Med-Surg II Endocrine- Chapter 67
The risk factors for Graves' disease are increased in clients with which of the following? (Select all that apply.) A. Autoimmune disease C. Type 1 diabetes D. Pernicious anemia
ANS: A, C, D Rationale: The pattern of inheritances of Graves' disease appears to be familial clustering. However, a specific gene or gene mutation has been identified as a cause of Graves' disease. People with autoimmune disease appear to be at a higher risk.
The client is receiving an antithyroid medication to treat hyperthyroidism. Which of the following should be included in client education regarding the initiation of this therapy? A. "Increased need for sleepy or not tolerating cold like you used to can occur when taking this medication. If it does, notify your physician."
ANS: A Antithyroid medication may result in hypothyroidism, which is manifested by sleepiness and intolerance to cold. The client must be closely monitored to determine the need for drug regimen changes. B is a side effect of the medication. C does not give the client specific parameters for "fast pulse." D uses medical terminology which the client may not understand.
What is the priority nursing diagnosis for the client newly diagnosed with hyperthyroidism? A. Decreased cardiac output related to tachycardia
ANS: A The cardiac problems of hyperthyroidism include increased systolic blood pressure, a widened pulse pressure, tachycardia, and other dysrhythmias. The goals of nonsurgical management are to decrease the effect of thyroid hormone on cardiac function and to reduce thyroid hormone secretion.
What is the priority nursing diagnosis for the client in thyroid crisis (storm)? A. Potential for Ineffective Breathing Pattern
ANS: A Thyroid crisis is a life-threatening emergency that has a 25% mortality rate, even with intervention. Maintaining a patent airway and providing adequate ventilation are the primary concerns for clients in thyroid crisis.
The client with hyperthyroid symptoms is having hormone studies done to confirm the diagnosis. Which set of values indicates non-Graves' disease hyperthyroidism? A. Elevated T3, elevated T4, high TSH levels
ANS: A With hyperthyroidism, both the T3 and T4 blood levels are elevated, causing the hypermetabolism. In Graves' disease, the autoantibodies bind to the TSH receptor and activate it, causing an overproduction of thyroid hormones. The increased metabolic rate negatively feeds back and suppresses hypothalamic secretion of thyrotropic hormone, which in turn suppresses thyroid-stimulating hormone (TSH). When the TSH levels are elevated, causing an increased synthesis of thyroid hormones, the hyperthyroidism is not a result of Graves' disease.
Which client is at greatest risk for hyperparathyroidism? B. 45-year-old client receiving dialysis for end-stage renal disease
ANS: B Clients who have chronic renal failure do not completely activate vitamin D and poorly absorb calcium from the GI tract. They are chronically hypocalcemic, which triggers overstimulation of the parathyroid glands.
Which clinical manifestation alerts the nurse to the possibility of Graves' disease as the cause of hyperthyroidism? B. Exophthalmos
ANS: B Graves' disease causes edema in the extraocular muscles and increased retro-orbital fat that pushes the globe of the eye forward. This exophthalmos is not a feature of hyperthyroidism from any other cause.
What intervention should the nurse use to prevent injury in the client with hyperparathyroidism? B. Use a lift sheet to assist the client with position changes.
ANS: B Hyperparathyroidism causes increased resorption of calcium from the bones, increasing the risk for pathologic fractures. The use of a lift sheet when moving or positioning the client, instead of pulling on the client, reduces the risk of bone injury.
The client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. Which of the following client reports alerts the nurse to side effects of this therapy? B. Increased thirst and urination
ANS: B Lithium antagonizes antidiuretic hormone and can cause symptoms of diabetes insipidus.
Which manifestation of Graves' disease is unaffected by medical treatment for the hyperthyroidism? B. Exophthalmos
ANS: B Medical or surgical therapy for hyperthyroidism does not reduce the exophthalmos, although these therapies will prevent progression of the associated eye changes.
For which client with hyperthyroidism is radioactive iodine therapy contraindicated? B. 28-year-old woman who is pregnant
ANS: B Radioactive iodine therapy is contraindicated in pregnant women because 131I crosses the placenta and can adversely affect the fetal thyroid gland.
Which of the following statements regarding thyroid disorders is true? B. The effects of thyroid dysfunction are found in all body tissues and organs.
ANS: B The presence of a goiter is associated with thyroid dysfunction; however, some types of hyperthyroidism cause a goiter and some types of hypothyroidism cause a goiter. Thyroid hormones affect virtually all metabolic processes in all body organs.
