NUR 3420 - PrepU Ch 17 - Exam 4

Confusion Hyperkalemia Hyponatremia Explanation: Manifestations of hypoadrenal function include confusion, hyponatremia, and hyperkalemia. Purpura and renal calculi are associated with hyperadrenal function.

Which would a nurse expect to assess in a patient with an adrenocortical hormone deficiency? (Select all that apply.)

Treatment of a disease with an inflammatory component Explanation: Because corticosteroids affect virtually every aspect of inflammatory and immune responses, they are used in the treatment of a broad spectrum of diseases with an inflammatory or immunologic component. Corticosteroids are not indicated for the treatment of diabetes mellitus, in fact, these medications can exacerbate the condition if prescribed to a client with this diagnosis. Corticosteroids can increase blood sugar levels.

While learning about corticosteroids in pharmacology class, a student asks the instructor to offer an example of indications for use. What could the instructor mention?

infections Explanation: Corticosteroids are contraindicated in systemic fungal infections, clients who are hypersensitive to drug formulations, clients at risk for infections, and clients with infections, diabetes mellitus, peptic ulcer disease, inflammatory bowel disorders, hypertension, congestive heart failure, or renal insufficiency. Corticosteroid therapy is not contraindicated by a history of depression, cognitive impairment, or urinary incontinence.

A nurse taking a medical history on a client prescribed a corticosteroid medication should focus on which condition?

This time mimics the normal peak diurnal concentration levels. Explanation: Typically a glucocorticoid is taken in the morning to mimic the normal peak diurnal concentration levels and thereby minimize suppression of the hypothalamic-pituitary axis. A glucocorticoid is taken in the morning to mimic the normal peak diurnal concentration levels and thereby minimize suppression of the hypothalamic-pituitary axis. Drug absorption is not affected by time of administration. The rationale for morning administration is to mimic the normal peak diurnal concentration levels.

A nurse tells a patient to take a prescribed glucocorticoid in the morning based on the understanding that:

The anatomy and physiology instructor is discussing reactions of the body to stress. According to the instructor, what is responsible for the release of cortisol (hydrocortisone) during times of stress?

Activation of the sympathetic nervous system Explanation: The stress response activates the sympathetic nervous system, causing the adrenal cortex to secrete adrenocortical hormones such as cortisol.

ulcers. Explanation: Corticosteroids are contraindicated in systemic fungal infections; clients who are hypersensitive to drug formulations; clients at risk for infections; and clients with infections, diabetes mellitus, peptic ulcer disease, inflammatory bowel disorders, hypertension, congestive heart failure, or renal insufficiency.

Clients taking a corticosteroid medication should be asked about any history of:

Pituitary ACTH levels Explanation: Several mechanisms control aldosterone levels: extracellular sodium and potassium levels (when serum sodium levels are low or potassium levels are high, aldosterone levels rise); renal renin release (a reduction in renal blood flow increases aldosterone levels by the renin-angiotensin-aldosterone system); and pituitary ACTH (the glucocorticoid hormones produced in the adrenal cortex have mineralocorticoid effects).

Naturally occurring aldosterone is regulated by which mechanism?

"Sadly, this is an adverse effect seen in women. It should improve when you finish the medication." Explanation: An adverse effect in women who take corticosteroids is acne and hair on the face. This side effect usually resolves after the medication is discontinued. The drug should never be stopped abruptly but weaned gradually.

A 45-year-old woman has been taking a corticosteroid and calls the clinic reporting the development of acne-like lesion on her face as well as facial hair. What is the nurse's best response?

Prednisone can lead to osteoporosis. Explanation: A clinically important adverse effect of long-term prednisone therapy is osteoporosis, which is often considered to be a major limitation of long-term prednisone therapy. Long-term prednisone therapy (doses over 7.5 mg/day) enhances calcium loss and increases parathyroid hormone levels. Calcium loss from bones decreases bone mineral density, thereby promoting an osteoporotic condition that increases the risk for hip, pelvic, rib, or vertebral fractures. Prednisone does cause poor wound healing, glucose intolerance, and fluid retention, but based on the patient's negative history, this would not be of greatest concern in this patient.

A 47-year-old female client with is admitted to a medical unit for exacerbation of asthma. The client has a BMI of 22 and no other health problems. The client is being treated with steriod therapy. The client asks why she cannot just stay on the prednisone long term. What would be the best answer based on the long-term effects of prednisone therapy?

