Deck 15: Thyroid and Parathyroid Surgery

Question 1

Substernal or intrathoracic thyroidectomy is indicated for extensions of 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.

Answer 1

C
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 2

Pamela Morris is a 62-year-old woman with a 4-year history of Graves' disease that has not responded to medical therapy.She is scheduled for a subtotal thyroidectomy.What 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) Hyperthyroidism with cricothyroid compression
D) Autoimmune hypothyroidism

Answer 2

A
Graves' disease,the most common cause of hyperthyroidism,is associated with diffuse,bilateral enlargement of the thyroid gland.Surgery is not the first response for Graves' disease,but is reserved for those patients who fail medical therapy (antithyroid drugs and radioactive iodine)or have a contraindication to medical therapy.Surgery is performed to relieve tracheal obstruction.

Question 3

Linda Martinez,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 Linda'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

Answer 3

C
Nontoxic nodular goiter involves production of insufficient hormones and is noninflammatory in character;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.

Question 4

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 5

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) the decrease in blood calcium levels.

Question 6

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 7

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 8

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 from that is an appropriate reflection of a thyroid diagnostic study.

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

Question 9

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 pulsating neck mass
D) TSH assay,neck or ear pain,dysphagia

Question 10

Norma Hightower,a 32-year-old thin and pale patient with hypothyroidism,is met by the
Perioperative nurse for her preoperative assessment.The nurse notes Norma's thin frame and pale,fragile skin.Norma states that she is so cold that she has all of her clothes on under her patient gown.Based on her assessment,the nursing diagnosis for Norma will focus interventions on her:

A) risk for hypothermia.
B) risk for skin and tissue injury.
C) risk for injury related to surgical positioning.
D) All of the nursing diagnoses are correct.

Question 11

Postoperative hoarseness,obstructed airway,or paralysis of the vocal cords is a serious complication 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 12

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's 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's tilt of the OR bed
D) Headrest,arms abducted at 90 degrees on armboards,and axillary roll

Question 13

Shari Donaldson is scheduled for a thyroidectomy.She is significantly underweight as a result of her thyroid disease.The perioperative nurse considers her to be at high risk for pressure and shearing injury to skin and tissues.An example of a nursing consideration in the preoperative phase for Shari would be:

A) perform a preoperative assessment of dependent pressure areas.
B) note patient issues with body image.
C) assure the patient that she will be carefully positioned and padded.
D) suggest a wound ostomy nurse referral for the patient for postoperative skin care.

Question 14

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 15

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) Include the fire risk score during the time-out briefing.
B) Prevent prep solution from pooling under the patient's head,neck,and shoulders.
C) Permit the prep solution to dry before draping.
D) All the options are risk reduction considerations.

Question 16

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 a nursing action(s)to reduce the risk of thyroid storm is:

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 17

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:

A) ask the patient if he/she is a vocalist and concerned about the postoperative effect of surgery on the voice.
B) confirm whether anticoagulation medication is being taken.
C) note the patient's muscle strength,elimination patterns,and history of weight loss.
D) note signs of anxiety and issues related to body image concerns with neck surgery.

Question 18

A patient having a subtotal thyroidectomy for tracheal or esophageal obstruction is best served by a surgical team that recognizes and is prepared for patients who are at risk for difficult intubation.An example of a nursing intervention during the postoperative phase would be:

A) monitor the patient closely for airway difficulty.
B) prevent coughing.
C) support the neck during movement.
D) prevent postoperative nausea and vomiting.

Question 19

Hypothyroidism results from undersecretion of thyroid hormone.The most common cause of primary hypothyroidism is chronic autoimmune thyroiditis (Hashimoto's disease).Select the set of symptoms that is most commonly associated with hypothyroidism.

A) Dry skin,edema,constipation,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 20

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 21

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

A) paying meticulous attention to sterile technique.
B) providing efficient and expedient hemostatic devices and materials as needed.
C) maintaining sterility of the instruments until the patient leaves the room in the case of need for emergency tracheostomy.
D) All the options reflect appropriate scrub role risk reduction techniques.

Question 22

Melissa Pepe is a 17-year-old female with cancer of the thyroid secondary to leukemia,which 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 Melissa and encouraged her to discuss her fears and expectations.Together,they collaborated on a plan for Melissa's discharge and care of her incision.The nurse documented Melissa's nursing diagnosis as:Disturbed Body Image related to surgical scar in prominent location.The nurse discussed Melissa's concerns with the surgical team before the incision was made.Melissa 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 Melissa with her postoperative education relative to her incision.Select all the incision care instructions that would be relevant for Melissa.

A) Instruct Melissa to focus on positive feelings related to body image.
B) Instruct Melissa 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.

Question 23

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 (select all that apply):

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 24

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.