Thyroid, adrenal, and pituitary questions reward one axis: is the gland doing too much or too little? Work through these 10 practice questions on hypo- and hyperthyroidism, thyroid storm and post-thyroidectomy care, Addison's versus Cushing's, SIADH versus diabetes insipidus, and calcium disorders, each with a full rationale.
Thyroid, Adrenal & Pituitary: Too Much vs Too Little
Endocrine questions reward pattern recognition around a single idea: is the gland doing too much or too little? Hypothyroidism slows the body down (fatigue, cold intolerance, weight gain, bradycardia, constipation, dry skin), and severe untreated disease can progress to myxedema coma. It is treated with lifelong levothyroxine taken on an empty stomach each morning at the same time and never stopped abruptly; too much replacement produces hyperthyroid signs. Hyperthyroidism (often Graves disease) speeds the body up (weight loss, heat intolerance, tachycardia, exophthalmos, goiter, diarrhea, anxiety), and its emergency is thyroid storm (very high fever, extreme tachycardia, hypertension, agitation). After a thyroidectomy, watch three dangers: airway obstruction from laryngeal edema (tracheostomy tray at bedside), hypocalcemia/tetany from parathyroid injury (Chvostek and Trousseau signs, IV calcium gluconate available), and hemorrhage (check behind the neck).
The adrenal cortex gives two mirror-image pictures. Addison disease (too little cortisol and aldosterone) causes hyponatremia, hyperkalemia, hypotension, hypoglycemia, weight loss, salt craving, and bronze hyperpigmentation; addisonian crisis is profound shock treated with IV hydrocortisone and fluids, and steroids are tapered, never stopped, and increased during stress. Cushing syndrome (too much cortisol) is the opposite: moon face, buffalo hump, truncal obesity, thin skin with purple striae, hyperglycemia, hypertension, hypokalemia, and fluid retention.
Two more high-yield pairs: SIADH (too much ADH) retains water, causing dilutional hyponatremia and concentrated urine, treated with fluid restriction; diabetes insipidus (too little ADH) dumps large volumes of dilute urine, causing hypernatremia and dehydration, treated with desmopressin in central DI (nephrogenic DI is managed with thiazides and a low-sodium diet). Remember: SIADH = too much water (restrict); DI = too little water (replace). Finally, hyperparathyroidism raises calcium ("bones, stones, groans, psychiatric moans") while hypoparathyroidism lowers it (tetany, positive Chvostek/Trousseau, seizures).
Thyroid, Adrenal & Pituitary Disorders NCLEX Practice Questions
Question 1 · Hypothyroidism
A nurse is assessing a client who has just been diagnosed with hypothyroidism. Which cluster of findings does the nurse expect to observe?
- A Weight loss, heat intolerance, and frequent loose stools
- B Tachycardia, exophthalmos, and heightened anxiety
- C Cold intolerance, weight gain, bradycardia, and constipation
- D Insomnia, fine hand tremors, and increased appetite
Show answer & rationale
Correct answer: C
Hypothyroidism means the thyroid is underactive, so the body's metabolism slows down. The correct finding cluster of cold intolerance, weight gain, bradycardia, and constipation reflects that generalized slowing, along with fatigue, dry skin, and mental sluggishness; the most severe form is myxedema coma. The cluster of weight loss, heat intolerance, and loose stools describes hyperthyroidism, where an overactive gland accelerates metabolism and gut motility. Tachycardia, exophthalmos, and anxiety are classic for Graves disease (hyperthyroidism), not hypothyroidism, because excess thyroid hormone stimulates the heart and sympathetic nervous system. Insomnia, tremors, and increased appetite likewise point to a hypermetabolic hyperthyroid state rather than the sluggish hypothyroid picture. A useful memory aid: hypO = slOw. Everything runs down and cold with low thyroid hormone, and up and hot with high thyroid hormone. On the exam, always anchor to the direction of the metabolic engine: hypothyroid clients are cold, slow, constipated, and gaining weight, while hyperthyroid clients are hot, fast, loose, and losing weight. Recognizing this single axis lets you sort most thyroid manifestation questions quickly and avoids confusing the two mirror-image disorders.
Question 2 · Levothyroxine teaching
A client is starting levothyroxine (Synthroid) for hypothyroidism. Which instruction should the nurse include in teaching?