Thinning of the skin Explanation: The client's thinning skin may make IV insertion more difficult because the skin is so much more fragile and it bruises so easily due to capillary fragility.

A 65-year-old client who has been on long-term corticosteroid therapy is admitted to the hospital and will need an IV inserted. What adverse effect of corticosteroid may negatively affect this procedure?

take measures to minimize the risk of falls. Explanation: Long-term glucocorticoid therapy can cause muscle weakness and fatigue, especially in the elderly, and can predispose them to falls. Long-term or high-dose glucocorticoid therapy also places the client at increased risk for osteoporosis, making fractures more likely. Hence, the client should be advised to take measures to minimize the risk of falls. There are no specific precautions related to avoiding direct sunlight during glucocorticoid therapy. A diet that controls carbohydrate and calorie intake is always important, but the client would not need to avoid red meat or dairy products while on glucocorticoid therapy.

A 72-year-old woman is on long-term glucocorticoid therapy. It will be most important for the nurse to instruct the client to:

"We need to cover the area snugly with plastic wrap to prevent scratching." Explanation: Covering the area with a dressing or diaper would increase the risk for systemic absorption of the drug and should be avoided. Topical corticosteroids should be used sparingly and should not be applied to any open lesions or excoriated areas to reduce the risk for systemic absorption.

A child is to receive a topical corticosteroid agent. Which statement by the parents indicates a need for additional teaching?

potassium Explanation: The combination of corticosteroids and diuretics constitutes a risk for hypokalemia. The nurse must pay particular attention to the client's potassium levels. This combination of medications is not associated with risks involving any of the other options.

A client being treated with oral prednisone is also prescribed furosemide. The nurse should prioritize assessment of what laboratory value?

an increase in sodium and water retention along with potassium depletion. Explanation: Increased doses of fludrocortisone may result in excess retention of sodium and water along with potassium depletion. Hypokalemia does not occur nor are sodium and water depleted or potassium retained. This drug is usually given in combination with a glucocorticoid. Therefore, toxic effects would not be expected.

A client has been admitted to the unit with salt-losing adrenogenital syndrome. The client is taking fludrocortisone (Florinef) for replacement therapy in combination with a glucocorticoid. The nurse would know that high-dose fludrocortisone requires the nurse to monitor for:

Addison's disease Explanation: Abrupt cessation of corticosteroid therapy can precipitate an addisonian crisis due to suppression of the hypothalamic-pituitary-adrenal (HPA) axis. The only option associated with adrenocortical insufficiency is Addison's disease.

A client has suddenly stopped corticosteroid therapy because the symptoms are now under control. The nurse should assess the client for signs and symptoms similar to what disorder?

in the morning. Explanation: Scheduling of drug administration is more important with corticosteroids than with most other drug classes. A major adverse reaction is suppression of the HPA axis and subsequent loss of adrenocortical function. Scheduling of medication (morning dosing) is often recommended to prevent or minimize HPA suppression. Daily administration is required in cases of chronic adrenocortical insufficiency. The entire daily dose can be taken each morning, between 6 and 9 a.m. This schedule simulates normal endogenous corticosteroid secretion.

A client is on daily doses of prednisone. To minimize adrenal suppression, the nurse's instructions for administration should include to take the medication:

buffalo hump moon face purple abdominal striae acne Explanation: Signs and symptoms of this Cushing-like (cushingoid) state include a buffalo hump (a hump on the back of the neck), moon face, oily skin and acne, osteoporosis, purple striae on the abdomen and hips, altered skin pigmentation, and weight gain.

A client is receiving corticosteroid therapy. The nurse instructs the client about which possible cushingoid effects? Select all that apply.

Truncal obesity Explanation: Signs and symptom of potential Cushing's syndrome manifestations include abdomen that sticks out and thin arms and legs (central obesity); acne; collection of fat between the shoulders; depression; euphoria not related to life situation; excessive facial hair growth in females; frequent and easy bruising; round, red, and full face; weakness; and weight gain.

A client is taking long-term corticosteroid therapy. Which finding would alert the nurse to a potential Cushing's syndrome manifestation?

The inhaled drug should be started during tapering of the oral drug. Explanation: When a client is being switched from an oral to an inhaled corticosteroid, the inhaled drug should be started during tapering of the oral drug, approximately 1 or 2 weeks before discontinuing or reaching the lowest anticipated dose of the oral drug.

