Chapter 63: Care of Patients with Problems of the Thyroid and Parathyroid Glands

18. The nurse is assessing a client with Graves' disease and finds that the client's temperature has risen 1° F. Before notifying the health care provider, which action by the nurse takes priority? a. Turn the lights down in the client's room and shut the door. b. Call for an immediate electrocardiogram (ECG). c. Calculate the client's apical-radial pulse deficit. d. Administer a dose of acetaminophen (Tylenol).

ANS: A A temperature increase of 1° F may indicate the development of thyroid storm, and the provider needs to be notified. Before notifying the provider, the nurse should take measures to reduce environmental stimuli that increase the risk of cardiac complications. The nurse can then call for an ECG. The apical-radial pulse deficit would not be necessary, and Tylenol is not needed because the temperature increase is due to thyroid activity.

6. The client is receiving methimazole (Tapazole). Which statement by the client indicates good understanding of teaching regarding this medication? a. "If I become pregnant, I need to notify my health care provider immediately." b. "Liver problems can occur with this drug so I need to report jaundice." c. "I will take my pulse daily, and if it is too fast, I will call my provider." d. "This medication may cause dyspnea or vertigo. I will be careful with activity."

ANS: A Methimazole can cause birth defects, and clients should not take it if they are pregnant. Liver problems can occur with propylthiouracil (PTU). The client does not need to take his or her pulse daily. Dyspnea and vertigo are not side effects of methimazole.

19. A client has undergone a complete thyroidectomy. Which statement by the client indicates that further instruction is needed? a. "I may need calcium replacement after surgery." b. "After surgery, I won't need to take thyroid medication." c. "I'll need to take thyroid hormones for life." d. "I can receive pain medication if I feel that I need it."

ANS: B After the client undergoes a thyroidectomy, the client must be given thyroid replacement medication for life. He or she may also need calcium if the parathyroid is damaged during surgery and can receive pain medication postoperatively.

A nurse plans care for a client with hyperparathyroidism. Which intervention should the nurse include in this client's plan of care? a. Ask the client to ambulate in the hallway twice a day. b. Use a lift sheet to assist the client with position changes. c. Provide the client with a soft-bristled toothbrush for oral care. d. Instruct the unlicensed assistive personnel to strain the client's urine for stones.

ANS: B b. Use a lift sheet to assist the client with position changes. Hyperparathyroidism causes increased resorption of calcium from the bones, increasing the risk for pathologic fractures. Using a lift sheet when moving or positioning the client, instead of pulling on the client, reduces the risk of bone injury. Hyperparathyroidism can cause kidney stones, but not every client will need to have urine strained. The priority is preventing injury. Ambulating in the hall and using a soft toothbrush are not specific interventions for this client

1. A client has been admitted with hypoparathyroidism. The client's serum laboratory values are as follows: calcium, 7.2 mg/dL; sodium, 144 mEq/L; magnesium, 1.2 mEq/L; potassium, 5.7 mEq/L. Which medications does the nurse anticipate administering? (Select all that apply.) a. Potassium chloride orally b. Calcium chloride IV c. 3% NS IV solution d. 50% magnesium sulfate e. Calcitriol (Rocaltrol) orally

ANS: B, D The client has hypocalcemia (treated with calcium chloride) and hypomagnesemia (treated with magnesium sulfate). The potassium level is high, so replacement is not needed. The client's sodium level is normal, so hypertonic IV solution is not needed. No information about a vitamin D deficiency is available, so calcitriol is not needed.

20. A client being treated for hypothyroidism has been admitted for pneumonia. Which activity does the nurse include as a priority in this client's care plan? a. Monitor the client's IV site every shift. b. Administer acetaminophen (Tylenol) for fever. c. Ensure that working suction equipment is in the room. d. Assess vital signs every 4 hours.

ANS: C A client with hypothyroidism who develops another illness is at risk for myxedema coma. In this emergency situation, maintaining an airway is a priority. The nurse should ensure that suction is available in the client's room because it may be needed if myxedema coma develops. The other interventions are necessary for any client with pneumonia, but having suction available is a safety feature for this client.

3. Which dietary modification does the nurse provide for a client with hyperthyroidism? a. Decreased calories and proteins and increased carbohydrates b. Elimination of carbohydrates and increased proteins and fats c. Increased calories, proteins, and carbohydrates d. Supplemental vitamins and reduction of calories

ANS: C The client is hypermetabolic and has an increased need for calories, carbohydrates, and proteins. Proteins are especially important because the client is at risk for a negative nitrogen balance. The other modifications are inappropriate for a client with hyperthyroidism.

A client scheduled for a partial thyroidectomy asks the nurse why she is being given an iodine preparation before surgery. Which is the nurse's best response? a. "Iodine will help make the internal surgical environment sterile." b. "It is given to stimulate the storage of excess thyroid hormones." c. "This will replace the hormones you will lose after your operation." d. "It will prevent excessive bleeding during surgery."

ANS: D Iodine preparations decrease the size and vascularity of the thyroid gland, reducing the risk for hemorrhage and the potential for thyroid storm during surgery. The other answers are not accurate.

