Cushing's Syndrome/Addison's Disease

During the first 24 hours after a client is diagnosed with Addisonian crisis, which intervention should the nurse perform frequently?

1. Weigh the client 2. Test urine for ketones 3. Assess vital signs 4. Administer oral hydrocortisone RATIONALES (3): Because the client in Addisonian crisis is unstable, vital signs and fluid and electrolyte balance should be assessed every 30 minutes until he's stable. Daily weights are sufficient when assessing the client's condition. The client shouldn't have ketones in his urine, so there is no need to assess the urine for their presence. Oral hydrocortisone isn't administered during the first 24 hours in severe adrenal insufficiency.

The nurse is teaching a client recovering from addisonian crisis about the need to take fludrocortisone acetate and hydrocortisone at home. Which statement by the client indicates an understanding of the instructions?

1. "I'll take my hydrocortisone in the late afternoon, before dinner." 2. "I'll take all of my hydrocortisone in the morning, right after I wake up." 3. "I'll take two-thirds of the dose when I wake up and one-third in the late afternoon." 4. "I'll take the entire dose at bedtime." RATIONALES (3): Hydrocortisone, a glucocorticoid, should be administered according to a schedule that closely reflects the body's own secretion of this hormone; therefore, two-thirds of the dose of hydrocortisone should be taken in the morning and one-third in the late afternoon. This dosage schedule reduces adverse effects.

Before discharge, what should a client with Addison's disease be instructed to do when exposed to periods of stress?

1. administer hydrocortisone I.M. 2. Drink 8 oz of fluids. 3. Perform capillary blood glucose monitoring four times daily 4. Continue to take his usual dose of hydrocortisone. RATIONALES: (1) Clients with Addison's disease and their family members should know how to administer I.M. hydrocortisone during periods of stress. It's important to keep well hydrated during stress, but the critical component in this situation is to know how and when to use I.M. hydrocortisone. Capillary blood glucose monitoring isn't indicated in this situation because the client doesn't have diabetes mellitus. Hydrocortisone replacement doesn't cause insulin resistance.

A client with Addison's disease is scheduled for discharge after being hospitalized for an adrenal crisis. Which statements by the client would indicate that client teaching has been effective?

1. "I have to take my steroids for 10 days." 2. "I need to weigh myself daily to be sure I don't eat too many calories." 3. "I need to call my doctor to discuss my steroid needs before I have dental work." 4. "I will call the doctor if I suddenly feel profoundly weak or dizzy." 5. "If I feel like I have the flu, I'll carry on as usual because this is an expected response." 6. "I need to obtain and wear a Medic Alert bracelet." RATIONALES:(3, 4, 6) Dental work can be a cause of physical stress; therefore, the client's physician needs to be informed about the dental work and an adjusted dosage of steroids may be necessary. Fatigue, weakness, and dizziness are symptoms of inadequate dosing of steroid therapy; the physician should be notified if these symptoms occur. A Medic Alert bracelet allows health care providers to access the client's history of Addison's disease if the client is unable to communicate this information. A client with Addison's disease doesn't produce enough steroids, so routine administration of steroids is a lifetime treatment. Daily weights should be monitored to monitor changes in fluid balance, not calorie intake. Influenza is an added physical stressor and the client may require an increased dosage of steroids. The client shouldn't "carry on as usual."

A client is admitted to the health care facility for evaluation for Addison's disease. Which laboratory test result best supports a diagnosis of Addison's disease?

1. BUN level of 12 mg/dl 2. Blood glucose level of 90 mg/dl 3. Serum sodium level of 134 mEq/L 4. Serum potassium level of 5.8 mEq/L RATIONALES: (4) Addison's disease decreases the production of aldosterone, cortisol, and androgen, causing urinary sodium and fluid losses, an increased serum potassium level, and hypoglycemia. Therefore, an elevated serum potassium level of 5.8 mEq/L best supports a diagnosis of Addison's disease. A BUN level of 12 mg/dl and a blood glucose level of 90 mg/dl are within normal limits. In a client with Addison's disease, the serum sodium level would be much lower than 134 mEq/L, a nearly normal level.