A client with a diagnosis of asthma has responded well to treatment with oral corticosteroids, and a switch to inhaled corticosteroids is planned. What strategy for managing this change in treatment should be implemented?

Corticosteroids impair growth in children. Explanation: Most immunosuppressants are used in children for the same disorders and with similar effects as in adults. Corticosteroids impair growth in children. As a result, some transplantation centers avoid prednisone therapy until a rejection episode occurs.

A female client asks the nurse why her 4-year old son is not receiving corticosteroids. The client read in an article that they are more effective to prevent transplant rejection than the medication that is currently prescribed. What is the appropriate response by the nurse?

"Your prescription must be tapered gradually with the provider's order." Explanation: Strategies to minimize HPA suppression and risks of acute adrenal insufficiency include gradually tapering the dose of any systemic corticosteroid.

A female client experiences weight gain secondary to her systemic steroid therapy for temporal arteritis. She calls the health care provider's office to ask if she can discontinue the medication for 1 week to fit into her dress for her class reunion. Which response is appropriate?

increased. Explanation: When a client receiving ongoing corticosteroid therapy requires surgery, the nurse should review the preoperative orders to make sure that the steroid dosage has been increased for several days. If not, the nurse should obtain the order from the prescriber. The increase is needed to promote recovery after the stress of surgery.

A female client has a diagnosis of adrenocortical insufficiency and is steroid dependent. The client is to undergo surgery to remove her uterus. The nurse will explain to the client that in order to promote recovery after the stress of the surgery, her steroid dosage will be:

adrenal insufficiency. Explanation: The client may develop adrenal insufficiency (addisonian crisis), which is characterized by glucocorticoid insufficiency without mineralocorticoid insufficiency. Hypokalemia occurs as a result of hyperaldosteronism. Gastrointestinal distress and menstrual irregularities are common adverse effects of the drug, but these effects are not as serious as preventing adrenal insufficiency.

A female client has been taking prednisone for her asthma for 1 month. The nurse will teach her to gradually decrease her dose of prednisone to avoid:

Corticosteroids Explanation: In adrenal insufficiency, hypotension is a common symptom in critically ill clients, and hypotension caused by adrenal insufficiency may mimic either hypovolemic or septic shock. If adrenal insufficiency is the cause of the hypotension, administration of corticosteroids can eliminate the need for vasopressor drugs to maintain adequate tissue perfusion.

A female client is diagnosed with adrenal insufficiency. She presents to the emergency department with hypotension. What would the nurse expect her to be prescribed?

The dosage of the medication may be increased. Explanation: The client's body may initiate a stress reaction due to the son's arrest. Normally, activation of the stress reaction can cause release of ACTH and secretion of the adrenocortical hormones. Someone with adrenocortical insufficiency may not be able to supplement the increase need for ACTH. The stress reaction may block the immune and inflammatory systems, making the body more susceptible to pathogens. Therefore, an increase in medication may be necessary to prevent further adrenal insufficiency and to meet the increase demands for corticosteroids under stress.

A female client who is steroid dependent due to adrenocortical insufficiency calls the clinic and is very upset. Her son has been arrested for manufacture and sale of illegal drugs. What should the nurse tell the client concerning her medication and added stress?

Acute infection Explanation: Acute infection is a contraindication for glucocorticoid use; the infection could become severe and possibly fatal with the blockage of the immune and inflammatory responses. Glucocorticoids are used cautiously in patients with peptic ulcer disease. Glucocorticoids are used cautiously in patients with peptic ulcer disease. Glucocorticoids are used cautiously in patients with endocrine disorders because additional imbalance can occur.

A group of students are reviewing the contraindications for glucocorticoid therapy. The students demonstrate understanding when they identify which condition?

Prednisone Explanation: Daily administration of corticosteroids and mineralocorticoids is required in cases of chronic adrenocortical insufficiency (Addison's disease).

A male client is diagnosed with Addison's disease. What daily medication would the nurse expect to be administered?

"I recently lost my health care coverage and need to look for another job." Explanation: For people receiving chronic corticosteroid therapy, dosage must be increased during periods of stress or illness. The nurse should recognize that the client has mentioned losing health care coverage and looking for a job. All the other statements are not related to stress or illness.

