1. Answer: B.

Rationale: After hypophysectomy, the patient should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid leak. If this occurs, the drainage should be collected and tested for the presence of cerebrospinal fluid. The cerebrospinal fluid contains glucose, and if positive, this would indicate that the drainage is cerebrospinal fluid. The head of the bed should remain elevated to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication.

  1. Answer: A, C, E

Rationale: Patients with SIADH experience excess secretion of antidiuretic hormone (ADH), which leads to excess intravascular volume, a declining serum osmolarity, and dilutional natremia and preventing cerebral edema. Hypertonic saline is prescribed when the hyponatremia is severe, less than 120 mEq/L (120 mmol/L). An intravenous (IV) infusion of 3% saline is hypertonic. Hypertonic saline must be infused slowly as prescribed and an infusion pump must be used. Fluid restriction is a useful strategy aimed at correcting dilutional hyponatremia. Vasopressin is an ADH; vasopressin antagonists are used to treat SIADH. Furosemide may be used to treat extravascular volume and dilutional hyponatremia in SIADH, but it is only safe to use if the serum sodium is at least 125 mEq/L (125 mmol/L). When furosemide is used, potassium supplementation should also occur and serum potassium levels should be monitored. To promote venous return, the head of the bed should not be raised more than 10 degrees for the patient with SIADH. Maximizing venous return helps to avoid stimulating stretch receptors in the heart that signal to the pituitary that more ADH is needed.

  1. Answer: B

Rationale:  Myxedema coma is a rare but serious disorder that results from persistently low thyroid production. Coma can be precipitated by acute illness, rapid withdrawal of thyroid medication, anesthesia and surgery, hypothermia, and the use of sedatives and opioid analgesics. In myxedema coma, the initial nursing action is to maintain a patent airway. Oxygen should be administered, followed by fluid replacement, keeping the patient warm, monitoring vital signs, and administering thyroid hormones by the intravenous route.

  1. Answer: A, C

Rationale: The role of parathyroid hormone (PTH) in the body is to maintain serum calcium homeostasis. In hyperparathyroidism, PTH levels are high, which causes bone resorption (calcium is pulled from the bones). Hypercalcemia occurs with hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis and thus polyuria. This diuresis leads to dehydration (weight loss rather than weight gain). Loss of calcium from the bones causes bone pain. Options 2, 4, and 5 are not associated with hyperparathyroidism. Some gastrointestinal symptoms include anorexia, nausea, vomiting, and constipation.

  1. Answer: A

Rationale: In hyperparathyroidism, patients experience excess parathyroid hormone (PTH) secretion. A role of PTH in the body is to maintain serum calcium homeostasis. When PTH levels are high, there is excess bone resorption (calcium is pulled from the bones). In patients with elevated serum calcium levels, there is a risk of nephrolithiasis.

One to 2 liters of fluids daily should be encouraged to protect the kidneys and decrease the risk of nephrolithiasis. Moderate physical activity, particularly weight-bearing activity, minimizes bone resorption and helps to protect against pathological fracture. Walking, as an exercise, should be encouraged in the patient with hyperparathyroidism. Patients should follow a moderate-calcium, high-fiber diet. Even though serum calcium is already high, patients should follow a moderate-calcium diet because a low-calcium diet will surge PTH. Calcium causes constipation, so a diet high in fiber is recommended. Alendronate is a bisphosphate that inhibits bone resorption. In bone resorption, bone is broken down and calcium is deposited into the serum.

  1. Answer: B, D, E

Rationale: Acromegaly results from excess secretion of growth hormone, usually caused by a benign tumor on the anterior pituitary gland. Treatment is the surgical removal of the tumor, usually with a sublingual transsphenoidal complete or partial hypophysectomy. The sublingual transsphenoidal approach is often through an incision in the inner upper lip at the gum line. Transsphenoidal surgery is a type of brain surgery and infection is a primary concern. Leukocytosis, or an elevated white count, may indicate infection. Diabetes insipidus is a possible complication of transsphenoidal hypophysectomy. In diabetes insipidus, there is decreased secretion of antidiuretic hormone and patients excrete large amounts of dilute urine. Following transsphenoidal surgery, the nasal passages are packed and a dripper pad is secured under the nares. Clear drainage on the dripper pad is suggestive of a cerebrospinal fluid leak. The surgeon should be notified and the drainage should be tested for glucose. A cerebrospinal fluid leak increases the postoperative risk of meningitis. Anxiety is a nonspecific finding that is common to many disorders. Chvostek’s sign is a test of nerve hyperexcitability associated with hypocalcemia and is seen as grimacing in response to tapping on the facial nerve. Chvostek’s sign has no association with complications of sublingual transsphenoidal hypophysectomy.

