# Situation: A 58-year-old woman with primary hyperparathyroidism is seen before a planned parathyroidectomy. She has passed two kidney stones in the past year. Her serum calcium is 11.6 mg/dL (8.6–10.2 mg/dL). The nurse reviews her home medicines. Which drug should the nurse report because it can raise her calcium further?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630408  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 58-year-old woman with primary hyperparathyroidism is seen before a planned parathyroidectomy. She has passed two kidney stones in the past year. Her serum calcium is 11.6 mg/dL (8.6–10.2 mg/dL).

The nurse reviews her home medicines. Which drug should the nurse report because it can raise her calcium further?

## 보기

1. Amlodipine besylate
2. Hydrochlorothiazide **✔ 정답**
3. Metoprolol tartrate
4. Losartan potassium

**정답: 2**

## 해설

Thiazide diuretics reduce urinary calcium excretion and raise serum calcium, so they are avoided in hyperparathyroidism and reported for review. Losartan, amlodipine, and metoprolol do not raise serum calcium.

## 심화 해설

The drug to report
She has primary hyperparathyroidism with a serum calcium of 11.6 mg/dL (normal 8.6–10.2) and recurrent kidney stones. Thiazide diuretics such as hydrochlorothiazide reduce urinary calcium excretion and raise serum calcium, so they are avoided in hyperparathyroidism and reported for review. Hydrochlorothiazide is the medicine the nurse reports.

How thiazides raise calcium
Thiazides act on the distal convoluted tubule of the kidney, where they block sodium reabsorption. As a secondary effect, they increase calcium reabsorption in the same segment, so less calcium leaves in the urine and more stays in the blood. In a person with normal parathyroid function this effect is modest, but in hyperparathyroidism, where calcium is already high, a thiazide can push the level higher and worsen symptoms such as fatigue, constipation, confusion, and dysrhythmias. Loop diuretics, by contrast, increase urinary calcium excretion.

| Drug | Class | Effect on serum calcium |
| --- | --- | --- |
| Amlodipine besylate | Calcium channel blocker | No rise |
| Hydrochlorothiazide | Thiazide diuretic | Raises it |
| Metoprolol tartrate | Beta blocker | No effect |
| Losartan potassium | Angiotensin receptor blocker | No rise |

Why the other drugs are not the concern
Amlodipine blocks calcium channels in vascular smooth muscle, but it does not change serum calcium; the word calcium in its class name is a common trap. Metoprolol slows the heart and lowers blood pressure without affecting calcium. Losartan lowers blood pressure through the renin-angiotensin system and does not raise serum calcium.

Nursing application
The nurse reports the hydrochlorothiazide so the provider can consider an alternative antihypertensive. The nurse also reviews other sources of calcium elevation, such as calcium supplements, vitamin D in high doses, and lithium, and encourages fluids and mobility while she awaits surgery.

Exam takeaway
Watch out Thiazides hold calcium in; loop diuretics push calcium out. In hypercalcemia or hyperparathyroidism, report any thiazide.

## 임상 시나리오

Thiazides in HyperparathyroidismA drug that raises calcium further
Hydrochlorothiazide increases calcium reabsorption in the distal tubule, reducing urinary calcium loss and raising serum calcium.

With a calcium of 11.6 mg/dL from primary hyperparathyroidism, a thiazide can worsen hypercalcemia and is reported for review. Amlodipine, metoprolol, and losartan do not raise calcium.

CautionAlso review calcium supplements, high-dose vitamin D, and lithium, which can contribute to high calcium.

## 핵심 개념

- **Primary hyperparathyroidism** — Excess parathyroid hormone from the parathyroid glands, causing high serum calcium.
- **Thiazide diuretic** — A diuretic acting on the distal tubule that also reduces urinary calcium excretion.
- **Hypercalcemia** — Serum calcium above the normal range, causing fatigue, constipation, stones, and dysrhythmias.
- **Distal convoluted tubule** — The kidney segment where thiazides act and where calcium reabsorption is regulated.

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