A nurse is caring for a client who is receiving a corticosteroid for arthritic pain. Which statement made by the client would raise concern about medication dosage revision?

edema Explanation: The nurse should monitor for edema, hypertension, heart failure, enlargement of the heart, increased sweating, and allergic skin rash in the client as adverse reactions to the drug. Sore throat, malaise, and nasal congestion are not adverse reactions to the fludrocortisone drug. The nurse needs to monitor for sore throat and malaise in the client receiving adrenocorticotropic hormone (ACTH). The nurse needs to monitor for nasal congestion as an adverse reaction in a client receiving vasopressin.

A nurse is caring for a client with adrenocortical deficiency. The health care provider has prescribed a fludrocortisone drug to the client. Which adverse reaction should the nurse monitor for in the client?

Take the oral drug with meals or snacks. Explanation: The nurse should instruct the patient to take the oral drug with meals or snacks to decrease the gastrointestinal effects and upsets in the teaching plan for the patient and family. Reporting any symptoms of sore throat or fever immediately and notifying the PHCP if glucose appears in the urine should be included in the teaching plan for a patient undergoing adrenocorticotropic hormone (ACTH) therapy. The nurse should instruct the patient to measure the amount of fluids taken each day in the teaching plan for the patient receiving vasopressin.

A nurse is caring for a patient who has been undergoing glucocorticoid therapy at a health care facility and is getting discharged. Which of the following instructions should the nurse include in the teaching plan for the patient and family?

Carefully assess the client for infections. Explanation: It is important to monitor clients who are taking prednisone carefully for signs of infection, because prednisone's immunologic activity may mask the symptoms of infection. Antacids may normally be used alongside prednisone. Headaches are not associated with the use of prednisone and IV administration is not typical.

A nurse is overseeing the care of a young man whose ulcerative colitis is being treated with oral prednisone. Which action should the nurse take in order to minimize the potential for risks associated with prednisone treatment?

dexamethasone Explanation: Dexamethasone is considered the corticosteroid of choice for cerebral edema associated with brain tumors, craniotomy, or head injury because dexamethasone is thought to penetrate the blood-brain barrier more readily and achieve higher concentrations in cerebrospinal fluids and tissues. Beclomethasone inhalation is used to prevent asthma attacks in adults and children who are at least 5 years old. Triamcinolone is used to treat a variety of skin conditions. Cytosine is one of the five main nucleobases used in storing and transporting genetic information within a cell in the nucleic acids DNA and RNA.

A nurse is preparing medication information for the spouse of a client diagnosed with cerebral edema. Which medication should the nurse include in this information?

Risk for infection related to immunosuppression Explanation: Risk for infection related to immunosuppression would be the appropriate nursing diagnosis because steroids suppress the immune system. Decreased cardiac output and excess fluid volume would also be appropriate nursing diagnoses for this client. Imbalanced nutrition: More than body requirements might be appropriate since usually clients taking steroids gain weight.

A nurse is writing a plan of care for a client who is receiving a glucocorticoid. What would be an appropriate nursing diagnosis for this client?

Moon face Buffalo hump Osteoporosis Explanation: A nurse should monitor a client taking short-term high-dose methylprednisolone (Medrol) for signs and symptoms of Cushing's syndrome which include buffalo hump, moon face, oily skin, acne, osteoporosis, purple striae on the abdomen and hips, altered skin pigmentation, and weight gain.

A nurse should monitor a client taking short-term high-dose methylprednisolone (Medrol) for signs and symptoms of Cushing's syndrome that include what sign or symptom? (Select all that apply.)

Adrenal atrophy Explanation: Prolonged use of corticosteroids suppresses the normal hypothalamic-pituitary axis and leads to adrenal atrophy from lack of stimulation.

A patient is taking low-dose corticosteroids on a long-term basis for COPD. What does prolonged use of corticosteroids put the patient at risk for?

Hypertension Explanation: Because they are not able to supplement the energy-consuming effects of the sympathetic reaction, patients who have an adrenal insufficiency enter an adrenal crisis, which can include physiological exhaustion, hypotension, fluid shift, shock, and even death.

A patient with adrenal insufficiency has been admitted to the ICU in adrenal crisis. In assessing this patient, what would the nurse know is not a side effect of adrenal insufficiency?

Fluid volume excess Explanation: Treatment with glucocorticoids such as prednisone is associated with numerous adverse effects, including the risk for excess fluid volume. Constipation and impaired gas exchange are not among the most common adverse effects and CNS effects are normally limited to anxiety, mood swings, and insomnia rather than acute confusion.