6. Twelve hours after a total thyroidectomy, the client develops stridor. Which is the nurse's priority intervention? a. Reassure the client that the voice change is temporary. b. Document the finding and assess the client hourly. c. Hyperextend the client's neck and apply oxygen. d. Prepare for emergency tracheostomy and call the health care provider

ANS: D Stridor on exhalation is a hallmark of respiratory distress, usually caused by obstruction resulting from edema. One emergency measure is to remove the surgical clips to relieve the pressure. This might be a physician function. The nurse should prepare to assist with emergency intubation or tracheostomy while notifying the provider or the Rapid Response Team. The other choices do not address the emergency situation.

A nurse assesses a client who is prescribed levothyroxine (Synthroid) for hypothyroidism. Which assessment finding should alert the nurse that the medication therapy is effective? a. Thirst is recognized and fluid intake is appropriate. b. Weight has been the same for 3 weeks. c. Total white blood cell count is 6000 cells/mm3. d. Heart rate is 70 beats/min and regular.

ANS: D d. Heart rate is 70 beats/min and regular. Hypothyroidism decreases body functioning and can result in effects such as bradycardia, confusion, and constipation. If a client's heart rate is bradycardic while on thyroid hormone replacement, this is an indicator that the replacement may not be adequate. Conversely, a heart rate above 100 beats/min may indicate that the client is receiving too much of the thyroid hormone. Thirst, fluid intake, weight, and white blood cell count do not represent a therapeutic response to this medication.

A client is being discharged with propylthiouracil (PTU). Which statement by the client indicates a need for further teaching by the nurse? a) "I can return to my job at the nursing home." b) "I must call if my urine is dark." c) "I must faithfully take the drug every 8 hours." d) "I need to report weight gain."

Correct Answer: a The client should avoid large crowds and people who are ill because PTU reduces blood cell counts and the immune response, which increases the risk for infection. The client does not, however, need to remain completely at home. Dark urine may indicate liver toxicity or failure, and the client must notify the provider immediately. Taking PTU regularly at the same time each day provides better drug levels and ensures better drug action. The client must notify the provider of weight gain because this may indicate hypothyroidism; a lower drug dose may be required.

What effect can starting a dose of levothyroxine sodium (Synthroid) too high or increasing a dose too rapidly have on a client? a) Bradycardia and decreased level of consciousness b) Decreased respiratory rate c) Hypotension and shock d) Hypertension and heart failure

Correct Answer: d Hypertension and heart failure are possible if the levothyroxine sodium dose is started too high or raised too rapidly, because levothyroxine would essentially put the client into a hyperthyroid state. The client would be tachycardic, not bradycardic. The client may have an increased respiratory rate. Shock may develop, but only as a late effect and as the result of "pump failure."

A nurse teaches a client with hyperthyroidism. Which dietary modifications should the nurse include in this client's teaching? (Select all that apply.) a. Increased carbohydrates b. Decreased fats c. Increased calorie intake d. Supplemental vitamins e. Increased proteins

a. Increased carbohydrates c. Increased calorie intake e. Increased proteins ANS: A, C, E The client is hypermetabolic and has an increased need for carbohydrates, calories, and proteins. Proteins are especially important because the client is at risk for a negative nitrogen balance. There is no need to decrease fat intake or take supplemental vitamins.

A nurse assesses a client with hypothyroidism who is admitted with acute appendicitis. The nurse notes that the client's level of consciousness has decreased. Which actions should the nurse take? (Select all that apply.) a. Infuse intravenous fluids. b. Cover the client with warm blankets. c. Monitor blood pressure every 4 hours. d. Maintain a patent airway. e. Administer oral glucose as prescribed.

a. Infuse intravenous fluids. b. Cover the client with warm blankets. d. Maintain a patent airway. ANS: A, B, D A client with hypothyroidism and an acute illness is at risk for myxedema coma. A decrease in level of consciousness is a symptom of myxedema. The nurse should infuse IV fluids, cover the client with warm blankets, monitor blood pressure every hour, maintain a patent airway, and administer glucose intravenously as prescribed.

While assessing a client with Graves' disease, the nurse notes that the client's temperature has risen 1° F. Which action should the nurse take first? a. Turn the lights down and shut the client's door. b. Call for an immediate electrocardiogram (ECG). c. Calculate the client's apical-radial pulse deficit. d. Administer a dose of acetaminophen (Tylenol).

a. Turn the lights down and shut the client's door. ANS: A A temperature increase of 1° F may indicate the development of thyroid storm, and the provider needs to be notified. But before notifying the provider, the nurse should take measures to reduce environmental stimuli that increase the risk of cardiac complications. The nurse can then call for an ECG. The apical-radial pulse deficit would not be necessary, and Tylenol is not needed because the temperature increase is due to thyroid activity.

After teaching a client who is recovering from a complete thyroidectomy, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional instruction? a. "I may need calcium replacement after surgery." b. "After surgery, I won't need to take thyroid medication." c. "I'll need to take thyroid hormones for the rest of my life." d. "I can receive pain medication if I feel that I need it."

b. "After surgery, I won't need to take thyroid medication." ANS: B After the client undergoes a thyroidectomy, the client must be given thyroid replacement medication for life. He or she may also need calcium if the parathyroid is damaged during surgery, and can receive pain medication postoperatively.

