life-threatening manifestations of a kidney infection. A heart rate of 100 bpm needs to be monitored, but is not considered severe tachycardia.

2 0.5 tablet First, convert 0.075 mg to mcg, which equals 75 mcg. Using ratio and proportion, multiply 37.5 by x and multiply 75 × 1 to yield 37.5x = 75. Divide 75 by 37.5 to yield 0.5 tablet.

4 Blood glucose Hyperglycemia, or increased blood glucose level, is an adverse effect of corticosteroid therapy. Sodium, calcium, and potassium levels are not affected directly by dexamethasone.

4 Managing lifelong corticosteroid replacement The patient with Addison's disease experiences hypofunctioning of the adrenal cortex, resulting in decreased production of glucocorticoids, mineral corticoids, and androgens. Patients with Addison's disease require lifelong glucocorticoid and mineral corticoid replacement therapy to avoid Addisonian crisis. Addisonian crisis is characterized by profound hypotension, dehydration, fever, tachycardia, hyponatremia, and hyperkalemia. Circulatory collapse may occur if the patient is treated inadequately. Although Addisonian crisis often is triggered by illness-related physiologic stress, and although avoiding infection is important, avoiding infection is of lower priority than managing lifelong corticosteroid replacement. Corticosteroid replacement must be increased during times of stress to prevent Addisonian crisis. Patients taking a mineralocorticoid should increase their salt intake. Emotional stress may contribute to the need for increased corticosteroid replacement. Stress management techniques are important. Practicing stress management techniques, however, is of lower priority than managing lifelong corticosteroid replacement.

3 The patient must notify the health care provider whenever experiencing vomiting or diarrhea. 4 The patient will need to take extra medication when experiencing either physical or emotional stress. Vomiting and diarrhea can deplete cortisol levels and parenteral replacement may be needed. The patient with Addison's disease is unable to tolerate physical or emotional stress without exogenous corticosteroids and may need to increase medication at these times. Patients with Addison's disease will need to increase their sodium intake, because they are at risk for hyponatremia. Antacid intake will necessitate increased corticosteroid hormone therapy. Corticosteroids must be given intramuscularly when the patient is unable to take them orally.

4 Adrenocorticosteroid replacement therapy Because Addison's disease results from a deficiency of adrenocorticosteroid hormones, steroid therapy is the primary treatment. Blood transfusions, thyroid ablation, and oral calcium supplements are not primary treatments for Addison's disease.

4 A 24-hour urine collection for fractionated metanephrines Pheochromocytoma should be suspected when hypertension does not respond to traditional treatment. The 24-hour urine collection for fractionated metanephrines is simple and reliable, with elevated values in 95% of people with pheochromocytoma. In a patient with pheochromocytoma preoperatively an α-adrenergic receptor blocker is used to reduce blood pressure. Abdominal palpation is avoided to avoid a sudden release of catecholamines and severe hypertension. Potassium-sparing diuretics are not needed; most likely they would be used for hyperaldosteronism, which is another cause of hypertension.

4 Lifelong replacement of corticosteroids will be required. Discharge instructions are based on the patient's lack of endogenous corticosteroids and resulting inability to physiologically react to stressors. Patients undergoing a bilateral adrenalectomy will require lifetime replacement therapy. ACTH injections are not an option, because both adrenal glands were removed during surgery. Exogenous cortisol is required at all times, and the dose needs to be increased dramatically if the patient experiences stress.

2 Maintaining a normotensive state A pheochromocytoma is a benign tumor of the adrenal gland, the major manifestation of which is severe hypertension due to excessive secretion of catecholamines, such as epinephrine. Therefore, the priority goal for this patient would be to maintain a normal blood pressure, or a normotensive state. At least 10% to 30% of patients require antihypertensive medication after the surgery. If the blood pressure returns to a normotensive state, the need to verbalize coping mechanisms, a decreased activity level, and compliance with dietary restrictions do not apply.

4 Rapid blood pressure changes The risk of hemorrhage is increased with surgery on the adrenal glands as well as large amounts of hormones being released in the circulation, which may produce hypertension and fluid and electrolyte imbalances for the first 24 to 48 hours after surgery. Vomiting, infection, and thromboembolism may occur postoperatively with any surgery.

2 Increased glucocorticoid replacement The patient with Addison's disease needs lifelong glucocorticoid and mineralocorticoid replacement and has an increased need with illness, injury, or stress, as this patient is experiencing. The patient with Addison's also may need a high-sodium diet. Suppression of pituitary ACTH synthesis is done for Cushing's syndrome. Elimination of mineralocorticoid replacement cannot be done for Addison's disease.

3 Prevention of adrenal insufficiency Sudden cessation of corticosteroid therapy can precipitate life-threatening adrenal insufficiency. Diabetes insipidus, hypothyroidism, and cardiovascular complications are not common consequences of suddenly stopping corticosteroid therapy.

3 Recognize edema and ways to restrict sodium intake. The nurse should teach the patient to recognize edema and ways to restrict sodium intake to less than 2000 mg/day if edema occurs. The nurse should ask the patient to see an eye specialist yearly to assess for cataracts. The patient should recognize the need for an increased dose of corticosteroids when stressed. The nurse should teach the patient and caregiver to plan a diet high in protein, calcium, and potassium but low in fat and concentrated simple carbohydrates such as sugar, honey, syrups, and candy.

