Concepts of Care for Pituitary & Adrenal Disorders
HPE1005 - Mental Health Issues
University of Cincinnati
Ignatavicius: Medical-Surgical Nursing, 10th Edition
Chapter 57: Concepts of Care for Patients With Pituitary and Adrenal Gland Problems
Answer Key – NCLEX Examination Challenges, Clinical Judgment Challenges, and Mastery
Questions
Answer Key – NCLEX Examination Challenges
NCLEX Examination Challenge 57-1 Physiological Integrity
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
57-1 A 30-year-old male client having an annual health physical reports that all of the following
changes have developed during the past year. Which ones alert the nurse to possible pituitary
hyperfunction? Select all that apply.
A. 15 lb weight gain
B. Decreased libido
C. Four sinus infections
D. Frequent constipation
E. Increased foot callus formation
F. Occasional dripping of clear fluid from both breasts
G. Severely sprained ankle from a volley ball injury Answers: A, B, F Rationale:
Several hormones secreted in excess can cause weight gain, although so can increased caloric
intake and decreased energy output. However in this instance it is occurring along with other
indicators of pituitary hyperfunction.
Decreased libido is associated with increased prolactin production, as well as decreased
gonadotropins.
Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin.
Increased sinus infections are not associated with changing pituitary hormone levels.
Constipation could be associated with decreased thyroid stimulating hormone but not pituitary
hyperfunction.
Callus formation and a sprained ankle are physical responses not related to endocrine function.
Cognitive Level: Applying or Higher
Client Needs Category: Physiological Integrity
Nursing Process Step: Assessment
NCLEX Examination Challenge Safe and Effective Care Environment
57-2. Which urine characteristics indicate to the nurse that the client being managed for
diabetes insipidus is responding appropriately to interventions?
A. Urine output volume increased; urine specific gravity increased
B. Urine output volume increased; urine specific gravity decreased
C. Urine output volume decreased; urine specific gravity increased
D. Urine output volume decreased; urine specific gravity decreased Answer: C
Rationale:
Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a
result, water is excessively excreted, causing a decrease in blood volume and an increase in
urine volume. Blood is concentration indicating dehydration and urine is very dilute, as
measured by specific gravity, is very low. When interventions to counter act DI are effective,
the adult increases water reabsorption so that urine output volume decreases at the same time
that urine concentration increases, seen as an increased urine specific gravity.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge Safe and Effective Care Environment
57-3. Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal
insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively
to this drug therapy?
A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L)
B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L)
C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L)
D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)
Answer: B
Rationale:
With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium
levels below normal (hyponatremia) and increase serum potassium levels above normal
(hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these
electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-
5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C
indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and
hyperkalemia.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
NCLEX Examination Challenge
Safe and Effective Care Environment
57-4. A nurse caring for a client with Cushing’s syndrome who must remain on continued
corticosteroid therapy for another health problem will use which of the following actions to
prevent harm?
A. Urging the client to salt his or her food.
B. Testing voided urine for the present of glucose.
C. Using non-adhesive methods to secure an IV access.
D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach. Answer:
C
Rationale:
The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured.
The client also is a increased risk for infection and an open skin site increases that risk. Using
nonadhesive methods to secure an IV access protects the skin from injury. Usually the client
on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine
testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach
lining and can cause GI bleeding for many reasons. They are recommended to be taken with
food to prevent GI irritation.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Evaluation
Answer Key – Clinical Judgement Challenge 57-1
The client is a 64-year-old man who was brought to the emergency department by his wife who
claims he is “just not acting right.” When asked to elaborate, the wife explains that over the
past 4 days the client has become quieter, mumbles that his head and stomach hurt, and now
does not recognize the neighbor who has been coming over daily for a short visit. The wife
further explains that her husband is a nuclear physicist.
On Assessment, the nurse finds the client somewhat responsive to his name, although he does
not talk, but is unable to lift his arm for a blood pressure measurement. His pulse is difficult to
palpate and is both irregular and slow. Blood pressure is 92/50. He has no obvious facial
drooping but appears too confused to stick out his tongue when asked or try to shrug his
shoulders. Pulse oximetry is 94% with a respiratory rate of 14. When the nurse asks about his
medication use, the wife reports that he is very healthy and only takes aspirin 81 mg every day.
Then she remembers that until 10 days ago, he was taking dexamethasone 10 mg twice daily
for about 4 weeks for his back pain. He stopped taking the drug and went back to work on
Monday (today is Sunday) because he was pain free.
1. What assessment information in this client situation is the most important and
immediate concern for the nurse? (Hint: Identify the relevant information first to determine
what is most important.)
Of most immediate concern is the change in cognition and the reduced cardiac function. It is
also concerning that he apparently stopped taking his prescribed dexamethasone abruptly.
2. What client conditions are consistent with the most relevant information? (Hint: Think
about priority collaborative problems that support and contradict the information presented in
this situation.)
It is possible that he is having or had a neurologic episode, such as a stroke, that could have
reduced his cognition over a short time period. He also could be having a problem related to
inadequate cortisol response as a result of abruptly stopping at rather high dose of
corticosteroids that had been taken daily for about 4 weeks.
