Cushings/Addison's

The nurse is planning the care of a client diagnosed with Addison's disease. Which intervention should be included? 1. Administer steroid medications. 2. Place the client on fluid restriction. 3. Provide frequent stimulation. 4. Consult physical therapy for gait training.

1 Clients diagnosed with Addison's disease have adrenal gland hypofunction. The hormones normally produced by the gland must be replaced. Steroids and androgens are produced by the adrenal gland.

The nurse is performing discharge teaching for a client diagnosed with Cushing's disease. Which statement by the client demonstrates an understanding of the instructions? 1. "I will be sure to notify my healthcare provider if I start to run a fever." 2. "Before I stop taking the prednisone, I will be taught how to taper it off." 3. "If I get weak and shaky, I need to eat some hard candy or drink some juice." 4. "It is fine if I continue to participate in weekend games of tackle football."

1 Cushing's syndrome/disease predisposes the client to develop infections as a result of the immunosuppressive nature of the disease.

Which of the following is a priority outcome for the client with Addison's disease? 1. Maintenance of medication compliance. 2. Avoidance of normal activities with stress. 3. Adherence to a 2 gram sodium diet. 4. Prevention of hypertensive episodes.

1 Medication compliance is an essential part of the self-care required to manage Addison's disease. The client must learn to adjust the glucocorticoid dose in response to the normal and unexpected stresses of daily living. The nurse should instruct the client never to stop taking the drug without consulting the health care provider to avoid an addisonian crisis. Regularity in daily habits makes adjustment easier, but the client should not be encouraged to withdraw from normal activities to avoid stress. The client does not need to restrict sodium. The client is at risk for hyponatremia. Hypotension, not hypertension, is more common with Addison's disease.

Which topic is most important to include in the teaching plan for a client newly diagnosed with Addison's disease who will be taking corticosteroids? 1. The importance of watching for signs of hyperglycemia. 2. The need to adjust the steroid dose based on dietary intake and exercise. 3. To notify the health care provider when the blood pressure is suddenly high. 4. How to decrease the dose of the corticosteroids when the client experiences stress.

1 Since Addison's disease can be life threatening, treatment often begins with administration of corticosteroids. Corticosteroids, such as prednisone, may be taken orally or intravenously, depending on the client. A serious adverse effect of corticosteroids is hyperglycemia. Clients do not adjust their steroid dose based on dietary intake and exercise, insulin is adjusted based on diet and exercise. Addisonian crisis can occur secondary to hypoadrenocorticism resulting in a crisis situation of acute hypotension, not increased blood pressure. Addison's disease is a disease of inadequate adrenal hormone and therefore the client will have inadequate response to stress. If the client takes more medication than prescribed, there can be a potential increase in potassium depletion, fluid retention, and hyperglycemia. Taking less medication than was prescribed can trigger Addisonian crisis state which is a medical emergency manifested by signs of shock.

The client diagnosed with Addison's disease is admitted to the emergency department after a day at the lake. The client is lethargic, forgetful, and weak. Which intervention should the nurse implement? 1. Start an IV with an 18-gauge needle and infuse NS rapidly. 2. Have the client wait in the waiting room until a bed is available. 3. Obtain a permit for the client to receive a blood transfusion. 4. Collect urinalysis and blood samples for a CBC and calcium level.

1 The client was exposed to wind and sun at the lake during the hours prior to being admitted to the emergency department. This predisposes the client to dehydration and an Addisonian crisis. Rapid IV fluid replacement is necessary.

The client with Addison's disease is taking glucocorticoids at home. Which of the following statements indicate that the client understands how to take the medication? 1."Various circumstances increase the need for glucocorticoids, so I will need to adjust the dosage." 2."My need for glucocorticoids will stabilize and I will be able to take a predetermined dose once a day." 3."Glucocorticoids are cumulative, so I will take a dose every third day." 4."I must take a dose every 6 hours to ensure consistent blood levels of glucocorticoids."