  1. Answer: D.

Rationale: A patient with DI has a deficiency of ADH with excessive loss of water from the kidney, hypovolemia, hypernatremia, and dilute urine with a low specific gravity. When vasopressin is administered, the symptoms are reversed, with water retention, decreased urinary output that increases urine osmolality, and an increase in blood pressure.

  1. Answer: A

Rationale: To prevent strain on the suture line postoperatively, the head must be manually supported while turning and moving in bed, but range-of-motion exercises for the head and neck are also taught preoperatively to be gradually implemented after surgery. There is no contraindication for coughing and deep breathing, and they should be carried out postoperatively. Tingling around the lips or fingers is a sign of hypocalcemia, which may occur if the parathyroid glands are inadvertently removed during surgery, and should be reported immediately.

  1. Answer: C

Rationale:  When a patient has had a subtotal thyroidectomy, thyroid replacement therapy is not given, because exogenous hormone inhibits pituitary production of TSH and delays or prevents the restoration of thyroid tissue regeneration. However, the patient should avoid goitrogens, foods that inhibit thyroid, such as soybeans, turnips, rutabagas, and peanut skins. Regular exercise stimulates the thyroid gland and is encouraged. Saltwater gargles are used for dryness and irritation of the mouth and throat following radioactive iodine therapy.

  1. Answer: A

Rationale:  The effects of glucocorticoid excess include weight gain from accumulation and redistribution of adipose tissue, sodium and water retention, glucose intolerance, protein wasting, loss of bone structure, loss of collagen, and capillary fragility. Clinical manifestations of corticosteroid deficiency include hypotension, dehydration, weight loss, and hyperpigmentation of the skin.

  1. Answer: C

Rationale: Vomiting and diarrhea are early indicators of Addisonian crisis and fever indicate an infection, which is causing additional stress for the patient. Treatment of a crisis requires immediate glucocorticoid replacement, and IV hydrocortisone, fluids, sodium, and glucose are necessary for 24hours. Addison’s disease is a primary insufficiency of the adrenal gland, and ACTH is not effective, nor would vasopressors be effective with the fluid deficiency of Addison’s. Potassium levels are increased in Addison’s disease and KCl would be contraindicated.

  1. Answer: B

Rationale: A pheochromocytoma is a catecholamine-producing tumor of the adrenal medulla, which may cause severe, episodic hypertension; severe, pounding headache; and profuse sweating. Monitoring for dangerously high BP before surgery is critical, as is monitoring for BP fluctuation during the medical and surgical treatment.

  1. Answer: B

Rationale: PTH increases the serum calcium level and decreases the serum phosphate level. PTH doesn’t affect sodium, potassium, or magnesium regulation.

  1. Answer: B

Rationale: If a nurse taps the patient’s facial nerve (which lies under the tissue in front of the ear), the patient’s mouth twitches and the jaw tightens. The response is identified as a positive Chvostek’s sign. The nurse may elicit a positive Trousseau’s sign 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 patient for spasm of the hand (carpopedal spasm), which is evidenced by the hand flexing inward. Deep tendon reflexes include the biceps, brachioradialis, triceps, and patellar reflexes. Tetany would be manifested by reports of numbness and tingling in the fingers or toes or around the lips, a voluntary movement that may be followed by an involuntary, jerking spasm, and muscle cramping. Tonic (continuous contraction) flexion of an arm or a finger may occur.

  1. Answer: C

Rationale: Patients with Addison’s disease and their family members should know how to administer I.M. hydrocortisone during periods of stress. Although it’s important for the patient to keep well hydrated during stress, the critical component in this situation is to know how and when to use I.M. hydrocortisone. Capillary blood glucose monitoring isn’t indicated in this situation because the patient doesn’t have diabetes mellitus. Hydrocortisone replacement doesn’t cause insulin resistance.