A woman with an inflammatory skin disorder has begun taking prednisone in an effort to control the signs and symptoms of her disease. The nurse who is providing care for this client should prioritize which potential nursing diagnoses in the organization of the client's care?

Fludrocortisone Explanation: Fludrocortisone is a mineralocorticoid. Beclomethasone is a glucocorticoid. Dexamethasone is a glucocorticoid. Flunisolide is a glucocorticoid.

After teaching a group of students about mineralocorticoids, the instructor determines that the teaching was successful when they state which agent as an example?

Increased serum cholesterol Explanation: Hematological effects include sodium and fluid retention, hypokalemia, hypocalcemia, increased blood sugar, increased serum cholesterol, decreased thyroid hormone levels.

All corticosteroids are derived from cholesterol and are released directly into the bloodstream. What is a hematological adverse effect from the use of corticosteroids?

6 AM to 9 AM Explanation: A peak response of increased adrenocorticotropic hormone and adrenocortical hormones occurs sometime early in the morning, about 6 AM to 9 AM. The corticosteroid levels fall to low levels by evening. Then, the hypothalamus and pituitary sense low levels of the hormones and begin the production and release of corticotropin-releasing hormone usually during sleep, around midnight.

At which time would a nurse expect peak levels of adrenocorticotropic hormone to occur?

Impaired wound healing Explanation: Clients taking long-term glucocorticoid therapy will have impaired wound healing so nursing care is directed toward promoting healing. The drug has an anti-inflammatory effect so that would not need to be overcome. There is no autoimmune response or lack of mobility so these do not have to be overcome.

Nursing care for the postoperative client requiring long-term glucocorticoid therapy will be directed at overcoming what adverse effect of the drug?

Release of epinephrine and norepinephrine Explanation: The adrenal medulla is actually part of the sympathetic nervous system (SNS). It is a ganglion of neurons that releases the neurotransmitters norepinephrine and epinephrine into circulation when the SNS is stimulated. The adrenal cortex surrounds the medulla and consists of three layers of cells, each of which synthesizes chemically different types of steroid hormones that exert physiological effects throughout the body. Negative feedback systems would be bypasses at this time and stimulation of the hypothalamus and atrophy of the adrenal cortex would not cause the release of cortisone.

The anatomy and physiology instructor is discussing what happens to the body during times of stress. What would the instructor tell the students causes the release of cortisone during times of stress?

Arthritis Explanation: Glucocorticoids are indicated for the short-term treatment of many inflammatory disorders, to relieve discomfort, and to give the body a chance to heal from the effects of inflammation. They block the actions of arachidonic acid, which leads to a decrease in the formation of prostaglandins and leukotrienes. Without these chemicals, the normal inflammatory reaction is blocked. Hypoglycemia would more safely be treated with glucose. Appendicitis and septicemia are infections that would contraindicate the use of glucocorticoids because of the immunosuppressant effects of the drugs.

The nurse anticipates an order for a glucocorticoid when caring for a client with what condition?

I will start this medication when I am feeling ill or tired. Explanation: Daily administration is required in cases of chronic adrenocortical insufficiency. Clients should be instructed to call their health care provider if a fever above 101°F develops, minimize exposure to anyone who may be ill, and report any weight gain above 5 pounds in 1 week.

The nurse has just completed client education relative to chronic adrenocortical insufficiency and corticosteroid medication treatment. What statement indicates the client requires further instruction?

Hypotension Explanation: Hypertension (rather than hypotension) is an adverse effect of corticosteroids. Long-term administration can cause Cushingoid characteristics, including muscle weakness and atrophy, obesity, and "moon face" (the presence of abnormal fat deposits in the cheeks).

The nurse is assessing a client with adrenocortical excess resulting from long-term use of corticosteroids. What is not a side effect related to this client's corticosteroid use?

Administering a systemic corticosteroid during high-stress situations in clients on long-term systemic therapy Explanation: Strategies to minimize HPA suppression and risks of acute adrenal insufficiency include administering a systemic corticosteroid during high-stress situations in clients who are on long-term systemic therapy (i.e., are steroid dependent).