A nurse assesses a client who is recovering from a subtotal thyroidectomy. On the second postoperative day the client states, "I feel numbness and tingling around my mouth." What action should the nurse take? a. Offer mouth care. b. Loosen the dressing. c. Assess for Chvostek's sign. d. Ask the client orientation questions

c. Assess for Chvostek's sign. ANS: C Numbness and tingling around the mouth or in the fingers and toes are manifestations of hypocalcemia, which could progress to cause tetany and seizure activity. The nurse should assess the client further by testing for Chvostek's sign and Trousseau's sign. Then the nurse should notify the provider. Mouth care, loosening the dressing, and orientation questions do not provide important information to prevent complications of low calcium levels.

A nurse plans care for a client who has hypothyroidism and is admitted for pneumonia. Which priority intervention should the nurse include in this client's plan of care? a. Monitor the client's intravenous site every shift. b. Administer acetaminophen (Tylenol) for fever. c. Ensure that working suction equipment is in the room. d. Assess the client's vital signs every 4 hours.

c. Ensure that working suction equipment is in the room. ANS: C A client with hypothyroidism who develops another illness is at risk for myxedema coma. In this emergency situation, maintaining an airway is a priority. The nurse should ensure that suction equipment is available in the client's room because it may be needed if myxedema coma develops. The other interventions are necessary for any client with pneumonia, but having suction available is a safety feature for this client.

A nurse cares for a client with elevated triiodothyronine and thyroxine, and normal thyroid-stimulating hormone levels. Which actions should the nurse take? (Select all that apply.) a. Administer levothyroxine (Synthroid). b. Administer propranolol (Inderal). c. Monitor the apical pulse. d. Assess for Trousseau's sign. e. Initiate telemetry monitoring.

c. Monitor the apical pulse d. Initiate telemetry monitoring ANS: C, E The client's laboratory findings suggest that the client is experiencing hyperthyroidism. The increased metabolic rate can cause an increase in the client's heart rate, and the client should be monitored for the development of dysrhythmias. Placing the client on a telemetry monitor might also be a precaution. Levothyroxine is given for hypothyroidism. Propranolol is a beta blocker often used to lower sympathetic nervous system activity in hyperthyroidism. Trousseau's sign is a test for hypocalcemia

A nurse assesses a client on the medical-surgical unit. Which statement made by the client should alert the nurse to the possibility of hypothyroidism? a. "My sister has thyroid problems." b. "I seem to feel the heat more than other people." c. "Food just doesn't taste good without a lot of salt." d. "I am always tired, even with 12 hours of sleep."

d. "I am always tired, even with 12 hours of sleep." ANS: D Clients with hypothyroidism usually feel tired or weak despite getting many hours of sleep. Thyroid problems are not inherited. Heat intolerance is indicative of hyperthyroidism. Loss of taste is not a manifestation of hypothyroidism.

A nurse assesses a client who is recovering from a total thyroidectomy and notes the development of stridor. Which action should the nurse take first? a. Reassure the client that the voice change is temporary. b. Document the finding and assess the client hourly. c. Place the client in high-Fowler's position and apply oxygen. d. Contact the provider and prepare for intubation.

d. Contact the provider and prepare for intubation. ANS: D Stridor on exhalation is a hallmark of respiratory distress, usually caused by obstruction resulting from edema. One emergency measure is to remove the surgical clips to relieve the pressure. This might be a physician function. The nurse should prepare to assist with emergency intubation or tracheostomy while notifying the provider or the Rapid Response Team. Stridor is an emergency situation; therefore, reassuring the client, documenting, and reassessing in an hour do not address the urgency of the situation. Oxygen should be applied, but this action will not keep the airway open

A nurse cares for a client who is recovering from a parathyroidectomy. When taking the client's blood pressure, the nurse notes that the client's hand has gone into flexion contractions. Which laboratory result does the nurse correlate with this condition? a. Serum potassium: 2.9 mEq/L b. Serum magnesium: 1.7 mEq/L c. Serum sodium: 122 mEq/L d. Serum calcium: 6.9 mg/dL

d. Serum calcium: 6.9 mg/dL ANS: D Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. This effect of hypocalcemia is enhanced in the presence of tissue hypoxia. The flexion contractions (Trousseau's sign) that occur during blood pressure measurement are indicative of hypocalcemia, not the other electrolyte imbalances, which include hypokalemia, hyponatremia, and hypomagnesemia.

A nurse teaches a client who is prescribed an unsealed radioactive isotope. Which statements should the nurse include in this client's education? (Select all that apply.) a. "Do not share utensils, plates, and cups with anyone else." b. "You can play with your grandchildren for 1 hour each day." c. "Eat foods high in vitamins such as apples, pears, and oranges." d. "Wash your clothing separate from others in the household." e. "Take a laxative 2 days after therapy to excrete the radiation."

ANS: A, D, E A client who is prescribed an unsealed radioactive isotope should be taught to not share utensils, plates, and cups with anyone else; to avoid contact with pregnant women and children; to avoid eating foods with cores or bones, which will leave contaminated remnants; to wash clothing separate from others in the household and run an empty cycle before washing other people's clothing; and to take a laxative on days 2 and 3 after receiving treatment to help excrete the contaminated stool faster.

17. A client has diabetes mellitus. Her daughter has recently been diagnosed with Graves' disease. The client asks the nurse if she is responsible for the fact that her daughter has Graves' disease. Which is the best response of the nurse? a. "No connection is known between Graves' disease and diabetes, so you can be certain that the fact that you have diabetes did not cause your daughter to have Graves' disease." b. "An association has been noted between Graves' disease and diabetes, but the fact that you have diabetes did not cause your daughter to have Graves' disease." c. "Graves' disease is associated with autoimmune diseases such as rheumatoid arthritis, but not with a disease such as diabetes." d. "Unfortunately, Graves' disease is associated with diabetes, and your diabetes could have led to your daughter having Graves' disease."

