Deck 7: Thyroid and Parathyroid Surgery

Question 1

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

Answer 1

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 face inward, and the wrist is maintained in a neutral position. Reduction of venous congestion can be accomplished by a 30-degree reverse Trendelenburg's tilt of the OR bed.

Question 2

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

Answer 2

A
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; infertility).

Question 3

Jennifer Peoples is a 41-year-old woman with suspected primary adenocarcinoma of the thyroid; she is scheduled for total thyroidectomy surgery. How can the scrub person, Joni, a new surgical technologist, participate in using risk reduction strategies in the scrub role?

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

Answer 3

D
Attention to sterile technique is a core team value. Gentle tissue handling reduces the risk of damage to nerves, parathyroid glands, and surrounding structures. Achieving and maintaining hemostasis promotes visibility and reduces postoperative bleeding. The scrub person keeps instruments sterile for those patients who are at risk for postoperative bleeding. This would include patients with large thyroids that necessitated finger dissection and those who were difficult to intubate.

Question 4

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 5

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 an action(s) the circulator and surgical technologist can take 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 6

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 7

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 8

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 9

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.

Question 10

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

Question 11

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 12

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 postoperative patient care management plan is:

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

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)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 14

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 from the options below):

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 15

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.