Which medication should the nurse be prepared to administer to a client with bradycardia as a result of hypothyroidism? B.Levothyroxine sodium
ANS: B The treatment for bradycardia from hypothyroidism is to treat the hypothyroidism.
The client with hypothyroidism as a result of Hashimoto's thyroiditis asks the nurse how long she will have to take thyroid medication. What is the nurse's best response? C. "You will need thyroid replacement hormone therapy for the rest of your life because the thyroid gland function will not return."
ANS: C Hashimoto's thyroiditis results in a permanent loss of thyroid function.
What is the priority nursing diagnosis for the client with hypothyroidism? C. Disturbed Thought Processes
ANS: C Hypothyroidism causes many problems in psychosocial functioning. Depression is the most common reason for seeking medical attention. The client may be too lethargic, apathetic, or drowsy to recognize changes in his or her condition. Memory and attention span may be impaired. Paranoia and agitation also may be present. The client may have such disturbed thought processes that they are unable to care for themselves.
On the second postoperative day after a subtotal thyroidectomy, the client tells the nurse that he feels numbness and tingling around the mouth. What is the nurse's best first action? C. Notify the physician.
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.
In collaboration with the dietician, what dietary modification should the nurse suggest for the client with hyperthyroidism? C. Increase calories, proteins, and carbohydrates.
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 client scheduled to have a thyroid scan asks the nurse how long she will be radioactive after the scan. What is the nurse's best response? C. "The dose of radiation is so low and is excreted by the kidneys in just a few days, so you are not considered radioactive."
ANS: C The radioactive iodine used in thyroid scans is low intensity and has such a short half-life that the client is not considered to be a radiation hazard, and no radiation precautions are necessary.
Which statement made by the client alerts the nurse to the possibility of hypothyroidism? D. "I am always tired, even when I get 10 or 12 hours of sleep."
ANS: D Clients with hypothyroidism usually feel tired or weak and often report an increase in time spent sleeping, sometimes up to 14 to 16 hours daily.
When taking the blood pressure of a client after a parathyroidectomy, the nurse notes that the client's hand has gone into flexion contractions. What is the nurse's interpretation of this observation? D. Hypocalcemia
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) occurring during blood pressure measurement are indicative of hypocalcemia.
Which clinical manifestation indicates to the nurse that treatment for the client with hypothyroidism is effective? D. The client has had a bowel movement every day for 1 week.
ANS: D Hypothyroidism decreases gastrointestinal motility significantly. One of the parameters that clients can use to determine if changes in the dose of thyroid replacement should be adjusted is the frequency of bowel movements. A bowel movement every day is a strong indication that the dose of thyroid replacement hormone is adequate.
The client scheduled for a partial thyroidectomy for hyperthyroidism asks the nurse why she is being given an iodine preparation before surgery. What is the nurse's best response? D. "To decrease the blood vessels in the thyroid and 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.
Twelve hours after a total thyroidectomy, the client develops stridor on exhalation. What is the nurse's best first action? D. Call for emergency assistance.
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. In some settings, this may be a nursing action; in other settings, this is a physician function. Emergency intubation also may be necessary.
The client has not taken the prescribed levothyroxine sodium (Synthroid) and is admitted to the emergency department for myxedema coma. Number the following nursing diagnoses in order of priority. ANS: 3_ Disturbed Thought Processes related to lethargy 4_ Hypothermia related to decreased metabolic rate 5_ Constipation related to decreased motility of the gastrointestinal tract 2_ Decreased Cardiac Output related to decreased metabolism 1_ Ineffective Breathing Pattern related to fatigue
Rationale: Myxedema coma is characterized by coma, respiratory failure, hypotension, hyponatremia, and hypothermia. In the unstable client, the priority of care is always airway, breathing, and circulation. Therefore, the nurse's priority, together with that of the medical staff, is to ensure an adequate and patent airway, monitor vital signs and intervene as necessary. Once an airway and circulation are managed, the client's neurologic status is checked. As cardiac output increases, perfusion to the client's brain increases and the client's level of consciousness should improve. Hypothermia must be managed to prevent further cardiovascular compromise, such as cardiac dysrhythmias.
Excessive thyroid hormone secretion leads to hyperthyroidism. The manifestation of hyperthyroidism is called ____________________. ANS: thyrotoxicosis
Rationale: This is a state of hypermetabolism affecting metabolism in all body organs.