ANS: B An association between autoimmune diseases such as rheumatoid arthritis and diabetes mellitus has been noted. The predisposition is probably polygenic and the client's diabetes did not cause her daughter's Graves' disease. The other statements are inaccurate.

13. The nurse is reviewing client medical histories. Which client is at greatest risk for hyperparathyroidism? a. Client with pregnancy-induced hypertension b. Client receiving dialysis for end-stage kidney disease c. Older adult client with moderate heart failure d. Older adult client on home oxygen therapy

ANS: B Clients who have chronic kidney disease do not completely activate vitamin D and poorly absorb calcium from the GI tract. They are chronically hypocalcemic, and this triggers overstimulation of the parathyroid glands. The other factors do not place a client at higher risk for hyperparathyroidism.

14. A client has hyperparathyroidism. Which intervention is the priority for the nurse to add to the client's plan of care? a. Instruct the client to place both hands behind the neck when moving. b. Use a lift sheet to assist the client with position changes. c. Instruct the client to use a soft-bristled toothbrush. d. Strain all urine for at least 24 hours and send stones to the laboratory.

ANS: B Hyperparathyroidism causes increased resorption of calcium from the bones, increasing the risk for pathologic fractures. Using a lift sheet when moving or positioning the client, instead of pulling on the client, reduces the risk of bone injury. Hyperparathyroidism can cause kidney stones, but not every client will need to have urine strained. The priority is preventing injury. Supporting the neck with movement and using a soft toothbrush are not needed for this client.

4. A client with hyperthyroidism is taking lithium carbonate. Which finding indicates that the client is having side effects of this therapy? a. Blurred vision b. Increased thirst and urination c. Increased sweating and diarrhea d. Decreased attention span and insomnia

ANS: B Lithium antagonizes antidiuretic hormone and can cause symptoms of diabetes insipidus. The other choices are not specific to lithium.

A client has been diagnosed with hypothyroidism. Which medication is the nurse prepared to administer to treat the client's bradycardia? a. Atropine sulfate b. Levothyroxine sodium (Synthroid) c. Propranolol (Inderal) d. Epinephrine (Adrenalin)

ANS: B The treatment for bradycardia from hypothyroidism is to treat the hypothyroidism using levothyroxine sodium. If the heart rate were so slow that it became an emergency, then atropine or epinephrine might be an option for short-term management. Inderal is a beta blocker and would be contraindicated for a client with bradycardia.

12. A client with hypothyroidism as a result of Hashimoto's thyroiditis asks the nurse how long she will have to take thyroid medication. Which is the nurse's best response? a. "You will need to take the thyroid medication until the goiter is completely gone." b. "Thyroiditis is cured with antibiotics. Then you won't need thyroid medication." c. "You'll need thyroid pills for life because your thyroid won't start working again." d. "When blood tests indicate normal thyroid function, you can stop the medication."

ANS: C Hashimoto's thyroiditis results in a permanent loss of thyroid function. The client will need lifelong thyroid replacement therapy. The other answers are incorrect.

A client has hypothyroidism. Which problem does the nurse address as a priority for this client? a. Heat intolerance b. Body image problems c. Depression and withdrawal d. Obesity

ANS: C Hypothyroidism causes many problems in psychosocial functioning. Depression is the most common reason for seeking medical attention. Memory and attention span may be impaired. The client's family may have great difficulty accepting and dealing with these changes. The client is often unmotivated to participate in self-care. Lapses in memory and attention require the nurse to ensure that the client's environment is safe. Heat intolerance is seen in hyperthyroidism. Body image problems and weight issues do not take priority over mental status and safety.

On the second postoperative day after a subtotal thyroidectomy, the client tells the nurse that he feels numbness and tingling around his mouth. Which is the nurse's priority intervention? a. Offer mouth care. b. Loosen the dressing. c. Assess Chvostek's sign. d. Assess the client hourly.

ANS: C Numbness and tingling around the mouth or in the fingers and toes are manifestations of hypocalcemia, which could progress to cause tetany and seizure activity. The nurse should assess the client further by testing for Chvostek's sign and Trousseau's sign. Then the nurse should notify the provider. The other choices do not address the emergency situation.

1. A client presents with elevations in triiodothyronine (T3) and thyroxine (T4) and with normal thyroid-stimulating hormone (TSH) levels. Which is the nurse's priority intervention? a. Administer levothyroxine (Synthroid). b. Administer propranolol (Inderal). c. Monitor the apical pulse. d. Assess for Trousseau's sign.

ANS: C The client's laboratory findings suggest that the client is experiencing hyperthyroidism. The increased metabolic rate can cause an increase in the client's heart rate, and the client should be monitored for the development of dysrhythmias. Placing the client on a telemetry monitor might also be a precaution. Synthroid is given for hypothyroidism. Propranolol is a beta blocker often used to lower sympathetic nervous system activity in

2. Which is the best instruction for the nurse to give a client scheduled for a thyroid scan? a. "You will have external beam radiation." b. "No radiation is used for this scan." c. "No special radiation precautions are needed." d. "Your thyroid will be radioactive for weeks

ANS: C The radioactive iodine used in thyroid scans is of low intensity and has such a short half-life that the client is not considered to be a radiation hazard. Thus, no radiation precautions are necessary. The other statements are inaccurate.