  1. Answer: C

Rationale: FSH stimulates the growth and secretion of ovarian follicles in women and the production of sperm in men. LH is not responsible for stimulating the growth and secretion of ovarian follicles in women and the production of sperm in men. In women, LH stimulates ovulation and the formulation of the corpus luteum. In men, LH is called ICSH and it influences the secretion of testosterone and other sex hormones from specialized areas in the testes. Melanocyte-stimulating hormone influences skin pigmentation and is not responsible for stimulating the growth and secretion of ovarian follicles in women and the production of sperm in men.

  1. Answer: C

Rationale: Hyperparathyroidism can cause hypercalcemia. Signs of hypercalcemia include polyuria, constipation, nausea and vomiting, lethargy, and muscle weakness.

  1. Answer: B

Rationale: DDAVP is used to treat diabetes insipidus by replacing the antidiuretic hormone that the patient is lacking. DDAVP can cause nasal irritation, headache, nausea, and other signs of hyponatremia.

  1. Answer: C

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

  1. Answer: C

Rationale: A urine study for free cortisol requires a 24-hour urine collection. The patient should be instructed to avoid stressful situations and excessive physical exercise that could unduly increase cortisol levels. The patient should also maintain a low-sodium diet before and during the urine collection period.

  1. Answer: A

Rationale: Macrovascular complications of diabetes include changes to large- and medium-sized blood vessels. They include cerebrovascular, cardiovascular, and peripheral vascular disease. Increased triglyceride levels are associated with these macrovascular changes. For this reason, the patient should limit the amount of fat in the diet.

  1. Answer: C

Rationale: Corticosteroids (glucocorticoids) should be administered before 9 a.m. Administration at this time helps to minimize adrenal insufficiency and mimics the burst of glucocorticoids released naturally by the adrenal glands each morning. Options 1, 2, and 4 are incorrect.

  1. Answer: B

Rationale: A typical sign of thyrotoxicosis is irritability caused by the high levels of circulating thyroid hormones in the body. This symptom decreases as the patient responds to therapy. Thyrotoxicosis does not cause confusion. The patient may be worried about her illness, and stress may influence her mood; however, irritability is a common symptom of thyrotoxicosis and the patient should be informed of that fact rather than blamed.

  1. Answer: D

Rationale: Sodium iodide 131I destroys the thyroid follicular cells, and thyroid hormones are no longer produced. RAI is commonly recommended for patients with Graves’ disease, especially the elderly. The treatment results in a “medical thyroidectomy.” RAI is given in lieu of surgery, not before surgery. RAI does not reduce uptake of thyroxine. The outcome of giving RAI is the destruction of the thyroid follicular cells. It is possible to slow the production of thyroid hormones with RAI.

  1. Answer: A

Rationale: A major focus of nursing care after transsphenoidal hypophysectomy is the prevention of and monitoring for a CSF leak. CSF leakage can occur if the patch or incision is disrupted. The nurse should monitor for signs of infection, including elevated temperature, increased white blood cell count, rhinorrhea, nuchal rigidity, and persistent headache. Hypoglycemia and adrenocortical insufficiency may occur. Monitoring for fluctuating blood glucose levels is not related specifically to transsphenoidal hypophysectomy. The patient will be given I.V. fluids postoperatively to supply carbohydrates. Cushing’s disease results from adrenocortical excess, not insufficiency. Monitoring for cardiac arrythmias is important, but arrythmias are not anticipated following a transsphenoidal hypophysectomy.

  1. Answer: A

Rationale: Each liter of 5% dextrose in a normal saline solution contains 170 calories. The nurse should consult with the physician and dietitian when a patient is on I.V. therapy or is on nothing-by-mouth status for an extended period because further electrolyte supplementation or alimentation therapy may be needed.

  1. Answer: C

Rationale: Electrolyte imbalances associated with Addison’s disease include hypoglycemia, hyponatremia, and hyperkalemia. Salted bouillon and fruit juices provide glucose and sodium to replenish these deficits. Diet soda does not contain sugar. Water could cause further sodium dilution. Coffee’s diuretic effect would aggravate the fluid deficit. Milk contains potassium and sodium.

