BIOLOGY 102. Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition CHAPTER 18

Medical-Surgical Nursing Critical Thinking in Client Care, 4th Edition Priscilla LeMon

CHAPTER 18

Chapter 18

1. The nurse is assessing the client for an endocrine problem. During the health assessment interview, it is essential that the nurse obtain which data about the skin when the client is experiencing hypothyroidism?

1.       Is the skin rough and dry?

2.       Is the skin smooth?

3.       Is the skin clammy?

4.       Does the client have brown shiny patches on the lower extremities?

2. The nurse is performing an assessment on client experiencing hypoparathyroidism. While taking a blood pressure on this client, the nurse notes spasms of the hands. The nurse should document this clinical manifestation as:

1.       Chvostek’s sign.

2.       Trousseau’s sign.

3.       Turner’s sign.

4.       Cullen’s sign.

3. A nurse assesses a client with hypoparathyroidism who has a positive Trousseau’s sign. The nurse should develop a plan of care based on which of these nursing diagnoses?

1.       Fluid Volume, Excess

2.       Breathing Pattern, Ineffective

3.       Comfort, Readiness for Enhanced

4.       Tissue Perfusion, Ineffective

4. When performing an endocrine assessment on a client, the nurse asks the client if she has experienced weight changes. Evaluating weight changes might provide the nurse with data about which endocrine systems? Select all that apply.

1.            Adrenal gland

2              Thyroid gland

3.            Parathyroid gland

4.            Pituitary gland

5.            Gonads

5. When assessing a client who presents with a pituitary disorder, for which of these clinical manifestations should the nurse evaluate the client?

1.            Enlargement of the hands and feet

2.            Smooth, silky hair

3.            Facial hair growth

4.            Purple striae over the trunk

6.           A client who has a clinical manifestation of exophthalmus is in the clinic. Based on this finding, the nurse would also assess the client for:

1.           Dry, thick nails.

2.           Dry skin.

3.           Decreased reflexes.

4.           An enlarged thyroid gland.

7.           Which of these factors in the client’s history is most likely related to the development of a pituitary disorder?

1.           Carpal spasms

2.           Dwarfism

3.           An enlarged thyroid nodule

4.           Hyperpigmentation of the skin

8.           Which of these laboratory results would be most important for the nurse to assess in the client who has Graves’ disease?

1.           Thyroxine

2.           Urine-specific gravity

3.           Cortisol level

4.           Calcium level

9.           Which of these approaches would be most appropriate for the nurse to take when assessing the thyroid gland of an adult client?

1.           Stand in front of the client and palpate the thyroid.

2.           Place the client supine and palpate one side of the neck at a time.

3.           Stand behind the client and palpate the thyroid.

4.           Have the client flex the neck forward and palpate the thyroid.

10.         In order to perform a physical assessment of the client experiencing an endocrine disorder, the nurse should include: (Select all that apply.)

1.           Measurement of height and weight.

2.           Assessment of skin, hair, and nails.

3.           Evaluation of deep tendon reflexes.

4.           Evaluation of the respiratory system.

5.           Assessment of the musculoskeletal system.

11.         A client scheduled for an assessment of the endocrine system asks the nurse “Is this going to hurt?” The nurse’s best response is:

1.           “The assessment will consist of a health assessment interview.”

2.           “A complete head-to-toe assessment will not be necessary.”

3.           “The assessment will involve anesthesia and multiple laboratory studies.”

4.           “The assessment will not be painful. What concerns or questions do you have? I will explain the procedure as I go along.”

12.         A client has been given instruction about an endocrine assessment. Which statement made by the client would indicate to the nurse that further instruction is necessary?

1.           “I will need to stay in the hospital for several days.”

2.           “The nurse will begin with a health assessment interview.”

3.           “The nurse will inspect my skin, nails, and hair.”

4.           “The nurse will need to palpate my thyroid gland.”

13.         During the health assessment interview for the assessment of the endocrine system, the nurse should ask the client to provide information about: (Select all that apply.)

1.           Occupation.

2.           Use of alcohol, drugs, and tobacco.

3.           Lifestyle.

4.           Alterations in bowel habits.

5.           Exercise and sleep patterns.

14.         Which of these questions seek the data that would be most important for a nurse to obtain when assessing the endocrine system of a female client?

1.           Do you have children?

2.           Are you able to provide for your children?

3.           Is your menstrual cycle regular?

4.           How old were you when your menses first began?

15.         During an endocrine assessment of the client in the clinic, the nurse discovers severe hypertension in the client. The nurse would conclude that this finding might indicate a disorder of the:

1.           Thyroid gland.

2.           Parathyroid gland.

3.           Gonads.

4.           Adrenal gland.