- A Take the medication on an empty stomach in the morning at the same time each day
- B Stop taking the medication once your energy and symptoms improve
- C Take the medication with your largest evening meal to reduce stomach upset
- D Plan to take this medication for about three months until the thyroid recovers
Show answer & rationale
Correct answer: A
Levothyroxine replaces the hormone the thyroid can no longer make. Taking it on an empty stomach in the morning at the same time each day maximizes absorption (food, calcium, iron, and antacids reduce it) and maintains steady blood levels; clients are typically taught to wait 30 to 60 minutes before eating. Stopping the drug when symptoms improve is dangerous because hypothyroidism is usually a lifelong condition; abruptly discontinuing therapy allows symptoms to return and can precipitate myxedema coma, so the medication must never be stopped without provider direction. Taking it with the largest evening meal undermines absorption and consistency, since food interferes with uptake and taking the dose with a meal breaks the recommended empty-stomach, same-time routine. Expecting to stop in about three months reflects a misunderstanding: replacement therapy is generally permanent, and the dose is titrated by TSH levels over time rather than discontinued. Clinical pearl: teach clients to watch for signs of over-replacement, which mimic hyperthyroidism (palpitations, tachycardia, weight loss, insomnia, heat intolerance), and to report them so the dose can be lowered. Consistency is everything with levothyroxine: same drug, same time, same empty stomach, every single day, for life.
Question 3 · Post-thyroidectomy care
A nurse is caring for a client immediately after a total thyroidectomy. Which interventions and assessments are nursing priorities? Select all that apply.
- A Encourage the client to talk continuously to exercise the voice
- B Keep a tracheostomy tray at the bedside
- C Assess for Chvostek and Trousseau signs
- D Position the client flat and supine for the first 24 hours
- E Inspect behind the neck and the back of the dressing for bleeding
- F Keep IV calcium gluconate readily available
Show answer & rationale
Correct answer: B, C, E, F
After thyroidectomy, three complications drive nursing care: airway obstruction, hypocalcemia, and hemorrhage. Keeping a tracheostomy tray at the bedside prepares for airway obstruction from laryngeal edema or swelling, which can develop rapidly and is life-threatening. Assessing for Chvostek and Trousseau signs screens for hypocalcemia and tetany, which occur if the parathyroid glands are accidentally injured or removed during surgery, so keeping IV calcium gluconate readily available is also correct because it is the treatment for acute hypocalcemia. Inspecting behind the neck and the back of the dressing detects hemorrhage, since blood pools posteriorly by gravity and an anterior dressing can look dry while bleeding collects behind the neck and compresses the airway. Encouraging continuous talking is wrong; the nurse assesses the voice periodically for hoarseness (laryngeal nerve involvement) but should limit unnecessary talking to reduce strain and swelling. Positioning the client flat and supine is incorrect; the client is placed in semi-Fowler position with the head and neck supported to reduce edema and tension on the suture line. Clinical pearl: at the bedside after thyroidectomy, always have suction, oxygen, a tracheostomy tray, and IV calcium gluconate immediately available, and check for the three dangers of airway, calcium, and bleeding.
Question 4 · Thyroid storm
A client with Graves disease develops a temperature of 104 F (40 C), heart rate of 160/min, blood pressure of 190/110 mm Hg, and severe agitation. The nurse recognizes these findings as which complication?
- A Myxedema coma
- B Addisonian crisis
- C Syndrome of inappropriate antidiuretic hormone (SIADH)
- D Thyroid storm (thyrotoxic crisis)
Show answer & rationale
Correct answer: D
Thyroid storm, also called thyrotoxic crisis, is a life-threatening surge of thyroid hormone effect, classically triggered by stress, infection, or surgery in a hyperthyroid client. The hallmark picture is exactly what this client shows: very high fever, extreme tachycardia, hypertension, and marked agitation or delirium, which can progress to arrhythmias and cardiovascular collapse. Management includes antithyroid drugs (methimazole or propylthiouracil), beta-blockers to control the cardiac and adrenergic symptoms, cooling measures, and supportive care. Myxedema coma is the opposite emergency, seen in severe hypothyroidism, and presents with hypothermia, bradycardia, hypotension, and decreased level of consciousness, not fever and tachycardia. Addisonian crisis results from acute adrenal insufficiency and causes profound hypotension and shock with hyponatremia and hyperkalemia; it is distinguished from thyroid storm by that hypotension (rather than hypertension), and although it may run a fever from a precipitating infection, it lacks the hypermetabolic tachycardic storm seen here. SIADH involves excess antidiuretic hormone leading to water retention and dilutional hyponatremia, which produces neurologic changes from low sodium but not the hypermetabolic fever-and-tachycardia storm seen here. Clinical pearl: think of thyroid storm as hyperthyroidism turned to its maximum, everything is hot and fast. The client is febrile, extremely tachycardic, hypertensive, and agitated. Recognizing it early and giving a beta-blocker plus an antithyroid agent while cooling the client can be lifesaving.
