Chapter 49 Endocrine Problems
The nurse is performing discharge education for a patient who was admitted for acute hypothyroidism. The patient is undergoing thyroid hormone therapy for the first time. What statement by the patient to the nurse confirms that discharge teaching was effective? 1 "I should take my levothyroxine every morning before eating my breakfast." 2 "I should only follow up with my doctor if I start having shortness of breath." 3 "I should keep the air conditioning a few degrees colder to help me with sweating." 4 "I should limit the amount of fiber I am eating to help keep me from getting constipated."
Answer: 1 A patient with a new diagnosis of hypothyroidism should be taught how to manage hypothyroidism, including taking the thyroid hormone in the morning before food. Patients with hypothyroidism need to be taught about the importance of regular follow-up care, not just when they are having abnormal symptoms. Patents with hypothyroidism should be taught to keep the environment warm and comfortable because of cold intolerance. Patients with hypothyroidism should increase the amount of fiber in their diet to prevent constipation; they should not limit the amount of fiber.
A patient who is diagnosed with hypothyroidism and coronary artery disease (CAD) states to the nurse, "I am constipated. My spouse wants me to try an enema to help relieve my discomfort." The nurse educates the patient that using enemas is contraindicated due to the diagnosis. Which is the rationale for this contraindication? 1 Vagus nerve stimulation 2 Olfactory nerve stimulation 3 Abducens nerve stimulation 4 Hypoglossal nerve stimulation
Answer: 1 Constipation is a common problem associated with hypothyroidism. The use of enemas, however, is contraindicated because they result in vagus nerve stimulation for patients with a history of cardiac disease. Olfactory, abducens, and hypoglossal nerves are not affected by the use of enemas.
Activity intolerance in a patient with hypothyroidism is related to what? 1 Fatigue 2 Diarrhea 3 Weight loss 4 Nervousness
Answer: 1 Activity intolerance in a patient with hypothyroidism is related to weakness and fatigue. Patients with hyperthyroidism, not hypothyroidism, experience weight loss, diarrhea, and nervousness.
Which patient statement indicates the need for further education regarding the management of both cardiac disease and hypothyroidism? 1 "I will use an enema for constipation." 2 "I will use a sedative to treat insomnia." 3 "I should take my thyroid medication in the morning before eating." 4 "I should not switch to another brand of hormone unless I check with my health care provider."
Answer: 1 Enemas are contraindicated for patients diagnosed with both cardiac disease and hypothyroidism. Enemas cause vagal stimulation that can lead to fainting. The patient is taught to use laxatives, stool softeners, and to consume a fiber-rich diet to treat constipation, rather than using enemas. Using low-dose sedatives is recommended if the patient is experiencing insomnia. Thyroid medication should be taken in the morning before food. Switching to different brands is not recommended, because bioavailability may differ with different brands.
The nurse assesses a patient that presents with eye protrusion. The patient states, "My eyes are dry and irritated." Based on these data, the nurse expects that what diagnosis will be made? 1 Graves' disease 2 Myxedema coma 3 Diabetes insipidus 4 Pheochromocytoma
Answer: 1 Eye protrusion is referred to as exophthalmos and this indicates Graves' disease. Exophthalmos results from an increase in fat and fluid in the orbital tissues. The increased pressure due to edema forces the eyeballs outwards, and the upper eye lids retract and become elevated. As a result, the corneal surface is exposed, causing eye dryness and irritation. Myxedema coma presents with generalized edema. Diabetes insipidus is characterized by the large amount of urine excretion (2 to 20 L/day). Pheochromocytoma is characterized by tachycardia, dysrhythmia, and metanephrines in urine.
A patient is prescribed levothyroxine. To promote optimal absorption, the nurse should instruct the patient to take the medication at which time? 1 0600 2 1200 3 1600 4 2100
Answer: 1 For maximum absorption, levothyroxine should be taken first thing in the morning on an empty stomach 30 minutes before breakfast. 1200, 1600, and 2100 may not result in adequate absorption.
