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

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?
Client with chronic hypothyroidism and dementia who takes levothyroxine (Synthroid) daily Correct
Client with follicular thyroid cancer who has vocal hoarseness and difficulty swallowing
Client with Graves' disease who is experiencing increasing anxiety and diaphoresis
Client with hyperparathyroidism who has just arrived on the unit after a parathyroidectomy
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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?
Client with chronic hypothyroidism and dementia who takes levothyroxine (Synthroid) daily Correct
Client with follicular thyroid cancer who has vocal hoarseness and difficulty swallowing
Client with Graves' disease who is experiencing increasing anxiety and diaphoresis
Client with hyperparathyroidism who has just arrived on the unit after a parathyroidectomy
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.
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)?
Ask the client about any numbness or tingling.
Check for bone deformities in the client's back.
Measure the client's intake and output hourly. Correct
Monitor the client for shortness of breath.
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.
Which action does the postanesthesia care unit (PACU) nurse perform first when caring for a client who has just arrived after a total thyroidectomy?
Assess the wound dressing for bleeding.
Give morphine sulfate 4 to 8 mg IV for pain.
Monitor oxygen saturation using pulse oximetry. Correct
Support the head and neck with sandbags.
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.
The RN has just received change-of-shift report on the medical-surgical unit. Which client will need to be assessed first?
Client with Hashimoto's thyroiditis and a large goiter
Client with hypothyroidism and an apical pulse of 51 beats/min
Client with parathyroid adenoma and flank pain due to a kidney stone
Client who had a parathyroidectomy yesterday and has muscle twitching Correct
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.
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 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?
"You should see effects of this medication immediately."
"You should see effects of this medication within 1 week."
"You should see full effects from this medication within 1 to 2 days."
"You should see some effects of this medication within 2 weeks." Correct
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.
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.
A client has hyperparathyroidism. Which incident witnessed by the nurse requires the nurse's intervention?
The client eating a morning meal of cereal and fruit
The physical therapist walking with the client in the hallway
Unlicensed assistive personnel pulling the client up in bed by the shoulders Correct
Visitors talking with the client about going home
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.
A client is being discharged with propylthiouracil (PTU). Which statement by the client indicates a need for further teaching by the nurse?
"I can return to my job at the nursing home." Correct
"I must call if my urine is dark."
"I must faithfully take the drug every 8 hours."
"I need to report weight gain."
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.
A client admitted with hyperthyroidism is fidgeting with the bedcovers and talking extremely fast. What does the nurse do next? Calls the provider Encourages the client to rest Correct Immediately assesses cardiac status Tells the client to slow downThe 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.Family members of a client diagnosed with hyperthyroidism are alarmed at the client's frequent mood swings. What is the nurse's response? "How does that make you feel?" "The mood swings should diminish with treatment." Correct "The medications will make the mood swings disappear completely." "Your family member is sick. You must be patient."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 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? Administers acetaminophen Alerts the Rapid Response Team Asks any visitors to leave Assesses the client's cardiac status completely CorrectIf 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 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? Advise the client to go to a calming environment. Ask whether the client has increased cold sensitivity or weight gain. Correct Instruct the client to see his health care provider immediately. Tell the client to check his pulse again and call back later.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 had a parathyroidectomy 18 hours ago. Which finding requires immediate attention? Edema at the surgical site Hoarseness Correct Pain on moving the head Sore throatHoarseness 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.The nurse is teaching a client about thyroid replacement therapy. Which statement by the client indicates a need for further teaching? "I should have more energy with this medication." "I should take it every morning." "If I continue to lose weight, I may need an increased dose." Correct "If I gain weight and feel tired, I may need an increased dose."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.A client recently admitted with hyperparathyroidism has a very high urine output. Of these actions, what does the nurse do next? Calls the health care provider Monitors intake and output Correct Performs an immediate cardiac assessment Slows the rate of IV fluidsDiuretic 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 with thyroid cancer has just received 131I ablative therapy. Which statement by the client indicates a need for further teaching? "I cannot share my toothpaste with anyone." "I must flush the toilet three times after I use it." "I need to wash my clothes separately from everyone else's clothes." "I'm ready to hold my newborn grandson now." CorrectClients 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.Which type of thyroid cancer often occurs as part of multiple endocrine neoplasia (MEN) type II? Anaplastic Follicular Medullary Correct PapillaryMedullary 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.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.) Calcium gluconate Correct Emergency tracheotomy kit Correct Furosemide (Lasix) Hypertonic saline Oxygen Correct Suction CorrectCalcium 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.