A nurse cares for a client who has hypothyroidism as a result of Hashimoto's thyroiditis. The client asks, "How long will I need to take this thyroid medication?" How should the nurse respond? a. "You will need to take the thyroid medication until the goiter is completely gone." b. "Thyroiditis is cured with antibiotics. Then you won't need thyroid medication." c. "You'll need thyroid pills for life because your thyroid won't start working again." d. "When blood tests indicate normal thyroid function, you can stop the medication."

ANS: C c. "You'll need thyroid pills for life because your thyroid won't start working again." Hashimoto's thyroiditis results in a permanent loss of thyroid function. The client will need lifelong thyroid replacement therapy. The client will not be able to stop taking the medication.

A nurse plans care for a client with hypothyroidism. Which priority problem should the nurse plan to address first for this client? a. Heat intolerance b. Body image problems c. Depression and withdrawal d. Obesity and water retention

ANS: C c. Depression and withdrawal Hypothyroidism causes many problems in psychosocial functioning. Depression is the most common reason for seeking medical attention. Memory and attention span may be impaired. The client's family may have great difficulty accepting and dealing with these changes. The client is often unmotivated to participate in self-care. Lapses in memory and attention require the nurse to ensure that the client's environment is safe. Heat intolerance is seen in hyperthyroidism. Body image problems and weight issues do not take priority over mental status and safety.

8. Which client statement alerts the nurse to the possibility of hypothyroidism? a. "My sister has thyroid problems." b. "I seem to feel the heat more than other people." c. "Food just doesn't taste good without a lot of salt." d. "I am always tired, even with 10 or 12 hours of sleep."

ANS: D Clients with hypothyroidism usually feel tired or weak despite getting many hours of sleep. Thyroid problems are not inherited. Heat intolerance is indicative of hyperthyroidism. Loss of taste is not a manifestation of hyperthyroidism.

15. When taking the blood pressure of a client after a parathyroidectomy, the nurse notes that the client's hand has gone into flexion contractions. Which laboratory result does the nurse correlate with this condition? a. Serum potassium, 2.9 mEq/L b. Serum potassium, 5.8 mEq/L c. Serum sodium, 122 mEq/L d. Serum calcium, 6.9 mg/dL

ANS: D Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. This effect of hypocalcemia is enhanced in the presence of tissue hypoxia. The flexion contractions (Trousseau's sign) that occur during blood pressure measurement are indicative of hypocalcemia, not the other electrolyte imbalances, which include hypokalemia, hyperkalemia, and hyponatremia.

11. A client has hypothyroidism and has been started on levothyroxine (Synthroid). Which assessment finding leads the nurse to conclude that the treatment is effective? Thirst is recognized and the client drinks fluids appropriately. b. Weight has been the same for 3 weeks. c. Total white blood cell count is 6000 cells/mm3. d. Heart rate is 70 beats/min and regular.

ANS: D Hypothyroidism decreases body functioning and can result in effects such as bradycardia, confusion, and constipation. If a client's heart rate is bradycardic while on thyroid hormone replacement, this is an indicator that the replacement may not be adequate. Conversely, a heart rate above 100 beats/min may indicate that the client is receiving too much of the thyroid hormone. The other assessment findings do not give any indication as to whether treatment is successful.

A client recently admitted with hyperparathyroidism has a very high urine output. Of these actions, what does the nurse do next? a) Calls the health care provider b) Monitors intake and output c) Performs an immediate cardiac assessment d) Slows the rate of IV fluids

Correct Answer: b Diuretic and hydration therapies are used most often for reducing serum calcium levels in clients with hyperparathyroidism. Usually, a diuretic that increases kidney excretion of calcium is used together with IV saline in large volumes to promote renal calcium excretion. The health care provider does not need to be notified in this situation, given the information available in the question. Cardiac assessment is part of the nurse's routine evaluation of the client. Slowing the rate of IV fluids is contraindicated because the client will become dehydrated due to the use of diuretics to increase kidney excretion of calcium.

A client had a parathyroidectomy 18 hours ago. Which finding requires immediate attention? a) Edema at the surgical site b) Hoarseness c) Pain on moving the head d) Sore throat

Correct Answer: b Hoarseness or stridor is an indication of respiratory distress and requires immediate attention. Edema at the surgical site of any surgery is an expected finding. Pain when the client moves the head or attempts to lift the head off the bed is an expected finding after a parathyroidectomy. Any time a client has been intubated for surgery, a sore throat is a common occurrence in the postoperative period. This is especially true for clients who have had surgery involving the neck.

A client being treated for hyperthyroidism calls the home health nurse and mentions that his heart rate is slower than usual. What is the nurse's best response? a) Advise the client to go to a calming environment. b) Ask whether the client has increased cold sensitivity or weight gain. c) Instruct the client to see his health care provider immediately. d) Tell the client to check his pulse again and call back later.