The nurse is caring for a patient who underwent removal of the thyroid gland (thyroidectomy) three days ago. The patient's serum chemistries reveal calcium of 3.2 mg/dL, potassium of 3.9 mEq/L, and phosphorus of 4.0 mg/dL. What condition do these findings indicate? 1 Hypocalcemia 2 Hypercalcemia 3 Hyperkalemia 4 Hypophosphatemia
Answer: 1 Hypocalcemia is a low serum calcium level. Surgical removal of the thyroid gland may also include removal of the parathyroid gland. This results in a deficiency of parathyroid hormone, which controls serum calcium by regulating absorption of calcium from the gastrointestinal tract, mobilizing calcium in bones, and excreting calcium in breast milk, feces, sweat, and urine. The normal serum calcium level ranges from 9.0 to 11.5 mg/dL. Potassium is within normal limits (3.5 to 5 mEq/L), and phosphorus is also within normal limits (2.8 to 4.5 mg/dL).
A nurse completes an assessment and notes that a patient's thyroid gland is enlarged. With which condition is this finding consistent? 1 Goiter 2 Fibroma 3 Thyrotoxicosis 4 Hyperthyroidism
Answer: 1 Thyroid abnormalities consist of three basic forms: goiter (enlarged thyroid gland), hypothyroidism, and hyperthyroidism. Goiter may be present in hyper- or hypofunction of the gland. A fibroma is a fibrous encapsulated connective tissue tumor not usually occurring in the thyroid gland. Thyrotoxicosis results from extreme hyperthyroidism or increased secretion of T3 and T4. Thyrotoxicosis is also known as thyroid storm or thyroid crisis. Hyperthyroidism is a condition resulting from an increase in production of T3 and T4.
The nurse is caring for a patient undergoing radioactive iodine therapy in the outpatient setting. What instructions should the nurse provide to this patient? Select all that apply. 1 Avoid preparing food for others. 2 Gargle with warm water before meals. 3 Launder personal towels, bed linens, and clothes separately at home. 4 Avoid being close to pregnant women or children for seven days after therapy. 5 Discontinue antithyroid drugs after RAI therapy.
Answer: 1, 3, & 4 The nurse should instruct the patient receiving RAI therapy to avoid preparing food for others; to launder personal towels, bed linens, and clothes separately at home; and to avoid being close to pregnant women or children for 7 days after therapy. These precautions are to limit radiation exposure to others. The patient is asked to use a salt and soda gargle three or four times per day to provide relief from dryness and irritation of the mouth and throat as a result of the therapy. RAI has a delayed response, and the maximum effect may not be seen for up to 3 months; therefore, the patient is usually treated with antithyroid drugs and propranolol before and for 3 months after the initiation of RAI therapy, until the effects of radiation become apparent.
Which clinical manifestations does the nurse expect during the assessment of a hospitalized patient experiencing exophthalmos? Select all that apply. 1 Dyspnea 2 Celiac disease 3 Cardiac hypertrophy 4 Distended abdomen 5 Bounding, rapid pulse
Answer: 1, 3, & 5 Exophthalmos is a classic finding in Graves' disease, which is caused by hyperthyroidism. Clinical manifestations anticipated by the nurse upon assessment include a bounding, rapid pulse; cardiac hypertrophy; and dyspnea. Clinical symptoms such as celiac disease and distended abdomen are associated with hypothyroidism.
A nurse reviewing the recent medical history of a patient with hypoparathyroidism expects to find a history of: 1 Hypertension 2 Thyroidectomy 3 Use of cocaine 4 Hypermagnesemia
Answer: 2 Because of the location of the parathyroid glands within the thyroid gland, a thyroidectomy sometimes results in the accidental surgical removal of one or more of the parathyroid glands, which in turn causes hypoparathyroidism. Hypertension and cocaine use are important items to note in a medical history, but they are not directly related to hypoparathyroidism. Hypomagnesemia, not hypermagnesemia, can lead to suppression of parathyroid hormone secretion.
The nurse is caring for a patient diagnosed with a toxic nodular goiter with painless thyroiditis. The nurse suspects that the patient has an autoimmune disease based on what assessment finding? 1 Enophthalmos 2 Exophthalmos 3 Rounded rosy face 4 Hypopigmentation
Answer: 2 Painless thyroiditis is an early clinical manifestation associated with Hashimoto's thyroiditis. Patients with Hashimoto's thyroiditis are at risk of autoimmune diseases such as Graves' disease, Addison's disease, or pernicious anemia. Exophthalmos is a clinical manifestation associated with Graves' disease. Enophthalmos is a clinical manifestation associated with Horner's syndrome. A rounded rosy face is associated with Cushing syndrome. Hypopigmentation is seen in vitiligo.