The nurse is aware that dosing strategies to minimize HPA suppression and risks of acute adrenal insufficiency include which corticosteroid administration schedule?

assessing blood glucose levels Explanation: Black clients develop increased toxicity to the corticosteroid methylprednisolone—particularly when it is used for immunosuppression after renal transplantation. This toxicity can include severe steroid-induced diabetes mellitus. A priority intervention with this client is monitoring blood glucose levels. Assessment of capillary refill time and cardiac rhythm would not be indicated by the data supplied about this client. Red blood cell counts are less likely to be affected client.

The nurse is caring for a black client who received a kidney transplant and receives methylprednisolone for immunosuppression. What is the nurse's priority assessment for this client?

Monitoring blood glucose levels frequently Explanation: Corticosteroids can cause an increase in the production of glucose and a decrease in its use. This promotes hyperglycemia and can lead to development of diabetes mellitus or aggravation of preexisting diabetes mellitus.

The nurse is caring for an 84-year-old client with diabetes who is receiving hydrocortisone 40 mg daily PO for treatment of an arthritic flare-up. When writing a plan of care for this client, which nursing intervention would be most appropriate?

Take daily blood glucose levels. Explanation: Caution should be used in patients with diabetes because the glucose-elevating effects disrupt glucose control. The use of hydrocortisone would not indicate increasing sodium, restricting protein, or increasing fluid in the diet.

The nurse is caring for an 84-year-old diabetic patient who is receiving hydrocortisone 40 mg daily, PO, for treatment of an arthritic flareup. When writing a plan of care for this patient, which nursing intervention would be most appropriate?

To minimize adverse effects Explanation: Use alternate-day maintenance therapy with short-acting drugs whenever possible to decrease the risk of adrenal suppression. Alternate day therapy would not eliminate side effects, prolong therapeutic effects, or prevent steroid tolerance.

The nurse is doing discharge teaching when the client asks the nurse why their prednisone has been ordered on alternate days. What would be the nurse's best response?

Growth pattern Explanation: Long-term systemic corticosteroid therapy in children can increase the child's risk for growth retardation; therefore, this would be most important to assess. Rectal bleeding can occur with corticosteroids administered via a retention enema. Epistaxis can occur with the use of intranasal corticosteroids. Cognitive development is not generally impacted by corticosteroid therapy.

The nurse is monitoring a child who has been receiving long-term therapy with systemic corticosteroids. Which would be most important for the nurse to assess?

Oral Explanation: Prednisone is available for oral use only.

The nurse is preparing to administer prednisone. The nurse would expect to administer this agent by which route?

Immediately on awakening in the morning Explanation: Corticosteroids should be taken immediately on awaking in the morning in order to mimic the normal diurnal pattern. The peak levels of cortisol usually come between 6:00 AM and 8:00 AM. The levels then fall off slowly and reach a low in the late evening with the lowest levels around midnight. For those clients who work night shifts, the schedule would be changed to accommodate their sleep pattern.

The nurse is providing client education to a client taking corticosteroids. When would the nurse advise the client to take their medication?

Fever Explanation: Glucocorticoids interfere with the immune and inflammatory reactions of the body, increasing a client's risk for infection. Thus, fever would need to be reported immediately. Weight gain, abdominal distention, and increased appetite are adverse effects that can occur and do not need to be reported immediately.

The nurse is teaching a client who is receiving a glucocorticoid about the drug. What would the nurse instruct the client to report immediately?

"Avoid large crowds of people in confined spaces." Explanation: With long-term therapy, the importance of avoiding exposure to infection—crowded areas, people with colds or the flu, activities associated with injury—should be stressed. If an injury or infection should occur, the client should be encouraged to seek medical care. These clients do not need to avoid work, exercise, or touching others but they should use good hand hygiene to avoid infection from these sources.

The nurse is teaching a client who will require long-term corticosteroid therapy how to reduce the risk of infection. What suggestions will the nurse include?

Supervising and monitoring the administration of the drug Explanation: Because of potentially serious adverse effects, especially with oral drugs, it is extremely important that corticosteroids be used as prescribed. A major responsibility of home care nurses is to teach, demonstrate, supervise, monitor, or do whatever is needed to facilitate correct use.

The nurse is working in a home care setting. A female client is prescribed oral corticosteroids by her health care provider secondary to a diagnosis of Addison's disease. What is the nurse's responsibility in this situation?

"I will start this medication as soon as I am feeling ill or tired." Explanation: Daily administration is required in cases of chronic adrenocortical insufficiency. Clients should be instructed to call their health care provider if a fever above 101°F (38.3°C) develops, minimize exposure to anyone who may be ill, and report any weight gain above 5 pounds in 1 week.

