Nokea
A nurse assesses a client who is recovering from a transsphenoidal hypophysectomy. The nurse notes nuchal rigidity. Which action should the nurse take first?
- A. I will no longer need to limit my fluid intake after surgery
- B. Document the finding and monitor the client
- C. Take vital signs, including temperature
- D. I will wear slip-on shoes after surgery to limit bending over
Correct Answer: C
Rationale: Nuchal rigidity may indicate a complication such as meningitis or cerebrospinal fluid leak following transsphenoidal hypophysectomy. Taking vital signs, including temperature, is the priority to assess for signs of infection or other systemic issues that require immediate intervention.
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How should the nurse interpret these results?
- A. Pituitary Hyperfunction
- B. Pituitary hypofunction
- C. Pituitary-induced diabetes mellitus
- D. Normal pituitary response to insulin
Correct Answer: D
Rationale: Some tests for pituitary function involve administering agents that are known to stimulate the secretion of specific pituitary hormones and then measuring the response. Such tests are termed stimulation tests. The stimulation test for GH or ACTH assessment involves injecting the client with regular insulin (0.05 to 1 unit/kg of body weight) and checking circulating levels of GH and ACTH. A normal response indicates adequate pituitary function.
A nurse is caring for a client who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The client's symptoms have now resolved and the client asks, 'When can I stop taking these medications?' How should the nurse respond?
- A. It is possible for the inflammation to recur if you stop the medication
- B. Once you start corticosteroids, you have to be weaned off them
- C. You have to decrease the dose slowly so your hormones will work again
- D. The drug suppresses your immune system, which must be built back up
Correct Answer: B
Rationale: One of the most common causes of adrenal insufficiency, a life-threatening problem, is the sudden cessation of long-term, high-dose corticosteroid therapy. This therapy suppresses the hypothalamic-pituitary-adrenal axis and must be withdrawn gradually to allow for pituitary production of adrenocorticotropic hormone and adrenal production of cortisol.
A nurse cares for a client who is recovering from a hypophysectomy. Which action should the nurse take?
- A. I must wash the incision with peroxide and redress it daily
- B. I shall cough and deep breathe every 2 hours while I am awake
- C. Avoid activities that increase intracranial pressure
- D. Apply petroleum jelly to lips to avoid dryness
Correct Answer: C
Rationale: After this surgery, the client must take care to avoid activities that can increase intracranial pressure. The client should avoid bending from the waist, bearing down, coughing, or lying flat. With this approach, there is no incision to clean and dress. Protection from sun exposure is not necessary after this procedure.
A nurse cares for a client with a growth hormone deficiency. Which action should the nurse include in this client's plan of care?
- A. Avoid intramuscular medication
- B. Place the client in protective isolation
- C. Use a lift sheet to re-position the client
- D. Monitor growth hormone levels regularly
Correct Answer: C
Rationale: Clients with growth hormone deficiency may have weakened bones due to reduced bone density. Using a lift sheet to reposition the client minimizes the risk of fractures or injury during movement, which is a priority in care planning.
A nurse assesses clients for potential endocrine dysfunction. Which client is at greatest risk for a deficiency of testosterone and growth hormone.
- A. A 36-year-old female who has used oral contraceptives for 5 years
- B. A 42-year-old male who experienced head trauma 3 years ago
- C. A 35-year-old female with hormone delivery to mellitus and iodine
- D. A 64-year-old male with adult-onset diabetes mellitus
Correct Answer: B
Rationale: Gonadotropin and growth hormone are anterior pituitary hormones. Head trauma is a common cause of anterior pituitary hypofunction. The other factors do not increase the risk of this condition.