1 The need for glucocorticoids changes with circumstances. The basal dose is established when the client is discharged, but this dose covers only normal daily needs and does not provide for additional stressors. As the manager of the medication schedule, the client needs to know signs and symptoms of excessive and insufficient dosages. Glucocorticoid needs fluctuate. Glucocorticoids are not cumulative and must be taken daily. They must never be discontinued suddenly; in the absence of endogenous production, addisonian crisis could result. Two-thirds of the daily dose should be taken at about 8 am and the remainder at about 4 pm. This schedule approximates the diurnal pattern of normal secretion, with highest levels between 4 and 6 am and lowest levels in the evening.

The client with Cushing's disease needs to modify dietary intake to control symptoms. In addition to increasing protein, which strategy would be most appropriate? 1. Increase calories. 2. Restrict sodium. 3. Restrict potassium. 4. Reduce fat to 10%.

2 A primary dietary intervention is to restrict sodium, thereby reducing fluid retention. Increased protein catabolism results in loss of muscle mass and necessitates supplemental protein intake. The client may be asked to restrict total calories to reduce weight. The client should be encouraged to eat potassium-rich foods because serum levels are typically depleted. Although reducing fat intake as part of an overall plan to restrict calories is appropriate, fat intake of less than 20% of total calories is not recommended.

The client who has undergone a bilateral adrenalectomy is concerned about persistent body changes and unpredictable moods. The nurse should tell the client that: 1. The body changes are permanent and the client will not be the same as before this condition. 2. The body and mood will gradually return to normal. 3. The physical changes are permanent, but the mood swings will disappear. 4. The physical changes are temporary, but the mood swings are permanent.

2 As the body readjusts to normal cortisol levels, mood and physical changes will gradually return to a normal state. The body changes are not permanent, and the mood swings should level off.

After stabilization of Addison's disease, the nurse teaches the client about stress management. The nurse should instruct the client to: 1. Remove all sources of stress from daily life. 2. Use relaxation techniques such as music. 3. Take antianxiety drugs daily. 4. Avoid discussing stressful experiences.

2 Finding alternative methods of dealing with stress, such as relaxation techniques, is a cornerstone of stress management. Removing all sources of stress from one's life is not possible. Antianxiety drugs are prescribed for temporary management during periods of major stress, and they are not an intervention in stress management classes. Avoiding discussion of stressful situations will not necessarily reduce stress.

Bone resorption is a possible complication of Cushing's disease. Which of the following interventions should the nurse recommend to help the client prevent this complication? 1. Increase the amount of potassium in the diet. 2. Maintain a regular program of weight-bearing exercise. 3. Limit dietary vitamin D intake. 4. Perform isometric exercises.

2 Osteoporosis is a serious outcome of prolonged cortisol excess because calcium is resorbed out of the bone. Regular daily weight-bearing exercise (eg, brisk walking) is an effective way to drive calcium back into the bones. The client should also be instructed to have a dietary or supplemental intake of calcium of 1,500 mg daily. Potassium levels are not relevant to prevention of bone resorption. Vitamin D is needed to aid in the absorption of calcium. Isometric exercises condition muscle tone but do not build bones.

Because of steroid excess after a bilateral adrenalectomy, the nurse should assess the client for: 1. Postoperative confusion. 2. Delayed wound healing. 3. Emboli. 4. Malnutrition.

2 Persistent cortisol excess undermines the collagen matrix of the skin, impairing wound healing. It also carries an increased risk of infection and of bleeding. The wound should be observed and documentation performed regarding the status of healing. Confusion and emboli are not expected complications after adrenalectomy. Malnutrition also is not an expected complication after adrenalectomy. Nutritional status should be regained postoperatively.

The nurse should monitor the client with Cushing's disease for which of the following? 1. Postprandial hypoglycemia. 2. Hypokalemia. 3. Hyponatremia. 4. Decreased urine calcium level.

2 Sodium retention is typically accompanied by potassium depletion. Hypertension, hypokalemia, edema, and heart failure may result from the hypersecretion of aldosterone. The client with Cushing's disease exhibits postprandial or persistent hyperglycemia. Clients with Cushing's disease have hypernatremia, not hyponatremia. Bone resorption of calcium increases the urine calcium level.

