1.
A patient is admitted to the medical unit with possible Graves’ disease (hyperthyroidism). Which assessment finding supports this diagnosis?
Correct Answer
C. ExopHthalmos
Explanation
Exophthalmos (abnormal protrusion of the eye) is characteristic of patients with hyperthyroidism due to Graves’ disease. Periorbital edema, bradycardia, and hoarse voice are all characteristics of patients with hypothyroidism. Focus: Prioritization
2.
Which change in vital signs would you instruct a nursing assistant to report immediately for a patient with hyperthyroidism?
Correct Answer
A. Increased and rapid heart rate
Explanation
The cardiac problems associated with hyperthyroidism include tachycardia, increased systolic blood pressure, and decreased diastolic blood pressure. Patients with hyperthyroidism also may have increased body temperature related to increased metabolic rate. Focus: Delegation/supervision
3.
For the patient with hyperthyroidism, what intervention should you delegate to the experienced certified nursing assistant?
Correct Answer
B. Check the apical pulse, blood pressure, and temperature every 4 hours.
Explanation
Monitoring and recording vital signs are within the education scope of nursing assistants. An experienced nursing assistant should have been taught how to monitor the apical pulse. However, the nurse should observe the nursing assistant to be sure that she has mastered this skill. Instructing and teaching patients, as well as performing venipuncture for laboratory samples, are more suited to the educational scope of licensed nurses. In some facilities, an experienced nursing assistant may perform venipuncture, but only after special training. Focus: Delegation/supervision
4.
A client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client’s medication?
Correct Answer
B. The client complains of increased thirst and increased urination.
Explanation
Increased thirst and increased urination are signs of lithium toxicity.
5.
Which nursing diagnosis takes highest priority for a female client with hyperthyroidism?
Correct Answer
D. Imbalanced nutrition: Less than body requirements related to thyroid hormone excess
Explanation
In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism. These conditions may result in a negative nitrogen balance, increased protein synthesis and breakdown, decreased glucose tolerance, and fat mobilization and depletion. This puts the client at risk for marked nutrient and calorie deficiency, making Imbalanced nutrition: Less than body requirements the most important nursing diagnosis.
6.
Matilda, with hyperthyroidism is to receive Lugol’s iodine solution before a subtotal thyroidectomy is performed. The nurse is aware that this medication is given to:
Correct Answer
D. Decrease the size and vascularity of the thyroid gland.
Explanation
Lugol’s solution provides iodine, which aids in decreasing the vascularity of the thyroid gland, which limits the risk of hemorrhage when surgery is performed.
7.
The physician orders laboratory tests to confirm hyperthyroidism in a female client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis?
Correct Answer
A. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test
Explanation
In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. A decreased TSH level indicates a pituitary deficiency of this hormone. Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level also occurs in malnutrition and liver disease and may result from administration of phenytoin and certain other drugs.
8.
Ms.Clark has hyperthyroidism and is scheduled for a thyroidectomy. The physician has ordered Lugol’s solution for the client. The nurse understands that the primary reason for giving Lugol’s solution preoperatively is to:
Correct Answer
C. Reduce the size and vascularity of the thyroid and prevent hemorrhage.
Explanation
Doses of over 30 mg/day may increase the risk of agranulocytosis. Lugol’s solution does not act to prevent tetany. Calcium is used to treat tetany. The client may receive iodine solution (Lugol’s solution) for 10 to 14 days before surgery to decrease vascularity of the thyroid and thus prevent excess bleeding. Lugol’s solution does not potentiate any other preoperative medication.
9.
A 38 year old woman returns from a subtotal thryroidectomy for the treatment of hyperthyroidism. Upon assessment, the immediate priority that the nurse would include is:
Correct Answer
D. Assess for respiratory distress
Explanation
Though fluid volume status, neurological status and pain are all important assessment, the immediate priority for postoperative is the airway management. Respiratory distress may result from hemorrhage, edema, laryngeal damage or tetany.
10.
Untreated hyperthyroidism during pregnancy may result in all of the following except:
Correct Answer
C. Autism
Explanation
In addition to the above-mentioned complications of uncontrolled hyperthyroidism in pregnancy, expectant mothers may suffer congestive heart failure and thyroid storm, which is life-threatening thyrotoxicosis with symptoms that include agitation, confusion, tachycardia, shaking, sweating, diarrhea, fever, and restlessness.
11.
Which nursing diagnosis takes highest priority for a client with hyperthyroidism?
Correct Answer
D. Imbalanced nutrition: Less than body requirements related to thyroid hormone excess
Explanation
In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism. These conditions may result in a negative nitrogen balance, increased protein synthesis and breakdown, decreased glucose tolerance, and fat mobilization and depletion. This puts the client at risk for marked nutrient and calorie deficiency, making Imbalanced nutrition: Less than body requirements the most important nursing diagnosis.
12.
A client is being returned after subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client’s bedside?
Correct Answer
B. Tracheostomy set
Explanation
After subtotal thyroidectomy, swelling of the surgical site ( the tracheal area) may obstruct the airway. Therefore tracheostomy set should be at the bedside in case of respiratory emergency.
13.
What are the functions of T3 and T4?
Correct Answer
D. Regulation of energy production
Explanation
T3 and T4, also known as thyroid hormones, play a crucial role in regulating energy production in the body. These hormones are responsible for controlling the metabolism of cells, which affects how the body uses energy. They stimulate the production of ATP, the energy currency of cells, and regulate the breakdown of fats, proteins, and carbohydrates to provide energy. Therefore, the correct answer is "Regulation of energy production."
14.
Which of the following nursing assessment is the most important in the patient with hyperthyroidism and risk for thyrotoxic crisis or thyroid storm?
Correct Answer
D. Vital signs
Explanation
In a patient with hyperthyroidism and risk for thyrotoxic crisis or thyroid storm, monitoring vital signs is the most important nursing assessment. Vital signs such as heart rate, blood pressure, respiratory rate, and temperature can provide crucial information about the patient's cardiovascular and metabolic status. Hyperthyroidism can cause an increase in heart rate and blood pressure, and monitoring these vital signs can help detect any abnormalities or signs of worsening thyrotoxic crisis. Assessing vital signs regularly allows for early identification and prompt intervention in case of any deterioration in the patient's condition.
15.
Which medication will the nurse have available for emergency treatment of tetany in the client who has had thyroidectomy?
Correct Answer
A. Calcium chloride
Explanation
After a thyroidectomy, a patient may develop hypocalcemia, which can lead to tetany (a condition characterized by muscle cramps and spasms). This occurs because the parathyroid glands, which regulate calcium levels in the blood, may be inadvertently damaged or removed during surgery. For emergency treatment of tetany, calcium chloride is used to rapidly increase calcium levels in the blood and alleviate the symptoms. Potassium chloride, magnesium chloride, and sodium bicarbonate are not used for treating tetany related to hypocalcemia.