Question 5 · Addison disease
A nurse reviews the assessment findings for a client with Addison disease (primary adrenal insufficiency). Which findings are consistent with this disorder? Select all that apply.
- A Hypertension
- B Hyponatremia
- C Hypokalemia
- D Hyperkalemia
- E Moon face and truncal obesity
- F Bronze hyperpigmentation of the skin
Show answer & rationale
Correct answer: B, D, F
Addison disease is a deficiency of cortisol and aldosterone. Without aldosterone, the body loses sodium and retains potassium, producing hyponatremia and hyperkalemia, both correct. The loss of sodium and water, combined with low cortisol, also causes hypotension, hypoglycemia, weight loss, fatigue, and salt craving. Bronze hyperpigmentation of the skin is a classic and correct finding in primary adrenal insufficiency: low cortisol triggers increased ACTH and melanocyte-stimulating hormone, darkening the skin, especially over creases and scars. Hypertension is incorrect because adrenal insufficiency causes hypotension from sodium and fluid loss. Hypokalemia is incorrect because the absence of aldosterone causes potassium to be retained, giving hyperkalemia instead. Moon face and truncal obesity are incorrect because they belong to Cushing syndrome, the mirror-image disorder of cortisol excess. A helpful contrast: Addison is the low-cortisol picture (low sodium, high potassium, low pressure, low sugar, bronze skin), while Cushing is the high-cortisol picture (high sodium, low potassium, high pressure, high sugar). Clinical pearl: addisonian crisis is an emergency of profound hypotension and shock treated with IV hydrocortisone and fluids, and clients must never stop corticosteroids abruptly; doses are tapered and increased during stress or illness.
Question 6 · Cushing syndrome
A nurse is caring for a client with Cushing syndrome. Which combination of laboratory and clinical findings does the nurse expect?
- A Hyponatremia and hyperkalemia
- B Hyperglycemia, hypertension, and hypokalemia
- C Hypotension with bronze skin pigmentation
- D Weight loss with strong salt craving
Show answer & rationale
Correct answer: B
Cushing syndrome results from excess cortisol, which drives the classic combination of hyperglycemia (cortisol raises blood glucose), hypertension and sodium/fluid retention, and hypokalemia (cortisol has mineralocorticoid effects that waste potassium). Clients with Cushing syndrome also typically show moon face, buffalo hump, truncal obesity, thin skin with purple striae, immunosuppression, and osteoporosis. Hyponatremia and hyperkalemia are incorrect because those electrolyte changes belong to Addison disease (adrenal insufficiency), where low aldosterone causes sodium loss and potassium retention; Cushing is the opposite. Hypotension with bronze skin pigmentation is also an Addison finding, since low cortisol causes fluid loss and increased ACTH-driven skin darkening, not the fluid retention and hypertension of cortisol excess. Weight loss with salt craving again describes Addison disease, where sodium loss triggers craving and low cortisol contributes to weight loss; Cushing instead causes weight gain and central obesity. Clinical pearl: Cushing and Addison are true mirror images, so learning one gives you the other by flipping every value. With too much cortisol (Cushing), think high sugar, high pressure, high sodium, low potassium, and a rounded, thin-skinned, immunosuppressed body. With too little cortisol (Addison), everything flips to low pressure, low sodium, high potassium, and low sugar.
Question 7 · SIADH
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) and has a serum sodium of 118 mEq/L. Which intervention does the nurse anticipate?