Correct Answer: b Increased sensitivity to cold and weight gain are symptoms of hypothyroidism, indicating an overcorrection by the medication. The client must be assessed further because he may require a lower dose of medication. A calming environment will not have any effect on the client's heart rate. The client will want to notify the health care provider about the change in heart rate. If other symptoms such as chest pain, shortness of breath, or confusion accompany the slower heart rate, then the client should see the health care provider immediately. If the client was concerned enough to call because his heart rate was slower than usual, the nurse needs to stay on the phone with the client while he re-checks his pulse. This time could also be spent providing education about normal ranges for that client.

A client has been diagnosed with hypothyroidism. What medication is usually prescribed to treat this disorder? a) Atenolol (Tenormin) b) Levothyroxine sodium (Synthroid) c) Methimazole (Tapazole) d) Propylthiouracil

Correct Answer: b Levothyroxine is a synthetic form of thyroxine (T4) that is used to treat hypothyroidism. Atenolol is a beta blocker that is used to treat cardiovascular disease. Methimazole and propylthiouracil are used to treat hyperthyroidism.

Family members of a client diagnosed with hyperthyroidism are alarmed at the client's frequent mood swings. What is the nurse's response? a) "How does that make you feel?" b) "The mood swings should diminish with treatment." c) "The medications will make the mood swings disappear completely." d) "Your family member is sick. You must be patient."

Correct Answer: b Telling the family that the client's mood swings should diminish over time with treatment will provide information to the family, as well as reassurance. Asking how the family feels is important; however, the response should focus on the client. Any medications or treatment may not completely remove the mood swings associated with hyperthyroidism. The family is aware that the client is sick; telling them to be patient introduces guilt and does not address the family's concerns.

The nurse manager for the medical-surgical unit is making staff assignments. Which client will be most appropriate to assign to a newly graduated RN who has completed a 6-week unit orientation? a) Client with chronic hypothyroidism and dementia who takes levothyroxine (Synthroid) daily b) Client with follicular thyroid cancer who has vocal hoarseness and difficulty swallowing c) Client with Graves' disease who is experiencing increasing anxiety and diaphoresis d) Client with hyperparathyroidism who has just arrived on the unit after a parathyroidectomy

Correct Answer: b The client with chronic hypothyroidism and dementia is the most stable of the clients described and would be most appropriate to assign to an inexperienced RN. A client with vocal hoarseness and difficulty swallowing is at higher risk for complications and requires close observation by a more experienced nurse. Increasing anxiety and diaphoresis in a client with Graves' disease can be an indication of impending thyroid storm, which is an emergency; this is not a situation to be managed by a newly graduated RN. A client who has just arrived on the unit after a parathyroidectomy requires close observation for bleeding and airway compromise and requires assessment by an experienced nurse.

1. A nurse assesses a client with hyperthyroidism who is prescribed lithium carbonate. Which assessment finding should alert the nurse to a side effect of this therapy? a. Blurred and double vision b. Increased thirst and urination c. Profuse nausea and diarrhea d. Decreased attention and insomnia

b. Increased thirst and urination ANS: B Lithium antagonizes antidiuretic hormone and can cause symptoms of diabetes insipidus. This manifests with increased thirst and urination. Lithium has no effect on vision, gastric upset, or level of consciousness.

A client admitted with hyperthyroidism is fidgeting with the bedcovers and talking extremely fast. What does the nurse do next? a) Calls the provider b) Encourages the client to rest c) Immediately assesses cardiac status d) Tells the client to slow down

Correct Answer: b The client with hyperthyroidism often has wide mood swings, irritability, decreased attention span, and manic behavior. The nurse should accept the client's behavior and provide a calm, quiet, and comfortable environment. Because the client's behavior is expected, there is no need to call the provider. Monitoring the client's cardiac status is part of the nurse's routine assessment. Telling the client to slow down is unsupportive and unrealistic.

Which action does the postanesthesia care unit (PACU) nurse perform first when caring for a client who has just arrived after a total thyroidectomy? a) Assess the wound dressing for bleeding. b) Give morphine sulfate 4 to 8 mg IV for pain. c) Monitor oxygen saturation using pulse oximetry. d) Support the head and neck with sandbags.

Correct Answer: c Airway assessment and management is always the first priority with every client. This is especially important for a client who has had surgery that involves potential bleeding and edema near the trachea. Assessing the wound dressing for bleeding is a high priority, although this is not the first priority. Pain control and supporting the head and neck with sandbags are important priorities, but can be addressed after airway assessment.

A client with hypothyroidism is being discharged. Which environmental change may the client experience in the home? a) Frequent home care b) Handrails in the bath c) Increased thermostat setting d) Strict infection-control measures

Correct Answer: c Manifestations of hypothyroidism include cold intolerance. Increased thermostat settings or additional clothing may be necessary. A client with a diagnosis of hypothyroidism can be safely managed at home with adequate discharge teaching regarding medications and instructions on when to notify the health care provider or home health nurse. In general, hypothyroidism does not cause mobility issues. Activity intolerance and fatigue may be an issue, however. A client with hypothyroidism is not immune-compromised or contagious, so no environmental changes need to be made to the home.

An older client with an elevated serum calcium level is receiving IV furosemide (Lasix) and an infusion of normal saline at 150 mL/hr. Which nursing action can the RN delegate to unlicensed assistive personnel (UAP)? a) Ask the client about any numbness or tingling. b) Check for bone deformities in the client's back. c) Measure the client's intake and output hourly. d) Monitor the client for shortness of breath.