The client is admitted to rule out Cushing's syndrome. Which laboratory tests should the nurse anticipate being ordered? 1. Plasma drug levels of quinidine, digoxin, and hydralazine. 2. Plasma levels of ACTH and cortisol. 3. A 24-hour urine for metanephrine and catecholamine. 4. Spot urine for creatinine and white blood cells (WBCs).

2 The adrenal gland secretes cortisol and the pituitary gland secretes adrenocorticotropic hormone (ACTH), a hormone used by the body to stimulate the production of cortisol.

A client with Addison's disease is taking corticosteroid replacement therapy. The nurse should instruct the client about which side effects of corticosteroids? Select all that apply. 1. Hyperkalemia 2. Skeletal muscle weakness 3. Mood changes 4. Hypocalcemia 5. Increased susceptibility to infection 6. Hypotension

2,3,4,5 The long-term administration of corticosteroids in therapeutic doses often leads to serious complications or side effects. Corticosteroid therapy is not recommended for minor chronic conditions; the potential benefits of treatment must always be weighed against the risks. Hypokalemia may develop; corticosteroids act on the renal tubules to increase sodium reabsorption and enhance potassium and hydrogen excretion. Corticosteroids stimulate the breakdown of protein for gluconeogenesis, which can lead to skeletal muscle wasting. CNS adverse effects are euphoria, headache, insomnia, confusion, and psychosis. The nurse watches for changes in mood and behavior, emotional stability, sleep pattern, and psychomotor activity, especially with long-term therapy. Hypocalcemia related to anti-vitamin D effect may occur. Corticosteroids cause atrophy of the lymphoid tissue, suppress the cell-mediated immune responses, and decrease the production of antibodies. The nurse must be alert to the possibility of masked infection and delayed healing (anti-inflammatory and immunosuppressive actions). Retention of sodium (and subsequently water) increases blood volume and, therefore, blood pressure.

Which of the following is the priority for a client in Addisonian crisis? 1. Controlling hypertension. 2. Preventing irreversible shock. 3. Preventing infection. 4. Relieving anxiety.

2. Addison's disease is caused by a deficiency of adrenal corticosteroids and can result in severe hypotension and shock because of uncontrolled loss of sodium in the urine and impaired mineralocorticoid function. This results in loss of extracellular fluid and dangerously low blood volume. Glucocorticoids must be administered to reverse hypotension. Preventing infection is not an appropriate goal of care in this life-threatening situation. Relieving anxiety is appropriate when the client's condition is stabilized, but the calm, competent demeanor of the emergency department staff will be initially reassuring.

The nurse writes a problem of "altered body image" for a 34-year-old client diagnosed with Cushing's disease. Which intervention should be implemented? 1. Monitor blood glucose levels prior to meals and at bedtime. 2. Perform a head-to-toe assessment on the client every shift. 3. Use therapeutic communication to allow the client to discuss feelings. 4. Assess bowel sounds and temperature every four (4) hours.

3 Allowing the client to ventilate feelings about the altered body image is the most appropriate intervention. The nurse cannot do anything to help the client's buffalo hump or moon face.

The nurse should assess a client with Addison's disease for which of the following? 1. Weight gain. 2. Hunger. 3. Lethargy. 4. Muscle spasms.

3 Although many of the disease signs and symptoms are vague and nonspecific, most clients experience lethargy and depression as early symptoms. Other early signs weight loss, muscle weakness, fatigue, nausea, and vomiting. Most clients experience a loss of appetite. Muscles become weak, not spastic, because of adrenocortical insufficiency.

The nurse is admitting a client diagnosed with primary adrenal cortex insufficiency (Addison's disease). Which clinical manifestations should the nurse expect to assess? 1. Moon face, buffalo hump, and hyperglycemia. 2. Hirsutism, fever, and irritability. 3. Bronze pigmentation, hypotension, and anorexia. 4. Tachycardia, bulging eyes, and goiter.