- A Administer intravenous desmopressin (DDAVP)
- B Encourage oral fluids up to 3000 mL per day
- C Infuse 0.45% sodium chloride rapidly
- D Restrict the client's fluid intake
Show answer & rationale
Correct answer: D
SIADH means too much antidiuretic hormone, so the kidneys retain water. This dilutes the blood, producing dilutional hyponatremia (here, 118 mEq/L), low serum osmolality, and concentrated urine. Because the core problem is excess water, the primary treatment is to restrict fluid intake, which allows sodium to rise back toward normal; in severe or symptomatic hyponatremia, hypertonic (3%) saline may be added carefully. Administering desmopressin is incorrect and dangerous: DDAVP is synthetic ADH used to treat diabetes insipidus, which is the opposite disorder; giving more ADH to a client who already has too much would worsen water retention and drop sodium further. Encouraging fluids up to 3000 mL per day is the exact wrong move, since adding water deepens the dilutional hyponatremia and raises the risk of cerebral edema and seizures. Infusing 0.45% sodium chloride rapidly is also wrong because half-normal saline is hypotonic and adds free water, further diluting the already low sodium; SIADH calls for removing water, not adding hypotonic fluid. Clinical pearl: SIADH = Soaked Inside (too much water), so restrict fluids; diabetes insipidus = Dry Inside (too little water), so replace fluids and give DDAVP. Matching the treatment to the direction of the water balance prevents fatal errors.
Question 8 · Diabetes insipidus
A client with diabetes insipidus has a urine output of 6 L in 24 hours, very dilute urine, and a serum sodium of 152 mEq/L. Which treatment does the nurse anticipate?
- A Strict fluid restriction
- B Rapid infusion of 3% hypertonic saline
- C Desmopressin (DDAVP)
- D Continuous intravenous insulin infusion
Show answer & rationale
Correct answer: C
Diabetes insipidus results from too little antidiuretic hormone (or kidney resistance to it), so the kidneys cannot concentrate urine. The client dumps large volumes of dilute urine (here, 6 L/day with low specific gravity), which leads to polyuria, polydipsia, hypernatremia (sodium 152 mEq/L), and dehydration. The anticipated treatment is desmopressin (DDAVP), a synthetic ADH that, in central DI (the classic exam scenario), lets the kidneys reabsorb water, reduce urine output, and correct the rising sodium, along with fluid replacement to restore volume. Strict fluid restriction is incorrect and dangerous because this client is losing enormous amounts of water and needs replacement, not restriction; withholding fluids would worsen dehydration and hypernatremia. Rapid infusion of 3% hypertonic saline is wrong because the sodium is already high at 152; adding concentrated sodium would push it dangerously higher, whereas hypertonic saline is instead used for the low sodium of SIADH. A continuous insulin infusion treats diabetic ketoacidosis or severe hyperglycemia, not diabetes insipidus; despite the shared word diabetes, DI is a problem of water balance and ADH, not glucose. Clinical pearl: DI = Dry Inside from too little ADH, so replace water and give DDAVP; SIADH is the flooded opposite treated with fluid restriction. Always check the sodium: high sodium with dilute urine points to DI.
Question 9 · SIADH vs DI
A nurse is teaching a nursing student about the features of syndrome of inappropriate antidiuretic hormone (SIADH). Which statements accurately describe this disorder? Select all that apply.
- A Serum sodium becomes diluted and low (dilutional hyponatremia)
- B The client is at high risk for hypernatremia and severe dehydration
- C There is too much antidiuretic hormone in the body
- D The urine is concentrated with a high specific gravity
- E Fluid restriction is a primary treatment
- F The client excretes large volumes of dilute urine
Show answer & rationale
Correct answer: A, C, D, E
SIADH is defined by too much antidiuretic hormone, which is correct and is the root of every other feature. Excess ADH makes the kidneys hold onto water, so serum sodium becomes diluted and low, giving the dilutional hyponatremia that is correct here and drives the neurologic risks of confusion and seizures. Because the problem is water overload, fluid restriction is a primary treatment, which is correct; hypertonic saline is reserved for severe or symptomatic hyponatremia. With water reabsorbed, the urine is concentrated with a high specific gravity, which is correct and reflects the small volume of dense urine these clients make. The statement that the client excretes large volumes of dilute urine is incorrect because that describes diabetes insipidus, the opposite disorder with too little ADH. The statement about high risk for hypernatremia and severe dehydration is also incorrect for SIADH; those describe DI, where water is lost. In SIADH the client retains water and trends toward hyponatremia and fluid overload. Clinical pearl: pair the two disorders as opposites. SIADH means too much ADH, water retention, low and dilute sodium, concentrated urine, and fluid restriction; DI means too little ADH, water loss, high sodium, dilute urine, and treatment with DDAVP plus fluids.
Question 10 · Parathyroid/calcium
A nurse is planning care for a client with hyperparathyroidism. Which set of findings and priority intervention does the nurse anticipate?