Which medication does the nurse expect to be prescribed for a patient diagnosed with metastatic thyroid cancer that has a calcitonin level of 25 pg/mL? 1 Cisplatin 2 Vandetanib 3 Doxorubicin 4 Cyclophosphamide
Answer: 2 Vandetanib is a drug that is used to treat metastatic thyroid cancer. Cisplatin is used to treat solid malignancies such as lung cancer, ovarian cancer, and bladder cancer. Doxorubicin and cyclophosphamide are used to treat follicular thyroid cancer and also are used after excision of tumors.
The patient has a prescription for levothyroxine 37.5 mcg. Available are 0.075 mg tablets. How many tablets should the nurse administer? 1 0.25 tablet 2 0.5 tablet 3 0.75 tablet 4 1 tablet
Answer: 2 First, convert 0.075 mg to mcg, which equals 75 mcg. Using ratio and proportion, multiply 37.5 by x and multiply 75 × 1 to yield 37.5x = 75. Divide 75 by 37.5 to yield 0.5 tablet.
A nurse is caring for a patient admitted for hyperthyroidism. What laboratory results will the nurse expect to see in the electronic chart to confirm hyperthyroidism? Select all that apply. 1 Elevated TSH level 2 Undetectable TSH level 3 Low free thyroxine (free T4) level 4 Elevated free thyroxine (free T4) level 5 Low thyroid-stimulating hormone (TSH) level
Answer: 2, 4, & 5 The primary laboratory findings to confirm the diagnosis of hyperthyroidism are low or undetectable TSH levels and elevated free thyroxine levels. Low free thyroxine levels and elevated TSH levels are found with hypothyroidism.
A patient diagnosed with hyperthyroidism presents with neck nodules that are less than 3 cm in size. Biopsy reveals the nodules are non-malignant. Which treatment does the nurse expect for this patient? 1 Iodine therapy 2 Subtotal thyroidectomy 3 Endoscopic thyroidectomy 4 Radioactive iodine therapy
Answer: 3
What is a nursing priority in the care of a patient with a diagnosis of hypothyroidism? 1 Providing a dark, low-stimulation environment 2 Closely monitoring the patient's intake and output 3 Patient teaching related to levothyroxine 4 Patient teaching related to radioactive iodine therapy
Answer: 3 A euthyroid state most often is achieved in patients with hypothyroidism by the administration of levothyroxine. It is not necessary to carefully monitor intake and output, and low stimulation and radioactive iodine therapy are indicated in the treatment of hyperthyroidism.
The health care provider was unable to spare a patient's parathyroid gland during a thyroidectomy. Which assessments should the nurse prioritize when providing postoperative care for this patient? 1 Assessing the patient's white blood cell levels and assessing for infection 2 Monitoring the patient's hemoglobin, hematocrit, and red blood cell levels 3 Monitoring the patient's serum calcium levels and assessing for signs of hypocalcemia 4 Monitoring the patient's level of consciousness and assessing for acute delirium or agitation
Answer: 3 Loss of the parathyroid gland is associated with hypocalcemia. Infection and anemia are not associated with loss of the parathyroid gland, whereas cognitive changes are less pronounced than the signs and symptoms of hypocalcemia.
A patient diagnosed with hyperthyroidism received radioactive iodine one week ago. The patient tells the nurse, "I don't think the medication is working, I don't feel any different." What is the best response by the nurse?' 1 "You should notify your primary health care provider immediately." 2 "You may need to have your thyroid removed sooner than anticipated." 3 "It may take several weeks to see the full benefits of the treatment." 4 "You don't feel any different? Would you like to sit down and talk about it?"
Answer: 3 Radioactive iodine has a delayed response, and the maximum effect may not be seen for up to three months. For this reason, it would not be necessary to contact the primary health care provider immediately, or for the patient to have the thyroid gland removed sooner. Asking the patient to sit and talk about it demonstrates that the nurse is being responsive to psychosocial/emotional needs, but is not the best nursing response at this time. - can take up to 3 mo
The nurse determines that the patient who is receiving radioactive iodine (RAI) therapy for the treatment of hyperthyroidism needs additional instructions when the patient makes which statement? 1 "I will need to flush the toilet twice after I use it." 2 "I should launder my laundry separately from those in my household." 3 "I will need to take anti-thyroid drugs for 6 to 9 months after I begin RAI therapy." 4 "If I develop a dry mouth I may gargle with a salt and soda mixture for relief."
