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.

Accepted Answer

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.

Accepted Answer

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:

Accepted Answer

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?

Accepted Answer

Graves' disease,the most common cause of hyperthyroidism,is associated with diffuse,bilateral enlargement of the thyroid gland.Surgery is reserved for those patients who fail medical therapy (antithyroid drugs and radioactive iodine)or have a contraindication to medical therapy.Surgery may be indicated to relieve tracheal or esophageal obstruction or to rule out a malignant nodule of the thyroid.

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.

Accepted Answer

Symptoms of hyperthyroidism include vision changes (e.g.,myopathy,ophthalmopathy,such as extraocular muscle enlargement or visual loss with prolonged optic nerve compression),emotional lability,mood changes,irritability,exercise intolerance,fatigue,weight loss,heat intolerance and flushing,hyperactivity (especially children),increased sweating,insomnia,tremor,muscle weakness,dyspnea,frequent bowel movements,and menstrual irregularity (oligomenorrhea,infertility).

Question 6

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

Accepted Answer

The parathyroid glands secrete PTH,an antagonist to calcitonin.Both PTH and calcitonin work together to maintain calcium homeostasis by increasing calcium removal from storage in bone and increasing absorption of calcium by the intestines.When the parathyroid glands do not secrete sufficient amounts of PTH,hypocalcemia may develop.

Question 7

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

Accepted Answer

Emergency care during thyroid storm requires the administration of antithyroid drugs such as propylthiouracil (PTU,Propyl-Thyracil),300 to 900 mg/day; or methimazole (MMI)(Tapazole),up to 60 mg/day.It is also important to maintain a patent airway and adequate ventilation.

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.

Accepted Answer

The AACE practice guidelines for the diagnostic evaluation of hyperthyroidism and hypothyroidism recommend TSH assay as the single best screening test.A thorough history and physical is indicated in screening for thyroid cancer.A history of being exposed to neck or whole-body radiation or being raised in iodine-poor areas should be assessed.A rapidly expanding neck mass,new onset of hoarseness,neck or ear pain,or cough are symptoms of concern.Patients with a fixed,immobile mass and/or hoarseness,dysphagia,or respiratory symptoms require CT or MRI imaging as part of the evaluation.These symptoms may be indicative of metastasis.Serum TSH measurement is the single most reliable test to diagnose all common forms of hypothyroidism and hyperthyroidism,with high sensitivity (98%)and specificity (92%).

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?

Accepted Answer

Proper patient positioning on the operating room (OR)bed is crucial for optimal exposure of the thyroid gland.The perioperative nurse should consider a patient who is not at optimal weight at high risk for pressure ulcer development and plan on padding pressure areas to prevent skin and tissue damage.

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:

Accepted Answer

Papillary carcinoma,which is poorly encapsulated,is the most common form (>70%)of malignant thyroid nodule.The second-most common form (10%),a well-differentiated form that is associated with iodine deficiency,is called follicular carcinoma.An undifferentiated form,medullary carcinoma accounts for 5% of malignancies.Anaplastic carcinoma is a highly aggressive and rapidly fatal malignancy that is more common in females and older adults.

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:

Accepted Answer

For patients with cancer of the thyroid,total or near-total thyroidectomy is the desired treatment.Following surgery,the thyroid cancer patient may be treated with radioactive ablation therapy for residual or metastatic disease and thyroid hormone suppression therapy.

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:

Accepted Answer

Studies show that patients with overactive thyroid conditions have an increased risk of various heart problems,particularly atrial fibrillation,that may lead to premature death.Atrial fibrillation can cause blood clots to form from the continuous blood turbulence in the atria.The perioperative nurse should determine whether anticoagulant and thyroid medications are being taken by the patient.The patient's baseline vital signs should be noted for an abnormally elevated resting pulse rate,elevated systolic blood pressure,and cardiac symptoms,such as palpitations or atrial fibrillation.

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.

Accepted Answer

When an alcohol-based prep solution is used around the head and neck,risk for surgical fire is increased.The patient's skin should be totally dry and all fumes from the prep solution should be dissipated prior to draping.Bedsheets or towels that become soaked with a flammable prep solution should be removed from the OR.Self-adherent tape strips or drapes reduce the risk of intraoperative fire hazard by sealing off the operative site from anesthetic vapors that may have leaked and become trapped under the drapes.

Question 14

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

Accepted Answer

Symptoms of hypothyroidism include fatigue,weight gain,cold intolerance,hair dryness or loss,dry skin,depression,hoarse voice,poor concentration,muscle stiffness and pain,edema,bradycardia,constipation,and menstrual irregularity (especially heavy menses and/or infertility).

Question 15

The pyramidal lobe of the thyroid is described as:

Accepted Answer

The pyramidal lobe,a long,thin projection of thyroid tissue protruding cephalad from the isthmus,is found in about 30% of patients at surgery; it is the vestige of the embryonic thyroglossal duct and migrates from the foramen cecum at the base of the tongue.

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:

Accepted Answer

Extensions of goiters enlarging into the substernal and intrathoracic regions may occur.If they cause tracheal and esophageal obstruction,they are usually excised surgically.Longer instruments are sometimes required.Splitting the sternum is rarely necessary,because access to the substernal part of the gland is usually satisfactory through the standard thyroid incision.

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:

Accepted Answer

By planning a quiet,calm atmosphere and helping the patient relax,the perioperative nurse can reduce the risk of thyroid storm.Collaborating with the surgical and anesthesia team,the perioperative nurse can plan for appropriate interventions to assist in reducing body temperature and heart rate,provide oxygen and intravenous (IV)solutions,and administer medications as prescribed in the event thyrotoxic crisis occurs.

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:

Accepted Answer

In the classic open approach,with the thyroid gland visible,bilateral neck exploration of the "normal" locations of the four parathyroid glands is conducted.A portion of a gland must remain to prevent hypocalcemia and its complications.The amount of remaining parathyroid tissue can then be adjusted to regulate PTH to the desired level.

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?

Accepted Answer

The recurrent laryngeal nerve,a branch of the vagus nerve,innervates the intrinsic muscles of the larynx.During surgery,care is taken to identify and protect this nerve.Immediate hoarseness occurs if the nerve is divided on one side.If the recurrent nerve is injured bilaterally,acute paralysis of both vocal cords may obstruct the airway and require emergency tracheotomy.Injury to the external branch of the superior laryngeal nerve,which innervates the cricothyroid muscle,results in difficulty shouting or singing high notes.

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.

Accepted Answer

Nontoxic nodular goiter involves production of insufficient hormones and is noninflammatory; in such cases thyroid tissue proliferates in an apparent attempt to produce the minimal hormonal requirement.Surgery may be indicated to relieve tracheal or esophageal obstruction or to rule out a malignant nodule of the thyroid.

Quiz 16: Thyroid and Parathyroid Surgery