- A Elevated calcium with risk for kidney stones; encourage increased fluid intake
- B Low calcium with muscle tetany; administer intravenous calcium gluconate
- C Positive Chvostek and Trousseau signs; institute seizure precautions
- D Low PTH and low calcium after neck surgery; provide calcium and vitamin D supplements
Show answer & rationale
Correct answer: A
Hyperparathyroidism means excess parathyroid hormone, which pulls calcium out of the bones and into the blood, producing hypercalcemia. The classic picture is remembered as bones (bone pain and fractures), stones (kidney stones), groans (abdominal and GI complaints), and psychiatric moans (fatigue, confusion, depression). Because high calcium promotes stone formation, the priority is to encourage increased fluid intake to dilute the urine and help flush calcium, making elevated calcium with risk for kidney stones and hydration the correct answer. The other three choices all describe hypoparathyroidism, the opposite disorder of low PTH and therefore low calcium. Low calcium with muscle tetany treated by IV calcium gluconate is the emergency management of hypocalcemia, not hyperparathyroidism. Positive Chvostek and Trousseau signs with seizure precautions are hallmark neuromuscular findings of hypocalcemia, since low calcium increases nerve excitability and causes muscle spasm and potential seizures. Low PTH and low calcium after neck surgery, treated with calcium and vitamin D supplements, describes hypoparathyroidism (often from parathyroid injury during thyroidectomy), not hyperparathyroidism. Clinical pearl: high calcium (hyperparathyroidism) makes muscles and nerves sluggish, so watch for stones and keep the client hydrated; low calcium (hypoparathyroidism) makes them hyperexcitable, so watch for tetany, positive Chvostek and Trousseau signs, and seizures, and keep IV calcium gluconate available.
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Thyroid, Adrenal & Pituitary FAQ
What is the easiest way to remember the difference between SIADH and diabetes insipidus?
Tie each disorder to how much antidiuretic hormone (ADH) is present and what happens to water. SIADH means too much ADH, so the body retains water: you see dilutional hyponatremia (low sodium), concentrated urine, and fluid overload, and the treatment is fluid restriction. Diabetes insipidus (DI) means too little ADH, so the body loses water: you see large volumes of dilute urine, hypernatremia (high sodium), and dehydration, and the treatment is fluid replacement plus desmopressin (DDAVP) for central DI (nephrogenic DI is managed with thiazides and a low-sodium diet). A quick phrase: SIADH = Soaked Inside (restrict fluids); DI = Dry Inside (replace fluids). Always check the serum sodium to confirm which direction the water is moving.
How should a client take levothyroxine, and can it ever be stopped?
Levothyroxine is taken once daily on an empty stomach in the morning, at the same time every day, ideally 30 to 60 minutes before food. Food, calcium, iron, and antacids reduce its absorption, so consistency matters. Hypothyroidism is usually lifelong, so the medication is not stopped when symptoms improve; abrupt discontinuation can allow symptoms to return and, in severe cases, trigger myxedema coma. The dose is adjusted based on TSH levels over time. Clients should also report signs of over-replacement, which mimic hyperthyroidism: palpitations, tachycardia, weight loss, insomnia, and heat intolerance.
How do I tell Addison disease and Cushing syndrome apart on the NCLEX?
They are mirror images built around cortisol. Addison disease is too little cortisol (and aldosterone): expect low sodium, high potassium, low blood pressure, low blood sugar, weight loss, salt craving, and bronze skin hyperpigmentation. Cushing syndrome is too much cortisol: expect high blood sugar, high blood pressure, high sodium with fluid retention, low potassium, moon face, buffalo hump, truncal obesity, thin skin with purple striae, and osteoporosis. Learn one and flip every value to get the other. Remember addisonian crisis is a shock emergency treated with IV hydrocortisone and fluids, and steroids are always tapered, never stopped abruptly, and increased during stress or illness.
What complications should the nurse watch for after a thyroidectomy?
Three dangers dominate care. First, airway obstruction from laryngeal edema or swelling, which is why a tracheostomy tray, suction, and oxygen are kept at the bedside. Second, hypocalcemia and tetany caused by accidental injury to the parathyroid glands during surgery; assess for positive Chvostek and Trousseau signs, tingling, and muscle spasms, and keep IV calcium gluconate available. Third, hemorrhage; because blood pools by gravity, check behind the neck and the back of the dressing rather than only the front. Position the client in semi-Fowler with head and neck support, limit unnecessary talking, and monitor the voice for hoarseness that could signal laryngeal nerve involvement.