Deck 16: Thyroid and Parathyroid Surgery

Question 1

The preoperative testing regimen for diagnosing thyroid disorders follows a structured plan of history taking,neck palpation,imaging scans,and fine needle aspiration.Select the statement that is an appropriate description of a thyroid diagnostic study.

A) Palpation: determines size, contour, swallowing function, lymph nodes, and bruits.
B) Fluoroscopy-guided fine needle aspiration: typically performed for frozen section.
C) Ultrasonic scans: the treatment of choice to evaluate thyroid nodules.
D) Magnetic resonance imaging (MRI) and computed tomography (CT) scans: evaluate local invasion of the tumor nodules within the thyroid capsule.

Answer 1

C
Ultrasonic scans evaluate thyroid nodules and are useful to determine the size and number of nodules within the thyroid as well as to monitor size progression during follow-up.In addition to palpation of the thyroid gland for size,contour,consistency,lymph nodes,fixation,tenderness,and bruits,scans are used to clarify thyroid anatomy.CT and MRI scans are used to assess a thyroid with suspected malignancy for encroachment of the tumor outside the thyroid capsule into the adjacent tissue of the neck.Scans are the most effective means to evaluate local invasion of surrounding tissue.Fine needle aspiration is usually performed under ultrasound guidance.Several samples are aspirated from various parts of the nodule.

Question 2

Anatomic exposure is promoted and supported by proper body alignment in collaboration with safe and secure surgical positioning.The optimal presentation of the thyroid and surrounding structures of the neck can be achieved with the patient in supine or beach-chair position.Select the positioning considerations that enhance visualization and access to important structures.

A) 30-degree Trendelenburg tilt of the OR bed, shoulder roll, and arms tucked snuggly at sides
B) Hyperflexion of the neck, shoulder roll, and arms tucked loosely at sides with palms facing up
C) Hyperextension of the neck, shoulder roll, and 30-degree reverse Trendelenburg tilt of the OR bed
D) Headrest, arms abducted at 90 degrees on arm boards, and axillary roll

Answer 2

C
Proper patient positioning on the OR bed is crucial for optimal exposure of the thyroid gland.The patient is positioned supine.Some surgeons prefer a beach-chair position or a wedge under the back.Hyperextension of the neck is required for maximal exposure.A headrest provides proper support,keeps the head straight,and prevents aggravation of prior neck problems.Alternatively,a shoulder roll may be used.The arms are tucked at the side,the elbows are padded to protect the ulnar nerve,the palms faced inward,and the wrist is maintained in a neutral position.Reduction of venous congestion can be accomplished by a 30-degree reverse Trendelenburg tilt of the OR bed.

Question 3

The primary function of the three thyroid hormones is to regulate:

A) energy metabolism.
B) body growth and development.
C) calcium storage in the bones.
D) blood calcium levels.

Answer 3

A
The thyroid gland produces three hormones: thyroxine (T₄)and triiodothyronine (T₃)(together known as the thyroid hormones [THs])and calcitonin.T₃ and T₄ cannot be synthesized without iodine and regulate energy metabolism and growth and development.Calcitonin inhibits calcium resorption from bone and increases calcium storage in the bone.In addition,calcitonin increases renal excretion of calcium and phosphorus and decreases serum calcium levels.When elevations in serum calcitonin are found in the patient's blood work,medullary thyroid cancer is suspected.

Question 4

A 62-year-old woman with a 4-year history of Graves' disease has not responded to medical therapy.She is scheduled for a subtotal thyroidectomy.Which condition,a complication of Graves' disease,is her probable indication for a subtotal thyroidectomy?

A) Tracheal obstruction
B) Diffuse unilateral enlargement of a lobe
C) Cricothyroid compression
D) Autoimmune hypothyroidism

Question 5

The patient with hyperthyroidism most likely has received appropriate drug therapy that has returned thyroid hormone levels and metabolic state to normal; however,the perioperative nurse should assess for any symptoms that relate to accelerated metabolism.Select the set of symptoms that is most commonly associated with hyperthyroidism.

A) Atrial fibrillation, anxiety, weight gain, and cold intolerance
B) Tachypnea, dry mouth, systemic pruritus, and heavy menses
C) Fatigue, vision changes, disturbed concentration, and vertigo
D) Increased sweating, insomnia, tremor, and muscle weakness

Question 6

What is the mechanism by which the parathyroid glands maintain calcium homeostasis?

A) They secrete parathyroid hormone (PTH), which promotes calcium storage in the intestines.
B) They produce a hormone that, with calcitonin, takes calcium from the bones and promotes calcium absorption by the intestines.
C) They stimulate the pituitary to produce PTH and calcitonin, which elevates serum calcium levels.
D) They secrete hormones that stimulate the production of calcium in the bones and small intestines when serum calcium levels fall below 4.5 mg/dL.