The nursing care for the client in addisonian crisis should include which intervention?

1. Encouraging independence with activities of daily living (ADLs) 2. Allowing ambulation as tolerated 3. Offering extra blankets and raising the heat in the room to keep the client warm 4. Placing the client in a private room RATIONALES(4): The client in addisonian crisis has a reduced ability to cope with stress due to an inability to produce corticosteroids. Compared to a multibed room, a private room is easier to keep quiet, dimly lit, and temperature controlled. Also, visitors can be limited to reduce noise, promote rest, and decrease the risk of infection. The client should be kept on bed rest, receiving total assistance with ADLs to avoid stress as much as possible. Because extremes of temperature should be avoided, measures to raise the body temperature, such as extra blankets and turning up the heat, should be avoided.

The nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find:

1. Hypotension 2. Thick, coarse skin 3. deposits of adipose tissue in the trunk and dorsocervical area 4. weight gain in arms and legs Rationale: (3) Because of changes in fat distribution, adipose tissue accumulates in the trunk, face (moonface), and dorsocervical areas (buffalo hump). Hypertension is caused by fluid retention. Skin becomes thin and bruises easily because of a loss of collagen. Muscle wasting causes muscle atrophy and thin extremities.

The nurse is caring for a client in acute addisonian crisis. Which laboratory data would the nurse expect to find?

1. hyperkalemia 2. reduced BUN 3. hypernatremia 4. hyperglycemia RATIONALES (1): In adrenal insufficiency, the client has hyperkalemia due to reduced aldosterone secretion. BUN increases as the glomerular filtration rate is reduced. Hyponatremia is caused by reduced aldosterone secretion. Reduced cortisol secretion leads to impaired glyconeogenesis and a reduction of glycogen in the liver and muscle, causing hypoglycemia.

A client with a history of Addison's disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. When he awoke this morning, his wife noticed that he acted confused and was extremely weak. The client's blood pressure is 90/58 mm Hg, his pulse is 116 beats/minute, and his temperature is 101° F (38.3° C). A diagnosis of acute adrenal insufficiency is made. What would the nurse expect to administer by I.V. infusion?

1. Insulin 2. Hydrocortisone 3. Potassium 4. Hypotonic saline RATIONALES (2) : Emergency treatment for acute adrenal insufficiency (Addisonian crisis) is I.V. infusion of hydrocortisone and saline solution. The client is usually given a dose containing hydrocortisone 100 mg I.V. in normal saline every 6 hours until the client's blood pressure returns to normal. Insulin isn't indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia. Potassium isn't indicated because these clients are usually hyperkalemic. The client needs normal — not hypotonic — saline solution.

The nurse is planning care for a 52-year-old male client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority?

1. Risk for Infection 2. Decreased cardiac output 3. Impaired physical mobility 4. Imbalanced nutrition: less than body requirement RATIONALES: (2) An acute addisonian crisis is a life-threatening event, caused by deficiencies of cortisol and aldosterone. Glucocorticoid insufficiency causes a decrease in cardiac output and vascular tone, leading to hypovolemia. The client becomes tachycardic and hypotensive and may develop shock and circulatory collapse. The client with Addison's disease is at risk for infection; however, reducing infection isn't a priority during an addisonian crisis. Impaired physical mobility is also an appropriate nursing diagnosis for the client with Addison's disease, but it isn't a priority in a crisis. Imbalanced nutrition: Less than body requirements is also an important nursing diagnosis for the client with Addison's disease but not a priority during a crisis.

Which nursing diagnosis is most appropriate for a client with Addison's disease?

1. Risk for infection 2. Excessive fluid volume 3. Urinary retention 4. Hypothermia RATIONALES:(1) Addison's disease decreases the production of all adrenal hormones, compromising the body's normal stress response and increasing the risk of infection. Other appropriate nursing diagnoses for a client with Addison's disease include Deficient fluid volume and Hyperthermia. Urinary retention isn't appropriate because Addison's disease causes polyuria.