Answer: 3 The maximum effect of RAI therapy may not occur for up to 3 months, and therefore the patient usually continues to be treated with anti-thyroid drugs for 3 months, not 6 to 9 months, after the initiation of radioactive iodine therapy. Flushing the toilet twice and laundering clothes separately will help to limit radiation exposure to household members. Radiation parotiditis may cause dryness and irritation of the mouth, and a salt and soda gargle may provide relief.The maximum effect of RAI therapy may not occur for up to 3 months, and therefore the patient usually continues to be treated with anti-thyroid drugs for 3 months, not 6 to 9 months, after the initiation of radioactive iodine therapy. Flushing the toilet twice and laundering clothes separately will help to limit radiation exposure to household members. Radiation parotiditis may cause dryness and irritation of the mouth, and a salt and soda gargle may provide relief.
A patient who underwent thyroid surgery develops neck swelling. What is the first action that the nurse should take? 1 Monitor calcium levels 2 Evaluate difficulty in speaking 3 Assess the patient for signs of hemorrhage 4 Place the patient in a semi-Fowler's position
Answer: 3 The patient who undergoes thyroid surgery is at risk for hemorrhage. Swelling is a clinical manifestation of hemorrhage. The first nursing action is to assess the patient. Monitoring calcium levels and evaluating difficulty in speaking helps in assessing the signs of hypoparathyroidism. Placing the patient in a semi-Fowler's position helps in avoiding flexion of the neck and tension on the suture lines.
A patient scheduled for a thyroidectomy is placed on potassium iodine. When the patient's family asks the nurse why this medication is needed, what is the nurse's best response? 1 "This medication will promote thyroid hormone synthesis." 2 "This medication will enhance healing following surgery." 3 "This medication will decrease the vascularity of the thyroid gland." 4 "This medication will inhibit the production of parathyroid hormone."
Answer: 3 When a patient is to undergo a thyroidectomy, before surgery antithyroid drugs, iodine, and adrenergic blockers may be administered to achieve a euthyroid state. Iodine reduces vascularization of the thyroid gland, reducing the risk of hemorrhage. Potassium iodide does not promote thyroid hormone synthesis, inhibit the production of parathyroid hormone, or enhance healing and electrolyte balance postoperatively.
The nurse is caring for a patient who is postoperative following a thyroidectomy. A priority of the patient's nursing care includes which action? 1 Assessment of hoarseness 2 Assessment of Babinski's reflex 3 Assessment of Chvostek's sign 4 Assessment of neck full range of motion
Answer: 3 A positive Chvostek's sign is a sign of life-threatening tetany, which could be caused by hypocalcemia because of accidental removal of the parathyroid glands. Hoarseness for three to four weeks postoperatively is an expected outcome of a thyroidectomy. A Babinski's reflex is not related to thyroid removal. Although it is advisable that the postoperative thyroidectomy patient exercise the neck muscles, neck flexion is contraindicated because it places tension on the suture line.
Which clinical manifestation is a classic finding in Graves' disease? 1 Gingivitis 2 Cretinism 3 Exophthalmos 4 Muscular dystrophy
Answer: 3 Exophthalmos is the protrusion of eyeballs from the orbits; it results from increased fat deposits and fluid in orbital tissues. It is a classic clinical manifestation in Graves' disease. Gingivitis, cretinism, and muscular dystrophy are not classic clinical manifestations associated with Graves' disease.
The nurse is caring for a patient admitted with suspected hyperparathyroidism. Because of the potential effects of this disease on electrolyte balance, the nurse should assess this patient for what manifestation? 1 Neurologic irritability 2 Declining urine output 3 Lethargy and weakness 4 Hyperactive bowel sounds
Answer: 3 Hyperparathyroidism can cause hypercalcemia. Signs of hypercalcemia include muscle weakness, polyuria, constipation, nausea and vomiting, lethargy, and memory impairment. Neurologic irritability, declining urine output, and hyperactive bowel sounds do not occur with hypercalcemia.
Which parameter would indicate the optimal intended effect of therapy with levothyroxine? 1 Blood pressure 120/78 mm Hg 2 Weight loss of 5 pounds 3 Thyroid-stimulating hormone (TSH) of 1.5 mIU/L 4 White blood cell count 8000 mm 3
Answer: 3 Levothyroxine is a thyroid preparation used for hypothyroidism. A normal TSH level (between 0.4 to 4 mIU/L) indicates optimal intended effects of the medication. Weight loss, blood pressure, and a normal white blood cell count are not indicators of effective treatment with levothyroxine.
