Ignatavicius: Medical-Surgical Nursing, 10th Edition
Chapter 56: Assessment of the Endocrine System
Answer Key – NCLEX Examination Challenges, Clinical Judgment Challenges, and
Mastery Questions
Answer Key – NCLEX Examination Challenges
NCLEX Examination Challenges
56-1.
Which action best exemplifies the expected outcome of appropriate negative feedback control over
endocrine gland hormone secretion?
A. Decreased secretion of glucagon when blood glucose approaches normal levels
B. Increased secretion of parathyroid hormone in response to a calcium-containing intravenous
infusion
C. Increased secretion of thyroid stimulating hormone in response to long-term exogenous thyroid
hormone replacement therapy
D. Decreased secretion of cortisol in response to a pituitary tumor stimulating the increased secretion
of adrenocorticotropic hormone
Answer: A
Rationale:
A negative feedback mechanism signals an endocrine gland to secrete a hormone in response to a body
change to cause a reaction that will result in actions to oppose the action of the initial condition change
and restore homeostasis. Serum calcium levels determine when and to what degree parathyroid hormone
PTH is released. PTH secretion decreases when serum calcium levels are high, and it increases when serum
calcium levels are low. If thyroid hormone levels are high, as would be the case if a client was taking
exogenous thyroid hormone replacement therapy, release of both thyrotropin-releasing hormone (TRH)
and thyroid stimulating hormone TSH is inhibited. Adrenocorticotropic hormone (ACTH) triggers the
release of cortisol from the adrenal cortex, not suppression of its release.
Cognitive Level: Understanding
Client Needs Category: Physiological Integrity
Nursing Process Step: N/A
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56-2.
Which assessment finding in a 40-year-old client is most relevant for the nurse to assess further
for a possible endocrine problem?
A. He has lost 10 lbs in the past month following a low carbohydrate eating plan.
B. The client reports now only needed to shave once weekly instead of daily.
C. His new prescription for eye glasses is for a higher strength.
D. The client’s father died of a stroke at age 70 years.
Answer: B
Rationale:
A change in degree of facial hair is could indicate an endocrine problem, particularly of the pathway for
testicular function. An intentional weight loss of 10 lb over a month’s time is within the normal range for
gender and age. Although the need for a stronger prescription for eye glasses at this age could potentially
be related to an endocrine problem, many other factors are more likely to be related to this problem. The
same is true of his father’s stroke.
Cognitive Level: Applying or Higher
Client Needs Category: Safe and Effective Health Care Environment
Nursing Process Step: Assessment
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Answer Key – Clinical Judgement Challenge 56-1
Patient-Centered Care; Safety
A 27-year-old graduate student comes to student health services with reports of feeling tired all the time
and having difficulty concentrating. She has gained 30 lb (13.6 kg) in the past 10 weeks without a change
in eating habits and states that she is having a hard time focusing on both her class work and laboratory
work. She further states that in the past 2 weeks she has fallen asleep in class several times despite sleeping
8 to 10 hours at night.
Vital signs:
•
T = 97.0 (36.1)
•
P = 58 bpm
•
BP = 88/40
•
R = 14
When the nurse asks whether any other changes have been noticed, she replies that she has not had a period
in 3 months and before that they had been regular. The nurse notes that the client is wearing a heavy sweater
even though the day is warm.
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.)
The most important information is that the client’s heart rate, blood pressure, respiratory rate, and blood
pressure are low or low normal, especially in view of the fact that she is 30 pounds over her usual weight.
She may not have adequate gas exchange or perfusion and need exogenous oxygen.
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.)
Her symptoms, of weight gain, tiredness, and absence of menses could indicate a possible pregnancy,
although the low body temperature and cold intolerance are not usually associated with any stage of
pregnancy. She may also have a cardiac problem that is causing the low blood pressure and heart rate,
although the low respiratory rate is not consistent with that as a health problem. The most likely health
problem is an endocrine problem, especially thyroid function, as this endocrine gland regulates many of
the body systems and areas that appear affected, including slowing of cognition.
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Answer Key – Mastery Questions
56-1. Which statement regarding trophic (tropic) hormones is true?
A. All are categorized as catecholamines.
B. Responses are independent of target tissue receptors.
C. Their target tissues are always another endocrine gland.
D. They represent the final hormone secreted in a complex negative feedback pathway.
Answer: C
Rationale:
Trophic (tropic) hormones stimulate the secretion of other hormones from another endocrine gland. Just
like any other hormone, a receptor is required for action (receptor can be on the receptor or somewhere
else inside the responsive target tissue. Only epinephrine, norepinephrine, and dopamine are
catecholamines. None of them are trophic hormones. Trophic hormones represent the initiating hormone
or an intermediate hormone in a more complex negative feedback pathway, not the final hormone.
Cognitive Level: Understanding
Client Needs Category: Physiological Integrity
Nursing Process Step: N/A
56-2.
Which instruction/precaution does the nurse teach a client to prevent harm during a 24-hour urine
specimen collection?
A. Be sure to keep the specimen cool for the entire collection period.
B. Avoid splashing urine in the container when a preservative is present.
C. Add the preservative to the collection container before adding any urine.
D. Discard the first specimen that marks the beginning of the 24-hour test period.
Answer: B
Rationale:
All instructions/precautions are needed for correct collection of a 24-hour urine collection. The only
precaution that will prevent harm is the one for avoiding the splashing of any urine in the container with
the preservative.
Cognitive Level: Applying or Higher
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Client Needs Category: Health Promotion and Maintenance
Nursing Process Step: Implementation
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