A 35-year-old female client who complains of weight gain, facial hair, absent menstruation, frequent bruising, and acne is diagnosed with Cushing's syndrome. Cushing's syndrome is most likely caused by:

1. an ectopic corticotropin-secreting tumor 2. adrenal carcinoma 3. a corticotropin-secreting pituitary adenoma 4. an inborn error of metabolism. RATIONALES: (3) A corticotropin-secreting pituitary adenoma is the most common cause of Cushing's syndrome in women ages 20 to 40. Ectopic corticotropin-secreting tumors are more common in older men and are often associated with weight loss. Adrenal carcinoma isn't usually accompanied by hirsutism. A female with an inborn error of metabolism wouldn't be menstruating.

A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of:

1. calcium and phosphorus abnormalities 2. chloride and magnesium abnormalities 3. sodium and chloride abnormalities 4. sodium and potassium abnormalities RATIONALES:(4) In Addison's disease, a form of adrenocortical hypofunction, aldosterone secretion is reduced. Aldosterone promotes sodium conservation and potassium excretion. Therefore, aldosterone deficiency increases sodium excretion, predisposing the client to hyponatremia, and inhibits potassium excretion, predisposing the client to hyperkalemia. Because aldosterone doesn't regulate calcium, phosphorus, chloride, or magnesium, an aldosterone deficiency doesn't affect levels of these electrolytes directly.

A client with Cushing's syndrome is admitted to the medical-surgical unit. During the admission assessment, the nurse notes that the client is agitated and irritable, has poor memory, reports loss of appetite, and appears disheveled. These findings are consistent with which problem?

1. depression 2. neuropathy 3. hypoglycemia 4. hyperthyroidism RATIONALES (1): Agitation, irritability, poor memory, loss of appetite, and neglect of one's appearance may signal depression, which is common in clients with Cushing's syndrome. Neuropathy affects clients with diabetes mellitus — not Cushing's syndrome. Although hypoglycemia can cause irritability, it also produces increased appetite, rather than loss of appetite. Hyperthyroidism typically causes such signs as goiter, nervousness, heat intolerance, and weight loss despite increased appetite.

When teaching a client with Cushing's syndrome about dietary changes, the nurse should instruct the client to increase intake of:

1. fresh fruits 2. dairy products 3. processed meats 4. cereals and grains RATIONALES: (1) Cushing's syndrome causes sodium retention, which increases urinary potassium loss. Therefore, the nurse should advise the client to increase intake of potassium-rich foods, such as fresh fruit. The client should restrict consumption of dairy products, processed meats, cereals, and grains because they contain significant amounts of sodium.

The nurse is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately?

1. pitting edema of the legs 2. an irregular apical pulse 3. dry mucous membranes 4. frequent urination RATIONALES (2): Because Cushing's syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician. Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. Dry mucous membranes and frequent urination signal dehydration, which isn't associated with Cushing's syndrome.

For a client in addisonian crisis, it would be very risky for a nurse to administer:

1. potassium chloride 2. normal saline solution 3. hydrocortisone 4. fludrocortisone RATIONALES: (1) Addisonian crisis results in hyperkalemia; therefore, administering potassium chloride is contraindicated. Because the client will be hyponatremic, normal saline solution is indicated. Hydrocortisone and fludrocortisone are both useful in replacing deficient adrenal cortex hormones.

In a 28-year-old female client who is being successfully treated for Cushing's syndrome, the nurse would expect a decline in:

1. serum glucose level 2. hair loss 3. bone mineralization 4. menstrual flow RATIONALES: (1) Hyperglycemia, which develops from glucocorticoid excess, is a manifestation of Cushing's syndrome. With successful treatment of the disorder, serum glucose levels decline. Hirsutism is common in Cushing's syndrome; therefore, with successful treatment, abnormal hair growth also declines. Osteoporosis occurs in Cushing's syndrome; therefore, with successful treatment, bone mineralization increases. Amenorrhea develops in Cushing's syndrome. With successful treatment, the client experiences a return of menstrual flow, not a decline in it.