  1. Answer: C

Rationale: Cushing’s disease is commonly caused by the loss of the diurnal cortisol secretion pattern. The patient’s random morning cortisol level may be within normal limits, but secretion continues at that level throughout the entire day. Cortisol levels should normally decrease after the morning peak. Analysis of a 24-hour urine specimen is often useful in identifying the cumulative excess. Patients will not have symptoms with normal cortisol levels. Hormones are present in the blood.

  1. Answer: B

Rationale: A primary dietary intervention is to restrict sodium, thereby reducing fluid retention. Increased protein catabolism results in loss of muscle mass and necessitates supplemental protein intake. The patient may be asked to restrict total calories to reduce weight. The patient should be encouraged to eat potassium-rich foods because serum levels are typically depleted. Although reducing fat intake as part of an overall plan to restrict calories is appropriate, a fat intake of less than 20% of total calories is not recommended.

  1. Answer: B

Rationale: As the body readjusts to normal cortisol levels, mood and physical changes will gradually return to a normal state. The body changes are not permanent, and the mood swings should level off.

  1. Answer: C

Rationale: Testosterone is an androgen hormone that is responsible for protein metabolism as well as maintenance of secondary sexual characteristics; therefore, it is needed by both males and females. Removal of both adrenal glands necessitates the replacement of glucocorticoids and androgens. Testosterone does not balance the reproductive cycle, stabilize mood swings or restore sodium and potassium balance.

  1. Answer: D

Rationale: Postoperative management is directed at maintaining normal blood pressure because the patient may be hypertensive immediately after surgery. The nurse must monitor blood pressure frequently and report abnormalities. Patients in hypertensive crisis should be in an intensive care unit for cardiac, blood pressure, and neurologic monitoring. Orthostatic hypotension may be a concern for patients on prolonged bed rest or with fluid deficits. Although hemorrhage may accompany surgery, it is unlikely with this surgery. Elevated blood glucose concentrations, not hypoglycemia, occur with pheochromocytoma.

  1. Answer: B

Rationale: Bending, lifting, and the Valsalva maneuver can precipitate hypertensive crises or paroxysms. These activities increase transabdominal pressure and may cause cardiac-stimulating effects. The blood pressure is very labile with these activities, and paroxysms may be accompanied by tachycardia, palpitations, angina, or electrocardiographic changes. Jogging, anxiety, and hypoglycemia are not triggers for hypertensive crises or paroxysms.

  1. Answer: B

Rationale: Proper and careful first-aid treatment is important when a patient with diabetes has a skin cut or laceration. The skin should be kept supple and as free of organisms as possible. Washing and bandaging the cut will accomplish this. Washing wounds with alcohol is too caustic and drying to the skin. Having the children help is an unrealistic suggestion and does not educate the patient about proper care of wounds. Tight control of blood glucose levels through adherence to the medication regimen is vitally important; however, it does not mean that careful attention to cuts can be ignored.

  1. Answer: D

Rationale: Diabetes mellitus is a multifactorial, systemic disease associated with problems in the metabolism of all food types. The patient’s diet should contain appropriate amounts of all three nutrients, plus adequate minerals and vitamins.

References

  1. Billings, D. (2019). Lippincott Q&A Review for NCLEX-RN. LWW.
  2. Brunner, L., Suddarth, D., & Squazzo, K. (2018). Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing. Wolters Kluwer.
  3. Craven, R. (2019). Fundamentals of Nursing. Wolters Kluwer.
  4. Irwin, B., & Burckhardt, J. (2018). NCLEX-RN Prep 2018. Kaplan Publishers.
  5. Lightsey, R., & Santopoalo, R. (2019). NCLEX-RN Practice Test Questions 2019 & 2020.
  6. Silvestri, L. (2019). Saunders Comprehensive Review for the NCLEX-RN EXAMINATION. Saunders.
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Nhiña Sandeep de Rosas, MAN, DIH, DSHRM, RN currently works for the Department of Health CHD Mimaropa as a Training Specialist. She is also a Nurse Licensure Exam and NCLEX-RN reviewer on her free time. She has her USRN licenses in New York and Vermont, having passed the NCLEX-RN in 2007.Since 2006, she has been a nurse educator and worked as a clinical instructor and classroom lecturer for Unciano Colleges (College of Nursing) in Antipolo City. She has earned her Master’s Degree in Nursing and Diploma in International Health at the University of the Philippines Open University; and her Diploma in Strategic Human Resource Management at the Ateneo de Manila University.

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