ADDISON'S & CUSHING'S

A registered nurse (RN) who is working with a nursing student assigns the student to care for a client with a diagnosis of Cushing's syndrome. The RN asks the student questions about this disorder. Which statement made by the student indicates understanding of Cushing's syndrome? a. "Cushing's syndrome is caused by excessive amounts of cortisol." b. "Cushing's syndrome is caused by decreased amounts of aldosterone." c. "Cushing's syndrome is caused by excessive amounts of antidiuretic hormone." d. "Cushing's syndrome is caused by decreased amounts of parathyroid hormone."

ANS: A

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

ANS: A

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? a. "I will be sure to notify my health-care provider if I start to run a fever." b. "Before I stop taking the prednisone, I will be taught how to taper it off." c. "If I get weak and shaky, I need to eat some hard candy or drink some juice." d. "It is fine if I continue to participate in weekend games of tackle football."

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

The nurse is caring for a client who has had an adrenalectomy and is monitoring the client for signs of adrenal insufficiency. Which signs and symptoms indicate adrenal insufficiency in this client? a. Hypotension and fever b. Mental status changes and hypertension c. Subnormal temperature and hypotension d. Complaints of weakness and hypertension

ANS: A The nurse would be alert to signs and symptoms of adrenal insufficiency after adrenalectomy. These signs and symptoms include weakness, hypotension, fever, and mental status changes.

Which finding indicates to the nurse that the current therapies are effective for a patient with acute adrenal insufficiency? a. Increasing serum sodium levels b. Decreasing blood glucose levels c. Decreasing serum chloride levels d. Increasing serum potassium levels

ANS: A Clinical manifestations of Addisons disease include hyponatremia and an increase in sodium level indicates improvement. The other values indicate that treatment has not been effective.

The nurse is providing home care instructions to the client with a diagnosis of Cushing's syndrome and prepares a list of instructions for the client. Which instructions would be included on the list? Select all that apply. a. The signs and symptoms of hypoadrenalism b. The signs and symptoms of hyperadrenalism c. Instructions to take the medications exactly as prescribed d. The importance of maintaining regular outpatient follow-up care5 e. A reminder to read the labels on over-the-counter medications before purchase

ANS: A, B, C, D The client with Cushing's syndrome needs to be instructed to take the medications exactly as prescribed. The nurse needs to emphasize the importance of continuing medications, consulting with the primary health care provider (PHCP) before purchasing any over-the-counter medications, and maintaining regular outpatient follow-up care. The nurse also would instruct the client in the signs and symptoms of both hypoadrenalism and hyperadrenalism.

A client is hospitalized with a diagnosis of adrenal insufficiency. Which findings does the nurse identify as supportive of this diagnosis? Select all that apply. a. Irritability b. Complaints of nausea c. Sodium level of 128 mEq/L d. Potassium level of 3.2 mEq/L e. Blood pressure lying 138/70 mm Hg and standing 110/59 mm Hg

ANS: A, B, C, E Findings consistent with a diagnosis of adrenal insufficiency include nausea, vomiting, and diarrhea; hyponatremia; salt craving; hyperkalemia; and orthostatic hypotension. Irritability and depression may also occur in primary adrenal hypofunction.

A nursing instructor is teaching the class about Addison's disease. The instructor determines that the class understands the disease process if they indicate which are affected in this disease? Select all that apply. a. Androgens b. Bicarbonate c. Electrolytes d. Glucocorticoids e. Mineralocorticoids

ANS: A, D, E In Addison's disease, all three classes of corticosteroids are affected: glucocorticoids, mineralocorticoids, and androgens. Electrolytes and bicarbonate are not directly affected by Addison's disease.

The nurse is developing a plan of care for a client with Cushing's syndrome. The nurse documents a client problem of excess fluid volume. Which nursing actions would be included in the care plan for this client? Select all that apply. a. Monitor daily weight b. Maintain a high-sodium diet c. Maintain a low-potassium diet d. Monitor intake and output e. Assess extremities for edema

ANS: A, D, E The client with Cushing's syndrome and a problem of excess fluid volume would be on daily weights and intake and output and have extremities assessed for edema. The client needs to be on a high-potassium, low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water.

The nurse is developing a plan of care for a client with Addison's disease. The nurse has identified a problem of risk for deficient fluid volume and identifies nursing interventions that will prevent this occurrence. Which nursing interventions would the nurse include in the plan of care? Select all that apply. a. Monitor for changes in mentation. b. Encourage an intake of low-protein foods. c. Encourage an intake of low-sodium foods. d. Encourage fluid intake of at least 3000 mL per day. e. Monitor vital signs, skin turgor, and intake and output.