2 Serum potassium: 6.5 mEq/L 3 Blood glucose levels: 80 mg/dL 5 Electrocardiogram (ECG): Peaked T waves Adrenocortical insufficiency leads to hyperkalemia, hypoglycemia, peaked T waves in ECG, hyponatremia, and increased blood urea nitrogen levels. The normal level of serum sodium is 135 to 145 mEq/L, serum potassium is 3.5 to 5 mEq/L, glucose level is 120 to 160 mg/dL, and blood urea nitrogen is 15 to 50 mg/dL. A serum potassium level of 6.5 mEq/L shows increased serum potassium levels (hyperkalemia). A blood glucose level of 80 mg/dL shows decreased glucose levels (hypoglycemia). Peaked T waves are observed in electrocardiogram due to hyperkalemia.

Addison's The drug prescribed in this case should be fludrocortisone

1 "Check plasma adrenocorticotropic hormone (ACTH) levels." 4 "Collect a 24-hour urine sample for testing free cortisol and 17-ketosteroids." 5 "Undergo computed tomography (CT) scan or magnetic resonance imaging (MRI)." Checking plasma adrenocorticotropic (ACTH) hormone levels will help assess the underlying cause of Cushing syndrome because a high or normal ACTH level indicates Cushing syndrome. A urine cortisol level higher than the normal range of 80 to 120 mcg/24 hr is an indicator of Cushing syndrome. Both a computed tomography (CT) scan and a magnetic resonance imaging (MRI) of the pituitary and adrenal glands are used to detect Cushing syndrome. Blood chemistries for sodium, potassium, and glucose are also a part of the diagnostic tests for Cushing syndrome. A complete blood count (CBC) with WBC, not RBC, differential is usually performed as part of the diagnostic tests for Cushing syndrome.

4 Severe pounding headaches and profuse sweating are clinical features. Severe pounding headache and profuse sweating are clinical features of pheochromocytoma. Although drug therapy is administered during preoperative care to reduce complications, the primary treatment is surgery. The attack is provoked by opioids, not antiepileptic medications. Epinephrine and norepinephrine levels rise in patients with pheochromocytoma.

4 Adrenocorticotropic hormone (ACTH) Adrenocorticotropic hormone (ACTH) may lead to acute adrenal insufficiency and shock. This may result in a life-threatening situation because of sodium and water depletion. Prolactin plays a role in lactation. Oxytocin is a hormone that is particularly functional during and after childbirth. Follicle-stimulating hormone (FSH) is associated with reproduction and is responsible for the development of eggs in females and sperm in males. The absence of these other hormones are not life threatening.

2 Decreased bone density 5 Increased level of blood pressure Decreased bone density due to the prolonged use of corticosteroids may lead to bone weakness; therefore, the patient is advised to take calcium supplements. Corticosteroids may increase the blood pressure by causing a decrease in the level of potassium and promoting retention of sodium. The drug may increase the risk of ulcers but only if taken on an empty stomach. Corticosteroids tend to suppress the immune system, thereby increasing the risk of infections.

2 Avoiding palpations of the patient's abdomen The nurse should avoid palpating the abdomen of a patient with suspected pheochromocytoma because the action may cause the sudden release of the catecholamines and severe hypertension. A healthy diet promotes the overall health of the patient. Advising the patient to rise slowly from the bed helps prevent orthostatic hypotension. Administering α- and β-blockers preoperatively helps prevent an intraoperative hypertensive crisis.

4 Administer large volumes of saline and dextrose. Addisonian crisis is a life-threatening emergency in which the patient has low levels of adrenal hormones, leading to a loss of water and sodium. The first course of action is to reverse hypotension by administering large volumes of saline and dextrose. Administration of fludrocortisone can be administered once hypotension is corrected. Increasing the salt in the diet would not have an immediate effect during the Addisonian crisis. Glucocorticoids are given as a long-term therapy.

3 Hypofunction of glucocorticoids Purplish red striae are seen in Cushing syndrome, which occurs due to the hypofunctioning of adrenal cortex. Purplish red striae are observed in a patient with Cushing syndrome due to the hypofunction of glucocorticoids. Hyperfunctioning of androgens may result in hirsutism and hyperpigmentation. Hypofunctioning of androgens may result in decreased axillary and pubic hair in women. Hyperfunctioning of glucocorticoids may result in bronzed skin or hyperpigmentation of face, neck, and hands.

4 Gradual discontinuance of corticosteroids Corticosteroid hormone doses should be decreased gradually until the discontinuation of therapy if the therapy leads to Cushing syndrome. The therapy should not be withheld for a few days. Alternate-day regimen cannot be applied for hormonal therapy. Discontinuing the therapy suddenly might lead to adrenal insufficiency, which is life threatening.

2 Hyperpigmentation 3 Weakness and fatigue 4 Orthostatic hypotension Hyperpigmentation, orthostatic hypotension, and weakness coupled with fatigue are all manifestations of Addison's disease. A patient with Addison's disease will have weight loss, not weight gain. Thin skin with ecchymosis is a manifestation of Cushing syndrome, not Addison's disease.

4 "Do not stop taking the medication abruptly." The patient should be instructed to not stop the medication abruptly because this can cause adverse side effects. Patients taking corticosteroids should not consume a high-carbohydrate diet, because corticosteroids increase blood sugar. Patients should also increase their daily intake of calcium to prevent bone loss due to the side effects of corticosteroids. Patients should also decrease, not increase, their daily intake of sodium to avoid fluid retention.

thinning of hair, red cheeks, acne, buffalo hump, moon face, supraclavicular fat pad, increased body/facial hair, weight gain, purple striae on pendulous abdomen, echymosis from easy bruising, thin extremities w/ muscle atrophy, thin skin/subcutaneous tissue, slow wound healing