The nurse just completed client education relative to chronic adrenocortical insufficiency and corticosteroid medication treatment. Which statement indicates the client requires further instruction?

Taper doses when discontinuing drug Explanation: Taper doses when discontinuing from high doses or from long-term therapy to give the adrenal glands a chance to recover and produce adrenocorticoids. All answers are correct, but most important to teach the client is tapering the drug.

The nursing instructor is discussing short-term versus long-term corticoid steroid therapy with the nursing students. What would be the most appropriate teaching for a client on long-term corticosteroid therapy?

They promote fat storage. Explanation: Glucocorticoids cause lipogenesis, the formation and storage of fat in the body. Glucorticoids stimulate an increase in glucose levels. Glucocorticoids increase the rate of protein breakdown. Glucocorticoids decrease the rate of protein formation from amino acids.

What would a nurse keep in mind about glucocorticoids when teaching a client?

Impaired wound healing Explanation: Sensitivity to light would not be appropriate to report as a side effect of the drug. Constipation and urinary retention are not side effects of methylprednisolone.

When a nurse is doing a shift assessment on a client, which symptom should be reported as a possible side effect from administration of methylprednisolone?

Infection Explanation: When planning care for a client taking long-term corticosteroid therapy, the nurse needs to incorporate interventions aimed at reducing risk of infection because the client's immune system will be suppressed, which places the client at increased risk. The drug is not associated with causing allergies, cognitive changes or anemia.

When caring for a client receiving long-term therapy with corticosteroids, the nurse would plan care incorporating interventions aimed at preventing what?

minimize the suppression of normal adrenal function. Explanation: Alternate-day therapy (ADT), in which a double dose is taken every other morning, is usually preferred for other chronic conditions. This schedule allows rest periods so that adverse effects are decreased while anti-inflammatory effects continue. ADT is used only for maintenance therapy.

When explaining the rationale for alternate-day administration of corticosteroids, the nurse would say that it is to:

A 70-year-old man whose rheumatoid arthritis has not responded to OTC pain relievers Explanation: There are numerous clinical indications for treatment with glucocorticoids such as prednisone. Among these are inflammatory diseases such as rheumatoid arthritis. Emphysema, hypertension, and leukemia are not health problems that are typically treated with corticosteroids.

Which client demonstrates the clearest indication for treatment with prednisone?

aldosterone Explanation: Aldosterone is the main mineralocorticoid and is responsible for approximately 90% of mineralocorticoid activity. Glucocorticoids include cortisol, corticosterone, and cortisone. Androgens are male sex hormones.

Which corticosteroid is classified as a mineralocorticoid?

buffalo hump Explanation: Signs and symptom of potential Cushing's syndrome manifestations include abdomen that sticks out and thin arms and legs (central obesity); acne; collection of fat between the shoulders (buffalo hump); depression; euphoria not related to life situation; excessive facial hair growth in females; frequent and easy bruising; round, red, and full face; weakness; and weight gain. Cushing's syndrome is not associated with insomnia, hair loss, or weight loss.

Which finding should alert the nurse to a potential Cushing's syndrome manifestation presented by a client prescribed long-term corticosteroid therapy?

Prednisone (Deltasone) Explanation: Prednisone is available in oral form only and is used for replacement therapy. Cortisone can be administered orally or intramuscularly and is used for replacement therapy. Hydrocortisone, used for replacement therapy, is administered by the oral, IV, IM, topical, ophthalmic, rectal, and intra-articular routes. Triamcinolone is administered by the oral, IM, inhalant, intra-articular, and topical routes and is used for treatment of allergic and inflammatory disorders and in the management of asthma.

Which glucocorticoid used for replacement therapy is available only as an oral agent?

"Taking it every other day minimizes adverse effects." Explanation: Alternate-day therapy, in which a double dose is taken every other day, is frequently ordered for maintenance therapy in the treatment of chronic events. This method allows rest periods so that many adverse effects are decreased while therapeutic effects continue.

While the nurse is preparing the client for discharge, the client asks why the health care provider has prescribed prednisone every other day instead of daily. What would be the nurse's best response?

Dexamethasone Explanation: Dexamethasone is considered the corticosteroid of choice for cerebral edema associated with brain tumors, craniotomy, or head injury because dexamethasone is thought to penetrate the blood-brain barrier more readily and achieve higher concentrations in cerebrospinal fluids and tissues.