3. Which possibilities or explanations are most likely to be present in this client situation?
Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and
determine their urgency and risk for this client.)
The most likely problem for this client is acute adrenal insufficiency from stopping the
dexamethasone therapy without taping the drug down over a week or longer. This level of
corticosteroid therapy could have led to adrenal suppression. Inadequate cortisol is a life-
threatening condition. Along with decreased cognition and reduced cardiac function, the
problem is associated with hypoglycemia and hyponatremia. If his blood pressure continues to
drop and perfusion is inadequate, death could result. The hypoglycemia could lead to shock.
4. What activities would most likely achieve the desired outcomes for this client? Which
actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes
first to decide which interventions are appropriate and those that should be avoided.)
The client needs to have the exact problem identified quickly. Blood levels of cortisol, sodium,
and glucose should be drawn immediately. Oxygen should be applied to improve gas exchange
(in the brain and everywhere else). Waiting and just observing the client could be very harmful.
5. Which actions are the most appropriate and how should they be implemented? In what
priority order should they be implemented? (Hint: Consider health teaching, documentation,
requested health care provider orders or prescriptions, nursing skills, collaboration with or
referral to health team members, etc.)
Performing a finger stick blood glucose level would identify whether hypoglycemia is present.
If present, providing oral glucose replacement while the client can still swallow would be of
benefit. If the client cannot safely swallow, IV replacement is needed.
The hypotension indicates the need for fluids. The nurse would request a prescription for IV
fluids (with glucose and saline). If the client’s cortisol levels are low, replacement with IV
cortisol should be done as soon as possible.
6. What client assessment would indicate the nurse’s actions were effective? (Hint: Think
aboutsigns that would indicate an improvement, decline, or unchanged patient condition.)
The first indicators of effective treatment are in increasing blood glucose level and an increased
blood pressure and heart rate. These should be evident within 15 minutes of initiating proper
therapy.
Improvement in cognition may be discernable in several hours.
Answer Key – Mastery Questions 57-1
57-1. Which precaution is most important for the nurse to teach a female client to prevent harm
while undergoing drug therapy with estrogen and progesterone for hypopituitarism?
A. “Use a barrier method of contraception to prevent an unplanned pregnancy.”
B. “Wear a hat with a brim and use sunscreen when outdoors.”
C. “Do not smoke or use nicotine in any form.”
D. “Avoid drinking caffeinated beverages.” Answer: C
Rationale:
Both estrogen therapy and progesterone therapy increase the risk for thromboembolism
formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary
embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is
unlikely to occur without further medical intervention. These hormones do not increase
photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no
recommendations for avoiding caffeine while taking these drugs.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-2
57-2. Which assessment has the highest priority for the nurse to perform for a client with
syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24
hours?
A. Evaluating serum sodium levels
B. Evaluating serum potassium levels
C. Examining the skin and sclera for jaundice
D. Examining the IV site for indications of phlebitis
Answer: A
Rationale:
Tolvaptan carries a black box warning of increased risk for developing hypernatremia within
12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not
directly affected by this drug. Although the drug is associated with an increased risk for
jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral
one.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Care Environment
Nursing Process Step: Assessment
Answer Key – Mastery Questions 57-3
57-3. Which of the following are the priority precautions the nurse will teach the client who
remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy
to prevent harm related to the disorder? Select all that apply.
A. Avoid crowds and people who are ill
B. Check your heart rate for irregular or skipped beats twice daily
C. Do not choose low sodium versions of prepared foods
D. Get up slowly from sitting or lying positions
E. Keep a source of glucose, such as candy, with you at all times
F. Never skip your hormone replacement drugs Answers: A, B, C, D, E, F
Rationale:
All precautions are a priority. The hormone replacement therapy reduces inflammation and
Immunity, increasing the risk for infection.
A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum
potassium levels that cause cardiac dysrhythmias.
Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate
intake of this mineral.
The disorder is associated with hypotension and postural hypotension.
Another common problem is hypoglycemia. The client should always have a concentrated oral
glucose source on hand and eat it whenever symptoms of hypoglycemia are present.
Skipping hormone replacement therapy increases the likelihood that serious and potentially
lifethreatening complications can occur quickly. Blood hormone levels need to be relatively
constant.
Cognitive Level: Applying or higher
Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
Answer Key – Mastery Questions 57-4
57-4. A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland
asks the nurse whether the physical changes from the excessive cortisol will go away as a result
of the surgery so she can look like herself again. What is the nurse’s best response?
A. “The surgery is to remove the tumor, not reconstructive surgery.”
B. “You will notice a great difference in your appearance starting within a week after
surgery.”
C. “All the changes will resolve but may take a year or longer to completely disappear.”
D. “The fatty changes and and acne will resolve with time but the stretch marks only fade.”
Answer: D Rationale:
The good news is that the changes that are not related to tissue structure, such as the moon face,
buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a
year or longer to do so. Her muscles can become stronger and larger again as well. However,
the stretch marks will only fade and become less noticeable. Although she did not ask about
bone changes and osteoporosis, this may never completely resolve.
Cognitive Level: Applying or higher
Client Needs Category: Psychosocial Integrity
Nursing Process Step: Implementation
