ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 50 : Caring for Clients With Disorders of the Endocrine System Questions
Question 1 of 5
The nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). The nurse notices that the client has become confused and extremely short of breath, and crackles are heard when lungs are auscultated. What is the first action by the nurse?
Correct Answer: B
Rationale: The nurse closely monitors fluid intake and output and vital signs. The nurse carefully assesses LOC and immediately reports any changes to the physician. The nurse checks closely for signs of fluid overload (confusion, dyspnea, pulmonary congestion, hypertension) and hyponatremia (weakness, muscle cramps, anorexia, nausea, diarrhea, irritability, headache, weight gain without edema). Laying the client flat would increase the shortness of breath and would deoxygenate the client. The nurse cannot administer a diuretic without the physician's order. Suctioning of the client will not clear the airway at this time.
Question 2 of 5
The nurse is assessing a client in the clinic who appears restless, excitable, and agitated. The nurse observes that the client has exophthalmos and neck swelling. What diagnosis do these clinical manifestations correlate with?
Correct Answer: B
Rationale: Clients with hyperthyroidism characteristically are restless despite feeling fatigued and weak, highly excitable, and constantly agitated. Fine tremors of the hand occur, causing unusual clumsiness. The client cannot tolerate heat and has an increased appetite but loses weight. Diarrhea also occurs. Visual changes, such as blurred or double vision, can develop. Exophthalmos, seen in clients with severe hyperthyroidism, results from enlarging muscle and fatty tissue surrounding the rear and sides of the eyeball. Hypothyroidism clinical manifestations are the opposite of what is seen in hyperthyroidism, and SIADH and DI clinical manifestations do not correlate with the symptoms manifested by the client.
Question 3 of 5
The nurse is administering a medication to a client with hyperthyroidism to block the production of thyroid hormone. The client is not a candidate for surgical intervention at this time. What medication should the nurse administer to the client?
Correct Answer: C
Rationale: Antithyroid drugs, such as propylthiouracil and methimazole, are given to block the production of thyroid hormone preoperatively or for long-term treatment for clients who are not candidates for surgery or radiation treatment. Levothyroxine would increase the level of thyroid and be contraindicated in this client. Spironolactone is a diuretic and does not have the action of blocking production of thyroid hormone, and neither does propranolol, which is a beta-blocker.
Question 4 of 5
What life-threatening outcome should the nurse monitor for in a client who is not compliant with taking prescribed antithyroid medication?
Correct Answer: A
Rationale: Thyrotoxic crisis, an abrupt and life-threatening form of hyperthyroidism, is thought to be triggered by extreme stress, infection, diabetic ketoacidosis, trauma, toxemia of pregnancy, or manipulation of a hyperactive thyroid gland during surgery or physical examination. Although rare, this condition may occur in clients with undiagnosed or inadequately treated hyperthyroidism. Myxedema coma is associated with hypothyroidism. Diabetes insipidus (DI) and syndrome of inappropriate antidiuretic hormone secretion (SIADH) clinical manifestations do not correlate with medication taken for hyperthyroidism.
Question 5 of 5
The nurse is caring for a client with hypoparathyroidism. When the nurse taps the client's facial nerve, the client's mouth twitches and the jaw tightens. What is this response documented as related to the low calcium levels?
Correct Answer: A
Rationale: If a nurse taps the client's facial nerve (which lies under the tissue in front of the ear), the client's mouth twitches and the jaw tightens. The response is identified as a positive Chvostek sign. A positive Trousseau sign is elicited by placing a BP cuff on the upper arm, inflating it between the systolic and diastolic BP, and waiting 3 minutes. The nurse observes the client for spasm of the hand (carpopedal spasm), which is evidenced by the hand flexing inward. Positive Babinski sign is elicited by stroking the sole of the foot. Paresthesia is not a symptom that can be elicited; it is felt by the client.