Question 7

An example of antithyroid drugs that would be administered during a thyroid storm crisis would be:

A) sodium iodide solution and Lugol's solution.
B) propylthiouracil and methimazole.
C) guanethidine and ipodate sodium.
D) propranolol and lithium.

Question 8

A number of symptoms and signs are well-established manifestations of thyroid dysfunction.The American Association of Clinical Endocrinologists (AACE)has established practice guidelines for the diagnostic evaluation and screening of hyperthyroidism and hypothyroidism.The AACE recommends the ___________ as the single best screening test.A history of ___________ are symptoms of concern,and patients with ___________ require MRI or CT imaging,because this may be indicative of metastasis.Select the clinical triad to complete this diagnostic screening guideline.

A) serum TSH; calcifications; cough
B) thyroxin profile; whole-body radiation; Hashimoto's disease
C) free thyroid hormone levels; thyroiditis; a fixed immobile neck mass
D) TSH assay, neck or ear pain, dysphagia

Question 9

A 19-year-old woman is scheduled for a thyroidectomy.She is significantly underweight as a result of her thyroid disease.Of the following,which is the high-priority nursing action in the preoperative phase for this patient?

A) Perform a preoperative assessment of dependent pressure areas.
B) Identify age-specific outcomes.
C) Identify baseline musculoskeletal status.
D) Treat the patient as being high-risk for falls.

Question 10

A total thyroidectomy may be done for a variety of malignant tumors.The most common form of malignant thyroid nodule is a poorly encapsulated type known as:

A) follicular carcinoma.
B) anaplastic carcinoma.
C) papillary carcinoma.
D) medullary carcinoma.

Question 11

Total thyroidectomy is the removal of both lobes of the thyroid and all thyroid tissue present.Total thyroidectomy is the desired surgical treatment for patients with:

A) hyperthyroidism with more than two episodes of thyroid storm.
B) thyroid cancer.
C) autoimmune inflammatory thyroid dysfunction.
D) hypothyroidism unresponsive to antithyroid medications.

Question 12

Patients with hyperthyroidism should be assessed and monitored for an abnormally elevated resting pulse rate,elevated systolic blood pressure,and cardiac symptoms.Atrial fibrillation is the most common cardiac complication of hyperthyroidism.An example of a nursing action during the nursing assessment phase would be to:

A) determine if muscle weakness or atrophy is present.
B) confirm whether anticoagulation medication is being taken.
C) monitor core temperature.
D) observe for seizures.

Question 13

Thyroid surgery is considered surgery of the head and neck.There is a high risk for surgical fires because of the proximity of all three components of the fire triangle.Select the statement that best reflects an appropriate nursing action to prevent a surgical fire.

A) Do not use self-adherent tape strips; they do not adequately seal the operative site from anesthetic vapors that may have leaked.
B) If bedsheets or towels become soaked with flammable prep solution, allow them to dry completely before surgery begins.
C) Ensure that the patient's skin is totally dry and all fumes from the prep solution have dissipated before draping.
D) Determine fire risk score during the postprocedure debriefing.

Question 14

Hypothyroidism results from undersecretion of thyroid hormone.Select the set of symptoms that is most commonly associated with hypothyroidism.

A) Dry scaly skin, patchy hair, muscle cramps, and depression
B) Irritability, mood changes, visual disturbances, and diarrhea
C) Heat intolerance, anorexia, hair loss, and menstrual irregularity
D) Bradycardia, hypotension, hypoxia, and poor concentration

Question 15

The pyramidal lobe of the thyroid is described as:

A) a small lobe often involved in 30% of cases of thyroid dysfunction.
B) a protrusion of an immature thyroglossal duct cyst overgrowth.
C) a thin upward protrusion of thyroid tissue from the isthmus.
D) a vestige of an embryonic thyroid cyst.

Question 16

Substernal or intrathoracic thyroidectomy is indicated for goiters that are encroaching into the substernal or intrathoracic regions,causing tracheal or esophageal obstruction.Access to the substernal compartment is typically facilitated by:

A) splitting the sternum.
B) using a right mini-thoracotomy approach.
C) using long instruments through a regular thyroid incision.
D) using a mediastinoscopy approach.

Question 17

Thyroid storm can occur in patients whose hyperthyroidism is partially controlled or untreated.Thyrotoxic crisis can be precipitated by a stressful event,such as surgery.An example of nursing action(s)to reduce the risk of thyroid storm is to:

A) administer potassium iodide before transfer to the OR.
B) provide a quiet, calm atmosphere and help the patient relax.
C) provide comfort measures, including a cooling blanket.
D) provide a quiet, calm atmosphere and help the patient relax, and provide comfort measures, including a cooling blanket.

