2. 1. Which nursing diagnosis takes priority for a client with hyperthyroidism? Imbalance nutrition: more than body requirements related to thyroid hormone excess Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing Disturbed body image related to weight gain and edema Imbalance nutrition: less than body requirements related to thyroid hormone excess
4. 1. Which nursing diagnosis takes priority for a client with hyperthyroidism? Imbalance nutrition: more than body requirements related to thyroid hormone excess Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing Disturbed body image related to weight gain and edema Imbalance nutrition: less than body requirements related to thyroid hormone excess
5. Rationale: In a client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increase nutrient metabolism. These condition may result in a negative nitrogen balance, increased protein synthesis and breakdown, decrease glucose tolerance and fat mobilization and depletion.
7. 2. The nurse should expect a client with hypothyroidism to report which of the following health concerns? Increase appetite and weight loss Puffiness of the face and hands Nervousness and tremors Enlarged thyroid gland
9. 2. The nurse should expect a client with hypothyroidism to report which of the following health concerns? Increase appetite and weight loss Puffiness of the face and hands Nervousness and tremors Enlarged thyroid gland
10. Hypothyroidism (myxedema) causes facial puffiness, extremity edema, and weight gain. Sign and symptoms of hyperthyroidism (graves disease) include an increase appetite, weight loss, nervousness, tremors and thyroid gland enlargement (goiter)
12. 3. To correct a client’s long term hypothyroid condition, synthroid may be ordered. When administering the drug, the nurse should be aware that: The larger the dose, the more quickly the client will feel better The client will need to take the drug for 6 months to improve Hypothyroidism must be corrected slowly because the body needs time to adjust The time of administration and the dosage amount aren’t relevant
14. 3. To correct a client’s long term hypothyroid condition, synthroid may be ordered. When administering the drug, the nurse should be aware that: The larger the dose, the more quickly the client will feel better The client will need to take the drug for 6 months to improve Hypothyroidism must be corrected slowly because the body needs time to adjust The time of administration and the dosage amount aren’t relevant
15. Rationale: A hypothyroidism state must be corrected slowly because a correction made too rapidly may result to angina, arrhythmias, or myocardial infarction. The improvement of symptoms may take 2-3 weeks. The dosage amount is relevant to client’s response.
17. 4. For a patient with Graves disease, which nursing intervention promotes comfort? Restricting intake of oral fluids Placing extra blankets on client’s bed Limiting intake of high carbohydrate foods Maintaining room temperature in the low-normal level
19. 4. For a patient with Graves disease, which nursing intervention promotes comfort? Restricting intake of oral fluids Placing extra blankets on client’s bed Limiting intake of high carbohydrate foods Maintaining room temperature in the low-normal level
20. Rationale: Graves disease causes sign and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client’s room temperature in to low-normal range.
22. 5. 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? Orange juice and hard candy Tracheostomy set Cardiac monitor and oxygen tank Indwelling catheter tray
24. 5. 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? Orange juice and hard candy Tracheostomy set Cardiac monitor and oxygen tank Indwelling catheter tray
25. Rationale: 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.
27. 6. What are the functions of T3 and T4? Retention of salt and water Maintenance of blood sugar Maintenance of blood pressure Regulation of energy production
29. 6. What are the functions of T3 and T4? Retention of salt and water Maintenance of blood sugar Maintenance of blood pressure Regulation of energy production
31. Which of the following statements by the patient with hypothyroidism indicates to the nurse that the plan of care has been effective? “I feel so much better now that my energy is returning” “I'm really glad the diarrhea has stop” “I’m so glad I won’t have to take medication for very long” “my fingers aren’t tingling anymore”
33. Which of the following statements by the patient with hypothyroidism indicates to the nurse that the plan of care has been effective? “I feel so much better now that my energy is returning” “I'm really glad the diarrhea has stop” “I’m so glad I won’t have to take medication for very long” “my fingers aren’t tingling anymore”
35. 8. Which of the following nursing assessment is the most important in the patient with hyperthyroidism and risk for thyrotoxic crisis or thyroid storm? Intake and output Heart sounds Bowel sounds Vital signs
37. 8. Which of the following nursing assessment is the most important in the patient with hyperthyroidism and risk for thyrotoxic crisis or thyroid storm? Intake and output Heart sounds Bowel sounds Vital signs
39. 9. Which medication will the nurse have available for emergency treatment of tetany in the client who has had thyroidectomy? Calcium chloride Potassium chloride Magnesium chloride Sodium bicarbonate
41. 9. Which medication will the nurse have available for emergency treatment of tetany in the client who has had thyroidectomy? Calcium chloride Potassium chloride Magnesium chloride Sodium bicarbonate
49. 12. A client with history of hyperparathyroidism admits to being non compliant. Based on the initial assessment the nurse formulates a nursing diagnosis of risk for injury. To complete the nursing diagnosis statement for this client, which “related to” phrase should the nurse add? Related to bone demineralization resulting in pathologic fractures Related to exhaustion secondary to accelerated metabolic rate Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces Related to tetany secondary to decrease serum calcium level
51. 12. A client with history of hyperparathyroidism admits to being non compliant. Based on the initial assessment the nurse formulates a nursing diagnosis of risk for injury. To complete the nursing diagnosis statement for this client, which “related to” phrase should the nurse add? Related to bone demineralization resulting in pathologic fractures Related to exhaustion secondary to accelerated metabolic rate Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces Related to tetany secondary to decrease serum calcium level
52. Rationale: Poorly controlled hyperparathyroidism may cause elevated serum calcium level. This, in turn may diminish calcium store in the bones, causing bone demineralization and setting stage for pathologic fracture and risk for injury.
54. 13. On the third day after subtotal thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and finger tips. Suspecting a life-threatening electrolyte imbalance , the nurse notifies the surgeon immediately. Which electrolyte imbalance most commonly follows thyroid surgery? Hypocalcemia Hyponatremia Hyperkalemia hypercalcemia
56. 13. On the third day after subtotal thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and finger tips. Suspecting a life-threatening electrolyte imbalance , the nurse notifies the surgeon immediately. Which electrolyte imbalance most commonly follows thyroid surgery? Hypocalcemia Hyponatremia Hyperkalemia hypercalcemia
57. Rationale: Hypocalcemia may follow thyroid surgery if the parathyroid glands were removed accidentally. Signs of tetany from hypocalcemia includes the chvosteks and troussea sign.