3 Bronze pigmentation of the skin, particularly of the knuckles and other areas of skin creases, occurs in Addison's disease. Hypotension and anorexia also occur with Addison's disease.

A client with Addison's disease is admitted to the medical unit. The client has fluid and electrolyte loss due to inadequate fluid intake and fluid loss secondary to inadequate adrenal hormone secretion. As the client's oral intake increases, which of the following fluids would be most appropriate? 1. Milk and diet soda. 2. Water and eggnog. 3. Bouillon and juice. 4. Coffee and milkshakes.

3 Electrolyte imbalances associated with Addison's disease include hypoglycemia, hyponatremia, and hyperkalemia. Salted bouillon and fruit juices provide glucose and sodium to replenish these deficits. Diet soda does not contain sugar. Water could cause further sodium dilution. Coffee's diuretic effect would aggravate the fluid deficit. Milk contains potassium and sodium.

The client with Addison's disease should anticipate the need for increased glucocorticoid supplementation in which of the following situations? 1.Returning to work after a weekend. 2.Going on vacation. 3.Having oral surgery. 4.Having a routine medical checkup.

3 Illness or surgery places tremendous stress on the body, necessitating increased glucocorticoid dosage. Extreme psychological stress also necessitates dosage adjustment. Increased dosages are needed in times of stress to prevent drug-induced adrenal insufficiency. Returning to work after the weekend, a vacation, or a routine checkup usually will not alter glucocorticoid dosage needs.

The client diagnosed with Cushing's disease has undergone a unilateral adrenalectomy. Which discharge instructions should the nurse discuss with the client? 1. Instruct the client to take the glucocorticoid and mineralocorticoid medications as prescribed. 2. Teach the client regarding sexual functioning and androgen replacement therapy. 3. Explain the signs and symptoms of infection and when to call the health-care provider. 4. Demonstrate turn, cough, and deep-breathing exercises the client should perform every two (2) hours.

3 Notifying the HCP if signs/symptoms of infection develop is an instruction given to all surgical clients on discharge.

A client who is recovering from a bilateral adrenalectomy has a patient-controlled analgesia (PCA) system with morphine sulfate. Which of the following actions is a priority nursing intervention for the client? 1. Observing the client at regular intervals for opioid addiction. 2. Encourage the client to reduce analgesic use and tolerate the pain. 3. Evaluating pain control at least every 2 hours. 4. Increasing the amount of morphine if the client does not administer the medication.

3 Pain control should be evaluated at least every 2 hours for the client with a PCA system. Addiction is not a common problem for the postoperative client. A client should not be encouraged to tolerate pain; in fact, other nursing actions besides PCA should be implemented to enhance the action of opioids. One of the purposes of PCA is for the client to determine frequency of administering the medication; the nurse should not interfere unless the client is not obtaining pain relief. The nurse should ensure that the client is instructed on the use of the PCA control button and that the button is always within reach.

When teaching a client newly diagnosed with primary Addison's disease, the nurse should explain that the disease results from: 1. Insufficient secretion of growth hormone (GH). 2. Dysfunction of the hypothalamic pituitary. 3. Idiopathic atrophy of the adrenal gland. 4. Oversecretion of the adrenal medulla.

3 Primary Addison's disease refers to a problem in the gland itself that results from idiopathic atrophy of the glands. The process is believed to be autoimmune in nature. The most common causes of primary adrenocortical insufficiency are autoimmune destruction (70%) and tuberculosis (20%). Insufficient secretion of GH causes dwarfism or growth delay. Hyposecretion of glucocorticoids, aldosterone, and androgens occur with Addison's disease. Pituitary dysfunction can cause Addison's disease, but this is not a primary disease process. Oversecretion of the adrenal medulla causes pheochromocytoma.

Which of the following indicates that the client with Addison's disease is receiving too much glucocorticoid replacement? 1. Anorexia. 2. Dizziness. 3. Rapid weight gain. 4. Poor skin turgor.