Question 18

Open parathyroidectomy is currently being replaced with less invasive and more targeted techniques; however,the amount of parathyroid tissue that should be removed remains controversial and relates to whether single or multiple glands are involved.A portion of a gland must remain to:

A) prevent hypocalcemia and its complications.
B) serve as a marker for later surgery should the gland fail to produce PTH.
C) regenerate into normal parathyroid tissue.
D) maintain the patient in a state of hypercalcemia to compensate for the lost glands.

Question 19

Postoperative hoarseness,obstructed airway,and paralysis of the vocal cords are serious complications of thyroid surgery.During surgery,care is taken to identify and protect which nerve?

A) Superior branch of the vagus nerve
B) Intrinsic cricothyroid nerve
C) Recurrent tracheoesophageal nerve
D) Recurrent laryngeal nerve

Question 20

A 61-year-old woman with nontoxic nodular goiter is scheduled for a subtotal thyroidectomy to relieve esophageal obstruction and rule out a malignant nodule.Select the statement that best describes the patient's thyroid dysfunction and cause.

A) Hypothyroidism resulting from inflammatory impairment of cells that produce hormones
B) Hyperthyroidism resulting from overproduction of enlarged normal thyroid cells
C) Hypothyroidism resulting from insufficient hormone production, increasing thyroid tissue proliferation
D) Hyperthyroidism resulting from malignant spread of mutated hormone-producing tissue

Question 21

A 32-year-old thin and pale patient with hypothyroidism is met by the perioperative nurse for her preoperative assessment.The nurse notes the patient's thin frame and pale,fragile skin.The patient states that she is so cold that she has all of her clothes on under her patient gown.Based on her assessment,the nursing diagnoses for the patient include:

A) ineffective thermoregulation.
B) risk for decreased cardiac tissue perfusion.
C) risk for perioperative positioning injury.
D) risk for electrolyte imbalance.
E) risk for metabolic deterioration.

Question 22

A 41-year-old woman with suspected primary adenocarcinoma of the thyroid is scheduled for total thyroidectomy surgery.The scrub person,a new perioperative nurse,is determined to participate in employing risk reduction strategies in the scrub role.Examples of risk reduction strategies for thyroid surgery,within the domain of the scrub role,would be:

A) allowing skin prep agents to dry and fumes to dissipate before draping.
B) providing efficient and expedient dressing materials as needed.
C) maintaining sterility of the instruments until the patient leaves the room in the case of need for emergency tracheostomy.
D) using self-adherent tape strips.
E) confirming patient allergies.

Question 23

Review the list below and select the answer that more accurately compares/contrasts thyroid storm and thyrotoxicosis.

A) Thyroid storm is a rare, severe, exaggerated, and life-threatening condition of thyrotoxicosis and is triggered by precipitating factors.
B) Thyroid storm and thyrotoxicosis may be differentiated by laboratory studies.
C) Antithyroid drugs remain the mainstay of treatment in both thyroid storm and thyrotoxicosis.
D) Both thyroid storm and thyrotoxicosis represent a hypometabolic state.

Question 24

A minimally invasive video-assisted thyroidectomy (MIVAT)procedure relies on Miccoli instruments added to the standard thyroid or neck dissection setup,a 30-degree endoscope,and an ultrasonic (harmonic)scalpel with scissors to ligate and divide the vessels.An important risk-reduction strategy for any minimally invasive procedure would be to:

A) note the amount of CO₂ volume in connected tank and tanks available.
B) consider and plan for the possibility of conversion to open thyroidectomy.
C) position and drape the patient as for thyroidectomy.
D) use fire-resistant light cords, endoscopes, light sources, and cable connections.

Question 25

A 17-year-old girl with cancer of the thyroid secondary to leukemia went into remission 7 years earlier.She is in good health and eager to get back to school in time for the prom and final exams; however,she is very concerned about scarring from the surgery.The circulating nurse sat with the patient and encouraged her to discuss her fears and expectations.Together,they collaborated on a plan for the patient's discharge and care of her incision.The nurse documented the patient's nursing diagnosis as disturbed body image related to surgical scar in a prominent location.The nurse discussed the patient's concerns with the surgical team before the incision was made.The patient had a minimally invasive thyroidectomy approach,which left a small scar that was closed with a 4-0 nonabsorbable subcuticular suture.In the postoperative phase,the nurse provided the patient with her postoperative education relative to her incision.Select all the incision care instructions that would be relevant for the patient.

A) Instruct the patient to focus on positive feelings related to body image.
B) Instruct the patient in postoperative turning measures that decrease strain on the suture line.
C) Suggest accessories (e.g., jewelry, scarves, and certain necklines) that can be used to cover the scar until normal fading occurs.
D) Instruct her to refrain from prolonged exposure to direct sunlight or tanning salons while the incision is healing.
E) Use cosmetic creams with cocoa butter to decrease scarring and discoloration.