You are caring for a client with cerebral edema caused by trauma. Which of the following medications would you anticipate being administered?

Increasing vitamin D intake Explanation: Osteoporosis is a potential adverse effect of corticosteroid therapy. Patients may be able to reduce the risk by increasing dietary intake of calcium, vitamin D, and protein.

You are talking to your class of nursing students about the adverse effects of corticosteroid therapy. What dietary change would you tell the students may help prevent osteoporosis related to long-term corticosteroid administration?

Mental changes ranging from mild agitation to psychosis. Explanation: Adverse effects of systemic corticosteroids may include infections, hypertension, glucose intolerance, obesity, cosmetic changes, bone loss, growth retardation in children, cataracts, pancreatitis, peptic ulcerations, and psychiatric disturbances.

Your client asks what the long-term adverse effects of corticosteroid therapy are. You explain that adverse effects may include:

"Don't stop this medication suddenly; you will have to taper dosage gradually." Explanation: Prednisone is usually ordered for short-term use with tapering dosage. It is important to instruct the parent to taper doses and to not just stop the drug suddenly when discontinuing from high doses so as to give the adrenal glands a chance to recover and produce adrenocorticoids. Parents should also be told to wait to have the child immunizationed until after drug therapy is completed. Insomnia or agitation is more likely than drowsiness and the drug does not create a risk for dysphagia or reflux. .

A 2-year-old client is placed on a course of prednisone following a series of hypersensitivity responses. What instruction should the nurse provide the client's family about this drug?

Blood pressure Explanation: Fludrocortisone acts on the distal renal tubule to enhance the reabsorption of sodium and to increase the urinary excretion of both potassium and hydrogen ions. In small oral doses, the mineralocorticoid effects of fludrocortisone predominate: urinary excretion of potassium, marked sodium retention, and a rise in blood pressure as a result of the physiologic effects of these electrolyte levels. The level of consciousness is not affected by fludrocortisone unless there are significant changes in the fluid balance.

A 31-year-old client is being treated with fludrocortisone for Addison disease. In addition to monitoring the client's urinary output, what other assessment should the nurse prioritize?

Increased calcium retention Explanation: Mineralocorticoids increase sodium reabsorption in the renal tubules, leading to sodium and water retention and increased potassium excretion. Calcium is not affected by mineralocorticoids.

After teaching a group of students about the effects of mineralocorticoids, the instructor determines that additional teaching is needed when the students identify what as an effect?

Cholesterol Explanation: All corticosteroids are derived from cholesterol and have similar chemical structures.

All corticosteroids derived from which of the following substances?

"Take it first thing in the morning." Explanation: Timing is dictated by frequency of administration, and if only taken once daily, the medication should be taken in the morning (so bedtime is inappropriate). Splitting the dose would decrease effectiveness and would be inappropriate for the nurse to suggest because it is outside the scope of nursing practice. Taking the medication before meals would mean it was being taken on an empty stomach.

The home health nurse provides client teaching to a client who is taking oral prednisolone. The nurse provides what instruction to the client?

hyperglycemia peptic ulcers mood disorders cataracts Explanation: Adverse effects of systemic corticosteroids may include infections, hypertension, glucose intolerance, obesity, cosmetic changes, bone loss, growth retardation in children, cataracts, pancreatitis, peptic ulcerations, and psychiatric disturbances

What adverse effects should the nurse discuss with a client prescribed long-term systemic corticosteroid therapy? Select all that apply.

Administering a systemic corticosteroid during high-stress situations in clients on long-term systemic therapy Explanation: Strategies to minimize HPA suppression and risks of acute adrenal insufficiency include administering a systemic corticosteroid during high-stress situations in clients who are on long-term systemic therapy (i.e., are steroid dependent).

What is a strategy to minimize HPA suppression and risks of acute adrenal insufficiency?

low serum levels of corticosteroids Explanation: The HPA axis normally functions according to a negative feedback mechanism; low levels of corticosteroids prompt synthesis and release. None of the other options have a significant impact on the triggering of corticosteroid production.

What stimulus would prompt the hypothalamic-pituitary-adrenal (HPA) axis to increase corticosteroid production?

Mineralocorticoids Glucocorticoids Explanation: Glucocorticoids, mineralocorticoids, and small amounts of sex hormones are secreted by the adrenal gland.

Which hormones are secreted by the adrenal gland? (Select all that apply.)