3 Rapid weight gain, because it reflects excess fluids, is a warning sign that the client is receiving too much hormone replacement. It may be difficult to individualize the correct dosage for a client taking glucocorticoids, and the therapeutic range between underdosage and overdosage is narrow. Maintaining the client on the lowest dose that provides satisfactory clinical response is always the goal of pharmacotherapeutics. Fluid balance is an important indicator of the adequacy of hormone replacement. Anorexia is not present with glucocorticoid therapy because these drugs increase the appetite. Dizziness is not specific to the effects of glucocorticoid therapy. Poor skin turgor is a late sign of fluid volume deficit.

A priority in the first 24 hours after a bilateral adrenalectomy is: 1. Beginning oral nutrition. 2. Promoting self-care activities. 3. Preventing adrenal crisis. 4. Ambulating in the hallway.

3 The priority in the first 24 hours after adrenalectomy is to identify and prevent adrenal crisis. Monitoring of vital signs is the most important evaluation measure. Hypotension, tachycardia, orthostatic hypotension, and arrhythmias can be indicators of pending vascular collapse and hypovolemic shock that can occur with adrenal crisis. Beginning oral nutrition is important, but not necessarily in the first 24 hours after surgery, and it is not more important than preventing adrenal crisis. Promoting self-care activities is not as important as preventing adrenal crisis. Ambulating in the hallway is not a priority in the first 24 hours after adrenalectomy

After surgery for bilateral adrenalectomy, the client is kept on bed rest for several days to stabilize the body's need for steroids postoperatively. Which of the following exercises will be most effective for preparing a client for ambulation after a period of bed rest? 1. Alternately flexing and extending the knees. 2. Alternately abducting and adducting the legs. 3. Alternately stretching the Achilles tendons. 4. Alternately flexing and relaxing the quadriceps femoris muscles.

4 Alternately flexing and relaxing the quadriceps femoris muscles helps prepare the client for ambulation. This exercise helps maintain the strength in the quadriceps, which is the major muscle group used when walking. The other exercises listed do not increase a client's readiness for walking

The nurse should teach the client with Addison's disease that the bronze-colored skin is thought to be caused by which of the following? 1. Hypersensitivity to sun exposure. 2. Increased serum bilirubin level. 3. Adverse effects of the glucocorticoid therapy. 4. Increased secretion of adrenocorticotropic hormone (ACTH).

4 Bronzing, or general deepening of skin pigmentation, is a classic sign of Addison's disease and is caused by melanocyte-stimulating hormone produced in response to increased ACTH secretion. The hyperpigmentation is typically found in the distal portion of extremities and in areas exposed to the sun. Additionally, areas that may not be exposed to the sun, such as the nipples, genitalia, tongue, and knuckles, become bronze-colored. Treatment of Addison's disease usually reverses the hyperpigmentation. Bilirubin level is not related to the pathophysiology of Addison's disease. Hyperpigmentation is not related to the effects of the glucocorticoid therapy.

Which of the following is the best indicator for determining whether a client with Addison's disease is receiving the correct amount of glucocorticoid replacement? 1.Skin turgor. 2.Temperature. 3.Thirst. 4.Daily weight.

4 Measuring daily weight is a reliable, objective way to monitor fluid balance. Rapid variations in weight reflect changes in fluid volume, which suggests insufficient control of the disease and the need for more glucocorticoids in the client with Addison's disease. Nurses should instruct clients taking oral steroids to weigh themselves daily and to report any unusual weight loss or gain. Skin turgor testing does supply information about fluid status, but daily weight monitoring is more reliable. Temperature is not a direct measurement of fluid balance. Thirst is a nonspecific and very late sign of weight loss.

The nurse should tell the client to do which of the following when teaching the client about taking oral glucocorticoids? 1. "Take your medication with a full glass of water." 2. "Take your medication on an empty stomach." 3. "Take your medication at bedtime to increase absorption." 4. "Take your medication with meals or with an antacid."