ANS: A, D, E The client at risk for deficient fluid volume needs to be encouraged to eat regular meals and snacks and to increase intake of sodium, protein, and complex carbohydrates and fluids. Oral replacement of sodium losses is necessary, and maintenance of adequate blood glucose levels is required. Mentation, vital signs, skin turgor, and intake and output need to be monitored for signs of fluid volume deficit.

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

ANS: B

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

ANS: B "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 with hypovolemia experiences activation of the renin-angiotensin system to maintain blood pressure. The registered nurse determines that the new nurse understands that what substance is secreted if which statement is made? a. "Cortisol will be secreted." b. "Aldosterone will be secreted." c. "Additional glucagon will be produced." d. "Adrenocorticotropic hormone production will increase."

ANS: B Aldosterone is the primary mineralocorticoid that is produced and secreted in response to lowered blood volume. Cortisol is a glucocorticoid. Glucagon is produced by the pancreas and functions to oppose the action of insulin in regulating blood glucose levels. Adrenocorticotropic hormone is produced by the pituitary gland and stimulates the adrenal cortex to produce glucocorticoids and mineralocorticoids.

A client is diagnosed with Cushing's syndrome. When reviewing the recent laboratory results, the nurse would expect an excess of which substance? a. Calcium b. Cortisol c. Epinephrine d. Norepinephrine

ANS: B Cushing's syndrome is characterized by an excess of cortisol, a glucocorticoid. Glucocorticoids are produced by the adrenal cortex. Calcium would be decreased in this disorder. Epinephrine and norepinephrine are produced by the adrenal medulla.

A client with Cushing's syndrome is anxious and verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which statement would the nurse plan to make to the client? a. "Don't be concerned; this problem can be covered with clothing." b. "Usually these physical changes slowly improve following treatment." c. "This is permanent, but looks are deceiving and are not that important." d. "Try not to worry about it; there are other things to be concerned about."

ANS: B The client with Cushing's syndrome need to be reassured that most physical changes resolve with treatment. All other options are not therapeutic responses.

A 38-year-old male patient is admitted to the hospital in Addisonian crisis. Which patient statement supports a nursing diagnosis of ineffective self-health management related to lack of knowledge about management of Addisons disease? a. I frequently eat at restaurants, and my food has a lot of added salt. b. I had the stomach flu earlier this week, so I couldnt take the hydrocortisone. c. I always double my dose of hydrocortisone on the days that I go for a long run. d. I take twice as much hydrocortisone in the morning dose as I do in the afternoon.

ANS: B The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given. The other patient statements indicate appropriate management of the Addisons disease.

The nurse is reviewing the laboratory test results for a client and notes that the serum potassium level is 5.5 mEq/L (5.5 mmol/L). The nurse understands that this value would be noted in which condition? a. Diarrhea b. Addison's disease c. Diabetes insipidus d. Dumping syndrome

ANS: B The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Many pathological conditions, including Addison's disease, adrenocortical insufficiency, anemia, burns, and ketoacidosis, result in an increased potassium level. Hyperkalemia can also cause abdominal cramping and diarrhea. The conditions in the remaining options would result in a decreased serum potassium level.

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

ANS: C

A nurse has provided dietary instructions to a client with Addison's disease. Which statement made by the client indicates that the client understands the instructions? a. "I will decrease my carbohydrate intake." b. "High fat intake is essential with this disease." c. "I will maintain a normal sodium intake in my diet." d. "I will need to restrict the amount of protein in my diet."

ANS: C A high-complex carbohydrate, high-protein diet will be prescribed for the client with Addison's disease. To prevent excess fluid and sodium loss, the client is instructed to maintain a normal salt intake daily (3 g) and to increase salt intake during hot weather, before strenuous exercise, and in response to fever, vomiting, or diarrhea. A high-fat diet is not prescribed.

The nurse is caring for a client with Addison's disease. The client asks the nurse about the risks associated with this disease, specifically about addisonian crisis. Regarding prevention of this complication, how would the nurse inform the client? a. "You can take either hydrocortisone or fludrocortisone for replacement." b. "You need to take your fludrocortisone 3 times a day to prevent a crisis." c. "You need to increase salt in your diet, particularly during stressful situations." d. "You need to decrease your dosages of glucocorticoids and mineralocorticoids during stressful situations."

