EXAM 2 Concepts (352)

The nurse is assessing a client with a suspected thyroid disorder. Which diagnostic studies will be most appropriate to confirm that the thyroid disorder is autoimmune in origin? Select all that apply. Free thyroxine Thyroglobulin antibody Thyroid peroxidase antibody Thyroid-stimulating antibody Thyroid-stimulating hormone

Thyroglobulin antibody Thyroid peroxidase antibody Thyroid-stimulating antibody Rationale: Thyroglobulin, thyroid peroxidase, and thyroid-stimulating antibodies are assessed in a thyroid antibody test. This test helps to differentiate other forms of thyroiditis from autoimmune thyroid disease. An active component of total T4 is measured by free thyroxine but cannot differentiate the origin. Thyroid-stimulating hormone levels are used to evaluate a thyroid dysfunction but cannot differentiate the origin.

What should the nurse emphasize when providing discharge instructions for a client with the diagnosis of Addison disease? Limit physical activity. Restrict sodium in the diet. Continue steroid replacement therapy. Schedule frequent health care appointments.

Continue steroid replacement therapy Rationale: Clients with Addison disease must take glucocorticoids regularly to enable them to adapt physiologically to stress and to prevent an addisonian crisis, a medical emergency similar to shock. Activity is permitted as tolerated. Sodium should be taken as desired because hyponatremia frequently occurs from diminished mineralocorticoid secretion. Frequent visits to a healthcare provider are not necessary after control has been established.

When taking the blood pressure of a client who had a thyroidectomy, the nurse identifies that the client is pale and has spasms of the hand. The nurse notifies the health care provider. Which should the nurse expect the health care provider to prescribe? Calcium Magnesium bicarbonate Potassium chloride

Calcium Rationale: These signs may indicate calcium depletion as a result of accidental removal of parathyroid glands during thyroidectomy. Symptoms associated with hypomagnesemia include tremor, neuromuscular irritability, and confusion. Symptoms associated with metabolic acidosis include deep, rapid breathing, weakness, and disorientation. Symptoms associated with hypokalemia include muscle weakness and dysrhythmias.

Which clinical findings should the nurse expect when assessing a client with hyperthyroidism? Select all that apply. Diarrhea Listlessness Weight loss Bradycardia Decreased appetite

Diarrhea Weight loss Rationale: Excessive thyroid hormones increase the metabolic rate, causing an increase in intestinal peristalsis. Excessive thyroid hormones increase the metabolic rate, causing weight loss. Listlessness occurs with hypothyroidism because of a decreased metabolic rate. A slow pulse rate accompanies hypothyroidism, not hyperthyroidism, because of a decreased metabolic rate. Appetite increases (polyphagia) with hyperthyroidism in an effort to meet metabolic needs.

A nurse is caring for a newly admitted client with a diagnosis of Graves disease. In preparing a teaching plan, the nurse anticipates which diet will be prescribed for this client? High-calorie diet Low-sodium diet High-roughage diet Mechanical soft diet

High-calorie diet Rationale: Because of the individual's increased metabolic rate, a high-calorie diet is needed to meet the energy demands of the body and prevent weight loss. Sodium is not restricted because clients with hyperthyroidism perspire heavily and lose sodium. Gastrointestinal motility is increased and does not require the additional stimulus of increased roughage. Modification of dietary consistency is unnecessary.

Which carcinoma is the most common type of thyroid cancer and is most often found in younger women? Papillary carcinoma Follicular carcinoma medullary carcinoma Anaplastic carcinoma

Papillary carcinoma Rationale: Papillary carcinoma is the most common type of thyroid cancer; it is most often seen in younger women. Follicular carcinoma occurs most often in older adults. Medullary carcinoma is seen mostly in clients older than 50 years. Anaplastic carcinoma is a rapid-growing, aggressive tumor.

Which parameter monitoring should be the nurse's priority while caring for a client with hypothyroidism? Pulse rate BP RR Body temperature

RR Rationale: Hypothyroidism is associated with a decreased respiratory rate. Therefore monitoring the client's respiratory rate should be the nurse's top priority. While hypotension, hypothermia, and pulse rate are important, they are not the priority.

A nurse is providing postoperative care for a client who has begun taking levothyroxine after undergoing a thyroidectomy. Which findings in the client may indicate potential thyrotoxic crisis? Elevated serum calcium Sudden drop in pulse rate Hypothermia and dry skin Rapid heartbeat and tremors

Rapid heartbeat and tremors Rationale: Thyrotoxic crisis (thyroid storm) refers to a sudden and excessive release of thyroid hormones, which causes pyrexia, tachycardia, and exaggerated symptoms of thyrotoxicosis; surgery, infection, and ablation therapy can precipitate this life-threatening condition. Hypercalcemia is not related to thyrotoxic crisis; hypocalcemia results from accidental removal of the parathyroid glands. Tachycardia is an increased, not decreased, heart rate, which occurs with thyrotoxic crisis because of the sudden release of thyroid hormones; thyroid hormones increase the basal metabolic rate. Fever, not hypothermia, and diaphoresis, not dry skin, occur with thyrotoxic crisis because of the sudden release of thyroid hormones, which increase the basal metabolic rate.

A nurse is caring for a client who had a thyroidectomy. Which client response should the nurse assess when concerned about an accidental removal of the parathyroid glands during surgery? Tetany myxedema Hypovolemic shock adrenocortical stimulation

Tetany Rationale: Parathyroid removal eliminates the body's source of parathyroid hormone (parathormone), which increases the blood calcium level. The resulting low body fluid calcium affects muscles, including the diaphragm, resulting in dyspnea, asphyxia, and death. Loss of the thyroid gland will upset thyroid hormone balance and may cause myxedema. The parathyroids are not involved in regulating plasma volume; the pituitary and adrenal glands are responsible. The parathyroids do not regulate the adrenal glands.