4 Oral steroids can cause gastric irritation and ulcers and should be administered with meals, if possible, or otherwise with an antacid. Only instructing the client to take the medication with a full glass of water will not help prevent gastric complications from steroids. Steroids should never be taken on an empty stomach. Glucocorticoids should be taken in the morning, not at bedtime.

The nurse is instructing a young adult with Addison's disease how to adjust the dose of glucocorticoids. The nurse should explain that the client may need an increased dosage of glucocorticoids in which of the following situations? 1. Completing the spring semester of school. 2. Gaining 4 lb (1.8 kg). 3. Becoming engaged. 4. Undergoing a root canal.

4. Adrenal crisis can occur with physical stress, such as surgery, dental work, infection, flu, trauma, and pregnancy. In these situations, glucocorticoid and mineralocorticoid dosages are increased. Weight loss, not gain, occurs with adrenal insufficiency. Psychological stress has less effect on corticosteroid need than physical stress.

Which actions prescribed by the health care provider for the patient with Addison disease should the nurse delegate to the experienced unlicensed assistive personnel (UAP)? Select all that apply. 1. Weigh the patient every morning. 2. Obtain fingerstick glucose before each meal and at bedtime. 3. Check vital signs every 2 hours. 4. Monitor for cardiac dysrhythmias. 5. Administer oral prednisone 10 mg every morning. 6. Record intake and output.

1, 2, 3, 6 Weighing patients, recording intake and output, and checking vital signs are all within the scope of practice for a UAP. An experienced UAP would have been trained to perform fingerstick glucose monitoring. The nurse should make sure that the UAP has mastered this skill and then instruct the UAP to record and inform him or her about the results. Administering medications and monitoring for cardiac dysrhythmias are within the scope of practice of licensed nurses.

The client has developed iatrogenic Cushing's disease. Which statement is the scientific rationale for the development of this diagnosis? 1. The client has an autoimmune problem causing the destruction of the adrenal cortex. 2. The client has been taking steroid medications for an extended period for another disease process. 3. The client has a pituitary gland tumor causing the adrenal glands to produce too much cortisol. 4. The client has developed an adrenal gland problem for which the health-care provider does not have an explanation.

2 "iatrogenic" means a problem has been caused by a medical treatment or procedure—in this case, treatment with steroids for another problem. Clients taking steroids over a period of time develop the clinical manifestations of Cushing's disease. Disease processes for which long-term steroids are prescribed include chronic obstructive pulmonary disease, cancer, and arthritis.

A client reports that she has gained weight and that her face and body are "rounder," while her legs and arms have become thinner. A tentative diagnosis of Cushing's disease is made. The nurse should further assess the client for: 1. Orthostatic hypotension. 2. Muscle hypertrophy in the extremities. 3. Bruised areas on the skin. 4. Decreased body hair.

3 Skin bruising from increased skin and blood vessel fragility is a classic sign of Cushing's disease. Hyperpigmentation and bruising are caused by the hypersecretion of glucocorticoids. Fluid retention causes hypertension, not hypotension. Muscle wasting occurs in the extremities. Hair on the head thins, while body hair increases.

The nurse is conducting discharge education with a client newly diagnosed with Addison's disease. Which information should be included in the client and family teaching plan? Select all that apply. 1. Addison's disease will resolve over a few weeks, requiring no further treatment. 2. Avoiding stress and maintaining a balanced lifestyle will minimize risk for exacerbations. 3. Fatigue, weakness, dizziness, and mood changes need to be reported to the physician. 4. A medical identification bracelet should be worn. 5. Family members need to be informed about the warning signals of adrenal crisis. 6. Dental work or surgery will require adjustment of daily medication.

2, 3, 4, 5, 6. Addison's disease occurs when the client does not produce enough steroids from the adrenal cortex. Lifetime steroid replacement is needed. The client should be taught lifestyle management techniques to avoid stress and maintain rest periods. A medical identification bracelet should be worn and the family should be taught signs and symptoms that indicate an impending adrenal crisis, such as fatigue, weakness, dizziness, or mood changes. Dental work, infections, and surgery commonly require an adjusted dosage of steroids.