Correct Answer: c Measuring intake and output is a commonly delegated nursing action that is within the UAP scope of practice. Numbness and tingling is part of the client assessment that needs to be completed by a licensed nurse. Bony deformities can be due to pathologic fractures; physical assessment is a complex task that cannot be delegated. An older client receiving an IV at 150 mL/hr is at risk for congestive heart failure; careful monitoring for shortness of breath is the responsibility of the RN.

An RN and LPN/LVN are caring for a group of clients on the medical-surgical unit. Which client will be the best to assign to the LPN/LVN? a) Client with Graves' disease who needs discharge teaching after a total thyroidectomy b) Client with hyperparathyroidism who is just being admitted for a parathyroidectomy c) Client with infiltrative ophthalmopathy who needs administration of high-dose prednisone (Deltasone) d) Newly diagnosed client with hypothyroidism who needs education about the use of thyroid supplements

Correct Answer: c Medication administration for the client with infiltrative ophthalmopathy is within the scope of practice of the LPN/LVN. Discharge teaching is a complex task that cannot be delegated to the LPN/LVN. A client being admitted for a parathyroidectomy needs preoperative teaching, which must be provided by the RN. A client who has a new diagnosis will have questions about the disease and prescribed medications; teaching is a complex task that is appropriate for the RN.

Which type of thyroid cancer often occurs as part of multiple endocrine neoplasia (MEN) type II? a) Anaplastic b) Follicular c) Medullary d) Papillary

Correct Answer: c Medullary carcinoma commonly occurs as part of MEN type II, which is a familial endocrine disorder. Anaplastic carcinoma is an aggressive tumor that invades surrounding tissue. Follicular carcinoma occurs more frequently in older clients and may metastasize to bone and lung. Papillary carcinoma is the most common type of thyroid cancer. It is slow growing and, if the tumor is confined to the thyroid gland, the outlook for a cure is good with surgical management.

A client has hyperparathyroidism. Which incident witnessed by the nurse requires the nurse's intervention? a) The client eating a morning meal of cereal and fruit b) The physical therapist walking with the client in the hallway c) Unlicensed assistive personnel pulling the client up in bed by the shoulders d) Visitors talking with the client about going home

Correct Answer: c The client with hyperparathyroidism is at risk for pathologic fracture. All members of the health care team must move the client carefully. A lift sheet should be used to re-position the client. The client with hyperparathyroidism is not restricted from eating and should maintain a balanced diet. The client can benefit from moderate exercise and physical therapy, and is not restricted from having visitors.

The nurse is teaching a client about thyroid replacement therapy. Which statement by the client indicates a need for further teaching? a) "I should have more energy with this medication." b) "I should take it every morning." c) "If I continue to lose weight, I may need an increased dose." d) "If I gain weight and feel tired, I may need an increased dose."

Correct Answer: c Weight loss indicates a need for a decreased dose, not an increased dose. One of the symptoms of hypothyroidism is lack of energy; thyroid replacement therapy should help the client have more energy. The correct time to take thyroid replacement therapy is in the morning. If the client is gaining weight and continues to feel tired, that is an indication that the dose may need to be increased.

The RN has just received change-of-shift report on the medical-surgical unit. Which client will need to be assessed first? a) Client with Hashimoto's thyroiditis and a large goiter b) Client with hypothyroidism and an apical pulse of 51 beats/min c) Client with parathyroid adenoma and flank pain due to a kidney stone d) Client who had a parathyroidectomy yesterday and has muscle twitching

Correct Answer: d A client who is 1 day postoperative for parathyroidectomy and has muscle twitching is showing signs of hypocalcemia and is at risk for seizures. Rapid assessment and intervention are needed. Clients with Hashimoto's thyroiditis are usually stable; this client does not need to be assessed first. Although an apical pulse of 51 is considered bradycardia, a low heart rate is a symptom of hypothyroidism. A client with a kidney stone will be uncomfortable and should be asked about pain medication as soon as possible, but this client does not need to be assessed first.

A client with thyroid cancer has just received 131I ablative therapy. Which statement by the client indicates a need for further teaching? a) "I cannot share my toothpaste with anyone." b) "I must flush the toilet three times after I use it." c) "I need to wash my clothes separately from everyone else's clothes." d) "I'm ready to hold my newborn grandson now."

Correct Answer: d Clients undergoing 131I therapy should avoid close contact with pregnant women, infants, and young children for 1 week after treatment. Clients should remain at least 1 meter (39 inches, or roughly 3 feet) away, and limit exposure to less than 1 hour per day. Some radioactivity will remain in the client's salivary glands for up to 1 week after treatment. Care should be taken to avoid exposing others to the saliva. Flushing the toilet three times after use will ensure that all urine has been diluted and removed. Clothing needs to be washed separately and the washing machine then needs to be run empty for a full cycle before it is used to wash the clothing of others.

The nurse reviews the vital signs of a client diagnosed with Graves' disease and sees that the client's temperature is up to 99.6° F. After notifying the health care provider, what does the nurse do next? a) Administers acetaminophen b) Alerts the Rapid Response Team c) Asks any visitors to leave d) Assesses the client's cardiac status completely

Correct Answer: d If the client's temperature has increased by even 1°, the nurse's first action is to notify the provider. Continuous cardiac monitoring should be the next step. Administering a nonsalicylate antipyretic such as acetaminophen is appropriate, but is not a priority action for this client. Alerting the Rapid Response Team is not needed at this time. Asking visitors to leave would not be the next action, and if visitors are providing comfort to the client, this would be contraindicated.

