NUR 213 Final
1. A client is experiencing health problems related to alterations in adrenal medulla function.
On which areas should the nurse focus when assessing this client?
Select all that apply.
A) Heart rate
B) Weight
C) Respiratory rate
D) Skin integrity
E) Blood pressure
Answer
A, B, C, E
Explanation
The adrenal medulla secretes the catecholamines of epinephrine and norepinephrine. These
hormones stimulate the heart, increase metabolism, increase respiration, and constrict blood
vessels. The nurse should focus the assessment on heart rate, weight, respiratory rate, and blood
pressure. Skin integrity is not influenced by these hormones.
2. The nurse is teaching an in-service about metabolic disorders. Which per- son is at the
greatest risk for malnutrition as a result of hypermetabolism?
A) A client with chronic obstructive pulmonary disease
B) A client with osteoporosis
C) A client who is a vegetarian
D) A client who has dysphagia
Answer
A
Explanation
The client with chronic obstructive pulmonary disease often is malnourished because of the
increased caloric need associated with breathing efforts. The client with dysphagia is at risk for
malnutrition because of the inability to eat adequate amounts of foods. Patients with osteoporosis
do not have higher metabolic rates.
There is no connection between hypermetabolism and vegetarianism.
3. The nurse is assessing the vital signs of a client experiencing hypoparathyroidism. While
monitoring the blood pressure, the nurse notes the client's hand begins to spasm. How should
the nurse document this assessment finding?
A) Trousseau sign
, B) Chvostek sign
C) Turner's sign
D) Cullen's sign
Answer
A
Explanation
Trousseau sign is elicited when placing a blood pressure cuff on the arm; when the cuff is
inflated, the client experiences carpal spasms. Chvostek sign is elicited by tapping on the face in
front of the ear and observing for contractions of the muscle. Turner's sign and Cullen's sign are
both associated with retroperitoneal bleeding.
4. While performing an endocrine assessment on a client suspected of having Cushing disease,
the nurse asks the female client if she has experienced recent weight changes. Which endocrine
systems is the nurse assessing? Select all that apply.
A) Gonads
B) Pituitary gland
C) Thyroid gland
D) Adrenal gland
E) Parathyroid gland
Answer
B, C, D
Explanation
In adrenal, thyroid, and pituitary disease, the client's weight changes might provide information
as to the endocrine disorder the client is experiencing. The client might gain weight with an adrenal
disorder such as Cushing disease, or thyroid disease such as hypothyroidism or hyperthyroidism.
The pituitary gland controls ADH, which influences water absorption by the renal tubules. The
parathyroid gland regulates calcium and phosphorous. The gonads influence estrogen and
androgens.
5. The nurse is reviewing the laboratory test results for a client with an en- docrine disorder.
For which tests should the nurse expect to have current values on the medical record?
Select all that apply.
A) Prothrombin time
B) Albumin
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