Preparing for Certification

Janet E. Burton

Hyperthyroidism
The Medical-Surgical Nursing Certification Board (MSNCB) encourages certification for all registered nurses who provide care in a medical-surgical setting. Initial certification is achieved through successful testing by written examination. The certification examination is based on Benners Nursing Model. Questions on the examination fall within the seven domains of nursing practice: Helping Role, Teaching-Coaching Function, Diagnostic and Patient Monitoring, Effective Management of Rapidly Changing Situations, Administering and Monitoring Therapeutic Interventions and Regimens, Monitoring and Ensuring the Quality of Health Care Practices, and Organizational and Work Role Competencies. The examination is designed to assess comprehensive knowledge of medical-surgical nursing. The medical-surgical practitioner must understand diseases, diagnoses, and treatment modalities to function as a caregiver and educator. The topic of this article is a part of the comprehensive examination given by MSNCB. The following scenario and questions offer an example that potential certificants may use to test their knowledge. For more information about MSNCB, visit www.msncb.org

yperthyroidism is a condition that results from increased secretion of thyroid hormone by the thyroid gland. Specific causes of primary hyperthyroidism are Graves disease, toxic multinodular goiter, solid hypersecreting nodules, and cancer. Secondary hyperthyroidism can be caused by a thyroid-stimulating hormone-secreting pituitary adenoma. Thyroiditis, a form of hyperthyroidism, is due to inappropriate synthesis of the thyroid hormone by the body or excess ingestion of the thyroid hormone (Jones & Huether, 2006). Graves disease, the most common form of hyperthyroidism, occurs more often in women than in men and develops most frequently in persons ages 20-40 (LeMone, Burke, & Bauldoff, 2011). The clinical manifestations of primary hyperthyroidism are due to the metabolic effects of the increased levels of circulating thyroid hormone. The result is an increased metabolic rate, with heat intolerance and an increased stimulation of the sympathetic nervous system. All body systems are affected, and will exhibit signs and symptoms of hyperactivity (Jones & Huether, 2006). The diagnosis of primary hyperthyroidism is based on clinical presentation, serum thyroid hormone levels, and radioiodine scanning (Scharf, Ahmad, Gaughan, & Soliman, 2006). Medical management includes antithyroid medications (methimazol [Felimazole], carbimazole [Neomercazole], propylthiouracil), iodine therapy (Strong Iodine Solution, potassium iodide, radioactive iodine 131), and a subtotal or total thyroidectomy (LeMone et al., 2011; Scharf et al., 2006). Prior to surgery, individuals are treated with an antithyroid medication to reduce thyroid hormone levels. Iodine preparations may be given preoperatively to reduce the risk of bleeding during and after surgery.
Janet E. Burton, MSN, RN, CMSRN, is a Clinical Nurse Specialist/ Clinical Instructor, Columbus Regional Hospital in Columbus, IN, and a Medical-Surgical Adjunct Nurse Educator, Ivy Tech Community College of Indiana, Columbus, IN. She is the editor of MedSurg Matters! and is a member of the Medical-Surgical Nursing Certification Test Development Committee.

Following surgery, lifelong hormone replacement therapy is necessary (LeMone et al., 2011). Postoperatively the patient should be placed in a semiFowlers position and the neck and head supported with pillows to prevent undue stress on the incision and to promote comfort. The nurse should assess for complications, which include hemorrhage (assessment for blood behind and under the patients neck and shoulder), respiratory distress resulting from hemorrhage or edema, laryngeal nerve damage (assessment of vocal quality), and hypocalcemia secondary to incidental removal of a parathyroid gland (assessment for tingling of toes, fingers, lips, and tongue; twitches; serum calcium or parathyroid levels) (Graff, Miller, Roehm, & Prihoda, 2010; LeMone et al., 2011).

Case Scenario
A 35-year-old female is admitted to a medical-surgical unit following a total thyroidectomy for Graves disease that has not responded to antithyroid medications. Her mother died of thyroid cancer when the patient was a teenager. Questions 1. The patient sought medical evaluation due to which of the following combination of clinical manifestations? a. Weight gain, constipation, bradycardia b. Weight loss, diarrhea, tachycardia c. Goiter, heat intolerance, menopause d. Goiter, cold intolerance, apathy
Are You Certified? Certification shows you have taken that extra step to validate your knowledge and skills. The Academy of MedicalSurgical Nurses (AMSN) and the Medical-Surgical Nursing Certification Board (MSNCB) encourage you to show your colleagues and patients your commitment to excellence in medical-surgical nursing practice. For more information, visit www.msncb.org

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The nurse should instruct the patient in which of the following to prevent postoperative complications? a. Rest in a semi-Fowlers position and support the head with pillows. b. Place a heating pad on the sides of the neck. c. Avoid coughing and deep breathing, and use an incentive spirometer. d. Follow a clear liquid for the first week after surgery and then advance to a soft diet. Seven hours after surgery, the patient complains of her lips and finger tips tingling. The nurse should evaluate which of the following laboratory results? a. Calcium b. Potassium c. Magnesium d. Sodium The patient is being discharged from the hospital 24 hours after her surgery. The nurse realizes the patient understands her prescription for levothyroxin (Synthroid) when she states, a. I know I will need to take my calcium at the same time I take my Synthroid. b. I know I will need to call the doctor if my heart rate is between 80 and 100. c. I know I will need to take this medication for life 60 minutes before breakfast. d. I know I will need to avoid taking aspirin when taking my Synthroid.

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increased sympathetic nervous system activity on the cardiac and gastrointestinal systems (LeMone et al., 2011). a This position and the supporting of the neck will decrease strain on the sutures and will promote comfort (LeMone et al., 2011). a Incidental injury or removal of parathyroid glands may result in hypocalcemia and tetany (LeMone et al., 2011). c Thyroid hormone replacement therapy must be taken for life following a total thyroidectomy. Taking the medication 60 minutes prior to breakfast provides the best absorption of levothyroxin (LeMone et al., 2011).

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REFERENCES Graff, A.T., Miller, F.R., Roehm, C.E., & Prihoda, T.J. (2010). Predicting hypocalcemia after total thyroidectomy: Parathyroid hormone level vs. serial calcium levels. ENT: Ear, Nose & Throat Journal, 89(9), 462-465. Jones, R.E., & Huether, S.E. (2006). Alterations of hormonal regulation. In K.L. McCance & S.E. Hueter (Eds.), Pathophysiology: The biological basis for disease in adults and children (5th ed.). St. Louis: Elsevier Mosby. LeMone, P., Burke, K., & Bauldoff, G. (2011). Medical-surgical nursing: Critical thinking in patient care (5th ed.). Upper Saddle River, NJ: Pearson. Scharf, J.L., Ahmad, S.M., Gaughan, J.P., & Soliman, A.M. (2006). Thyroidectomy for Graves disease: A case-control study. The Annals of Otology, Rhinology & Laryngology, 115(12), 902-907. ADDITIONAL READINGS Quinn, L. (2009). The endocrine system. In H. Craven (Ed.), Core curriculum for medical-surgical nursing (pp. 277-292). Pitman, NJ: Academy of Medical-Surgical Nurses. Roberts, D. (2008). Medical-surgical nursing review questions (2nd ed.). Pitman, NJ: Academy of Medical-Surgical Nurses.

Answers with Rationale 1. b Weight loss, diarrhea, and tachycardia are related to the effect of an increased metabolic rate on the gastrointestinal system, and the effect of

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