A client is taking methimazole (Tapazole) for hyperthyroidism and would like to know how soon this medication will begin working. What is the nurse's best response? a) "You should see effects of this medication immediately." b) "You should see effects of this medication within 1 week." c) "You should see full effects from this medication within 1 to 2 days." d) "You should see some effects of this medication within 2 weeks."

Correct Answer: d Methimazole is an iodine preparation that decreases blood flow through the thyroid gland. This action reduces the production and release of thyroid hormone. The client should see some effects within 2 weeks; however, it may take several more weeks before metabolism returns to normal. Although onset of action is 30 to 40 minutes after an oral dose, the client will not see effects immediately. Effects will take longer than 1 week to become apparent when methimazole is used. Methimazole needs to be taken every 8 hours for an extended period of time. Levels of triiodothyronine (T3) and thyroxine (T4) will be monitored and dosages adjusted as levels fall.

The nurse is preparing the room for the client returning from a thyroidectomy. Which items are important for the nurse to have available for this client? (Select all that apply.) a) Calcium gluconate b) Emergency tracheotomy kit c) Furosemide (Lasix) d) Hypertonic saline e) Oxygen f) Suction

Correct Answers: a, b, e, f Calcium gluconate should be available at the bedside to treat hypocalcemia and tetany that might occur if the parathyroid glands have been injured during the surgery. Equipment for an emergency tracheotomy must be kept at the bedside in the event that hemorrhage or edema should occlude the airway. Respiratory distress can result from swelling or damage to the laryngeal nerve leading to spasm, so it is important that the nurse work with respiratory therapy to have oxygen ready at the bedside for the client on admission. Because of the potential for increased secretions, it is important that a working suction device is present at the bedside for admission of the client from the operating room. Furosemide might be useful in the postoperative client to assist with urine output; however, this is not of added importance for this client. Hypertonic saline would not be of benefit to this client as the client is not hyponatremic.

A nurse cares for a client newly diagnosed with Graves' disease. The client's mother asks, "I have diabetes mellitus. Am I responsible for my daughter's disease?" How should the nurse respond? a. "The fact that you have diabetes did not cause your daughter to have Graves' disease. No connection is known between Graves' disease and diabetes." b. "An association has been noted between Graves' disease and diabetes, but the fact that you have diabetes did not cause your daughter to have Graves' disease." c. "Graves' disease is associated with autoimmune diseases such as rheumatoid arthritis, but not with a disease such as diabetes mellitus." d. "Unfortunately, Graves' disease is associated with diabetes, and your diabetes could have led to your daughter having Graves' disease."

b. "An association has been noted between Graves' disease and diabetes, but the fact that you have diabetes did not cause your daughter to have Graves' disease." ANS: B An association between autoimmune diseases such as rheumatoid arthritis and diabetes mellitus has been noted. The predisposition is probably polygenic, and the mother's diabetes did not cause her daughter's Graves' disease. The other statements are inaccurate.

A nurse assesses clients for potential endocrine disorders. Which client is at greatest risk for hyperparathyroidism? a. A 29-year-old female with pregnancy-induced hypertension b. A 41-year-old male receiving dialysis for end-stage kidney disease c. A 66-year-old female with moderate heart failure d. A 72-year-old male who is prescribed home oxygen therapy

b. A 41-year-old male receiving dialysis for end-stage kidney disease ANS: B Clients who have chronic kidney disease do not completely activate vitamin D and poorly absorb calcium from the GI tract. They are chronically hypocalcemic, and this triggers overstimulation of the parathyroid glands. Pregnancy-induced hypertension, moderate heart failure, and home oxygen therapy do not place a client at higher risk for hyperparathyroidism.

MULTIPLE RESPONSE 1. A nurse evaluates the following laboratory results for a client who has hypoparathyroidism: Calcium 7.2 mg/dL Sodium 144 mEq/L Magnesium 1.2 mEq/L Potassium 5.7 mEq/L Based on these results, which medications should the nurse anticipate administering? (Select all that apply.) a. Oral potassium chloride b. Intravenous calcium chloride c. 3% normal saline IV solution d. 50% magnesium sulfate e. Oral calcitriol (Rocaltrol

b. Intravenous calcium chloride d. 50% magnesium sulfate ANS: B, D The client has hypocalcemia (treated with calcium chloride) and hypomagnesemia (treated with magnesium sulfate). The potassium level is high, so replacement is not needed. The client's sodium level is normal, so hypertonic IV solution is not needed. No information about a vitamin D deficiency is evident, so calcitriol is not needed.

A nurse cares for a client who presents with bradycardia secondary to hypothyroidism. Which medication should the nurse anticipate being prescribed to the client? a. Atropine sulfate b. Levothyroxine sodium (Synthroid) c. Propranolol (Inderal) d. Epinephrine (Adrenalin)

b. Levothyroxine sodium (Synthroid) ANS: B The treatment for bradycardia from hypothyroidism is to treat the hypothyroidism using levothyroxine sodium. If the heart rate were so slow that it became an emergency, then atropine or epinephrine might be an option for short-term management. Propranolol is a beta blocker and would be contraindicated for a client with bradycardia