Test Bank Medical Surgical Nursing 9th Edition Ignatavicius Workman
Chapter 61: Assessment of
the Endocrine System
MULTIPLE CHOICE
1. A nurse cares for a client who is prescribed a drug that blocks a hormones receptor
site. Which therapeutic effect should the nurse expect?
a.Greater hormone metabolism
b.Decreased hormone activity
c.Increased hormone activity
d.Unchanged hormone response
ANS: B
Hormones cause activity in the target tissues by binding with their specific cellular receptor sites, thereby changing the activity of the cell. When receptor sites are occupied by other substances that block hormone binding, the cells response is the same as when the level of the hormone is decreased.
DIF: Understanding/Comprehension REF: 1234
KEY: Endocrine system| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
2. A nurse cares for a client with a deficiency of aldosterone. Which assessment finding should the nurse correlate with this deficiency?
a.Increased urine output
b.Vasoconstriction
c.Blood glucose of 98 mg/dL
d.Serum sodium of 144 mEq/L
ANS: A
Aldosterone, the major mineralocorticoid, maintains extracellular fluid volume. It promotes sodium and water reabsorption and potassium excretion in the kidney tubules. A client with an aldosterone deficiency will have increased urine output. Vasoconstriction is not related. These sodium and glucose levels are normal; in aldosterone deficiency, the client would have hyponatremia and hyperkalemia.
DIF: Applying/Application REF: 1237
KEY: Endocrine system| assessment/diagnostic examination MSC: Integrated Test Bank Medical Surgical Nursing 9th Edition Ignatavicius Workman
Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse cares for a client with excessive production of thyrocalcitonin (calcitonin).
For which electrolyte imbalance should the nurse assess?
a.Potassium
b.Sodium
c.Calcium
d.Magnesium
ANS: C
Parafollicular cells produce thyrocalcitonin (calcitonin), which regulates serum calcium levels. Calcitonin has no impact on potassium, sodium, or magnesium balances.
DIF: Applying/Application REF: 1238
KEY: Endocrine system| assessment/diagnostic examination| electrolyte imbalance MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. A nurse assesses a client who is prescribed a medication that stimulates beta1 receptors. Which assessment finding should alert the nurse to urgently contact the
health care provider?
a.Heart rate of 50 beats/min
b.Respiratory rate of 18 breaths/min
c.Oxygenation saturation of 92%
d.Blood pressure of 144/69 mm Hg
ANS: A
Stimulation of beta1 receptor sites in the heart has positive chronotropic and inotropic actions. The nurse expects an increase in heart rate and increased cardiac output. The client with a heart rate of 50 beats/min would be cause for concern because this would indicate that the client was not responding to the medication. The other vital signs are within normal limits and do not indicate a negative response to the medication.
DIF: Applying/Application REF: 1238
KEY: Endocrine system| medications| adverse effects MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
5. A nurse prepares to palpate a clients thyroid gland. Which action should the nurse take when performing this assessment?
a.Stand in front of the client instead of behind the client.
Chapter 61: Assessment of
the Endocrine System
MULTIPLE CHOICE
1. A nurse cares for a client who is prescribed a drug that blocks a hormones receptor
site. Which therapeutic effect should the nurse expect?
a.Greater hormone metabolism
b.Decreased hormone activity
c.Increased hormone activity
d.Unchanged hormone response
ANS: B
Hormones cause activity in the target tissues by binding with their specific cellular receptor sites, thereby changing the activity of the cell. When receptor sites are occupied by other substances that block hormone binding, the cells response is the same as when the level of the hormone is decreased.
DIF: Understanding/Comprehension REF: 1234
KEY: Endocrine system| assessment/diagnostic examination MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
2. A nurse cares for a client with a deficiency of aldosterone. Which assessment finding should the nurse correlate with this deficiency?
a.Increased urine output
b.Vasoconstriction
c.Blood glucose of 98 mg/dL
d.Serum sodium of 144 mEq/L
ANS: A
Aldosterone, the major mineralocorticoid, maintains extracellular fluid volume. It promotes sodium and water reabsorption and potassium excretion in the kidney tubules. A client with an aldosterone deficiency will have increased urine output. Vasoconstriction is not related. These sodium and glucose levels are normal; in aldosterone deficiency, the client would have hyponatremia and hyperkalemia.
DIF: Applying/Application REF: 1237
KEY: Endocrine system| assessment/diagnostic examination MSC: Integrated Test Bank Medical Surgical Nursing 9th Edition Ignatavicius Workman
Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse cares for a client with excessive production of thyrocalcitonin (calcitonin).
For which electrolyte imbalance should the nurse assess?
a.Potassium
b.Sodium
c.Calcium
d.Magnesium
ANS: C
Parafollicular cells produce thyrocalcitonin (calcitonin), which regulates serum calcium levels. Calcitonin has no impact on potassium, sodium, or magnesium balances.
DIF: Applying/Application REF: 1238
KEY: Endocrine system| assessment/diagnostic examination| electrolyte imbalance MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. A nurse assesses a client who is prescribed a medication that stimulates beta1 receptors. Which assessment finding should alert the nurse to urgently contact the
health care provider?
a.Heart rate of 50 beats/min
b.Respiratory rate of 18 breaths/min
c.Oxygenation saturation of 92%
d.Blood pressure of 144/69 mm Hg
ANS: A
Stimulation of beta1 receptor sites in the heart has positive chronotropic and inotropic actions. The nurse expects an increase in heart rate and increased cardiac output. The client with a heart rate of 50 beats/min would be cause for concern because this would indicate that the client was not responding to the medication. The other vital signs are within normal limits and do not indicate a negative response to the medication.
DIF: Applying/Application REF: 1238
KEY: Endocrine system| medications| adverse effects MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
5. A nurse prepares to palpate a clients thyroid gland. Which action should the nurse take when performing this assessment?
a.Stand in front of the client instead of behind the client.