In developing a teaching plan for the patient with exophthalmos, the nurse understands that the highest priority is placed on 1 Avoiding eyestrain 2 Improving self-esteem 3 Preventing corneal injury 4 Minimizing the risk of nerve damage
Answer: 3 The patient with exophthalmos may not be able to close the eyelids completely. This puts the patient at risk for dry eyes, for overexposure to environmental irritants, and for corneal injury. Lubricating eye drops can be used to combat drying, and dark glasses are encouraged to decrease exposure to environmental irritants. Preventing corneal injury is the priority for the patient with exophthalmos. Exophthalmos may create a function limitation in extraocular movements because of forward protrusion of the globe of the eye. The patient with exophthalmos is encouraged to move the eyes through the six cardinal fields of gaze several times a day to maintain ocular muscle flexibility. Avoiding eyestrain is not a priority for the patient with exophthalmos. Patients may suffer from decreased self-esteem because of the physical changes associated with exophthalmos. Good grooming is encouraged as a strategy to improve self-esteem. Improving self-esteem is of lower priority than preventing corneal injury. Exophthalmos is not associated with ocular nerve damage.
What does the nurse include in the teaching plan for the client who is receiving radioactive iodine? 1 Private bathroom facilities are not necessary unless the patient is incontinent. 2 Radioactive iodine therapy is contraindicated in women of childbearing age. 3 Towels that are used by the patient should not be used by other family members. 4 The patient should avoid being around pregnant women and children for 48 hours after treatment.
Answer: 3 To decrease risk of radiation exposure to household contacts, towels and bed linens used by the patient should not be handled by other members of the household and should be washed daily, separate from other household laundry. The patient who has been treated with radioactive iodine should use separate bathroom facilities and should flush two to three times after each use. Radioactive iodine may not be given to a pregnant woman. A pregnancy test must be administered to women of childbearing age to rule out pregnancy, before initiation of therapy. The patient who has received radioactive iodine should avoid close proximity to pregnant woman or children for seven days following treatment.
A nurse caring for a patient with hyperparathyroidism should monitor the patient for which complication? 1 Seizures 2 Cataracts 3 Constipation 4 Cardiac dysrhythmias
Answer: 4 Cardiac dysrhythmias may result because of the increased serum calcium level in hyperparathyroidism. Seizures and cataracts are complications seen in hypoparathyroidism. Constipation is not directly associated with parathyroid disorders.
A patient reports "eye problems". On assessment of this patient, the nurse notes exophthalmos. What other abnormal assessments should the nurse expect to find in this patient? 1 Puffy face, decreased sweating, and dry hair 2 Muscle aches and pains and slow movements 3 Decreased appetite and increased thirst and pallor 4 Systolic hypertension and increased heart rate
Answer: 4 The patient's symptoms point to Graves' disease, or hyperthyroidism; its symptoms would also include systolic hypertension, increased heart rate, and increased thirst. Puffy face, decreased sweating, dry, coarse hair, muscle aches and pains, slow movements, decreased appetite, and pallor are all manifestations of hypothyroidism.
A patient is scheduled for a total thyroidectomy. What information does the nurse include when teaching this patient about recovery after the procedure? 1 Exercise will be restricted for up to six months. 2 A low- or no-sodium diet will be prescribed. 3 Physical therapy will need to be continued. 4 Life-long hormone replacement will be needed.
Answer: 4 This patient will need life-long thyroid hormone replacement with levothyroxine because the entire thyroid gland will be missing after surgery. Exercise will not be restricted for six months. Lengthy exercise restriction or physical therapy generally is not indicated following a thyroidectomy. A sodium-restricted diet would not ordinarily be necessary.
The nurse is preparing to administer levothyroxine to a patient newly diagnosed with hypothyroidism. The patient's resting heart rate is 110. Which initial action should the nurse take? 1 Administer the medication 2 Notify the health care provider 3 Obtain a blood pressure measurement 4 Administer all other scheduled medications except levothyroxine
answer: 3 When thyroid hormone therapy is initiated, patients must be monitored carefully for increased pulse and blood pressure, because increased pulse and blood pressure may lead to angina and cardiac dysrhythmias. The nurse should first obtain a blood pressure measurement and assess for other signs of increased thyroid levels, such as chest pain, nervousness, and tremors. Thyroid hormone medication should not be administered until the health care provider is notified. The health care provider should be notified after the nurse collects the appropriate assessment data. Other scheduled medications can be given, but blood pressure assessment is the initial action.