ANS: C Addison's disease is a result of adrenocortical insufficiency, and management is focused on treating the underlying cause. Hormone therapy is used for replacement. Hydrocortisone has both glucocorticoid and mineralocorticoid properties and needs to be taken 3 times daily, with two thirds of the daily dose taken on awakening. Fludrocortisone is taken once daily in the morning. Salt additives are necessary, particularly during times of stress, to compensate for excess heat or humidity as a result of the condition. There needs to be an increased dose of cortisol given for stressful situations such as surgery or hospitalization. Therefore, option 3 is the correct answer.

The nurse is caring for a postoperative client who has had an adrenalectomy. What would the nurse check for during the client's focused assessment? a. Peripheral edema b. Bilateral exophthalmos c. Signs and symptoms of hypovolemia d. Signs and symptoms of hypocalcemia

ANS: C Aldosterone, secreted by the adrenal cortex, plays a major role in fluid volume balance by retaining sodium and water. Thus, a deficiency can cause hypovolemia. A deficiency of adrenocortical hormones (such as after adrenalectomy) does not cause the clinical manifestations noted in the remaining options.

The nurse is instructing a client with Cushing's syndrome on follow-up care. Which of these client statements would indicate a need for further instruction? a. "I need to avoid contact sports." b. "I would check my ankles for swelling." c. "I need to avoid foods high in potassium." d. "I need to check my blood glucose regularly."

ANS: C Hypokalemia is a common characteristic of Cushing's syndrome, and the client is instructed to consume foods high in potassium. Clients with this condition experience activity intolerance, osteoporosis, and frequent bruising. Fluid volume excess results from water and sodium retention. Hyperglycemia is caused by an increased cortisol secretion.

A 37-year-old patient is being admitted with a diagnosis of Cushing syndrome. Which findings will the nurse expect during the assessment? a. Chronically low blood pressure b. Bronzed appearance of the skin c. Purplish streaks on the abdomen d. Decreased axillary and pubic hair

ANS: C Purplish-red striae on the abdomen are a common clinical manifestation of Cushing syndrome. Hypotension and bronzed-appearing skin are manifestations of Addisons disease. Decreased axillary and pubic hair occur with androgen deficiency.

The nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which laboratory finding would the nurse expect to note in this client? a. A platelet count of 200,000 mm3 (200 × 109/L) b. A blood glucose level of 99 mg/dL (5.5 mmol/L) c. A potassium (K+) level of 3.0 mEq/L (3.0 mmol/L) d. A white blood cell (WBC) count of 6000 mm3 (6 × 109/L)

ANS: C The client with Cushing's syndrome experiences hypokalemia, hyperglycemia, an elevated WBC count, elevated plasma cortisol and adrenocorticotropic hormone levels among other abnormalities. These abnormalities are caused by the effects of excess glucocorticoids and mineralocorticoids in the body.

A client with suspected Cushing's syndrome is scheduled for adrenal venography. A nurse has provided instructions to the client regarding the test. Which statement by the client indicates a need for further instruction? a. "I need to sign an informed consent." b. "The insertion site will be locally anesthetized." c. "I will be placed in a high-sitting position for the test." d. "I may feel a burning sensation after the dye is injected."

ANS: C The test aids in determining whether signs and symptoms are caused by abnormalities in the adrenal gland. The nurse assesses the client for allergies to iodine before the test. The client is informed that the supine position is necessary to access the femoral vein. An informed consent form is required, the insertion site will be locally anesthetized, and the client will experience a transient burning sensation after the dye is injected.

The nurse is providing discharge instructions to a client who has Cushing's syndrome. Which client statement indicates that instructions related to dietary management are understood? a. "I will need to limit the amount of protein in my diet." b. "I am fortunate that I can eat all of the salty foods I enjoy." c. "I am fortunate that I do not need to follow any special diet." d. "I need to eat foods that have a lot of potassium in them."

ANS: D A diet low in carbohydrates and sodium but ample in protein and potassium is encouraged for a client with Cushing's syndrome. Such a diet promotes weight loss, reduction of edema and hypertension, control of hypokalemia, and rebuilding of wasted tissue.

A client is admitted to the hospital with a diagnosis of Addison's disease. The nurse would assess for which problem as a manifestation of this disorder? a. Edema b. Obesity c. Hirsutism d. Hypotension

ANS: D Common manifestations of Addison's disease include postural hypotension from fluid loss, syncope, muscle weakness, anorexia, nausea and vomiting, abdominal cramps, weight loss, depression, and irritability. The remaining options do not occur with this disease.

The nurse has documented the problem of body image distortion for a client with a diagnosis of Cushing's syndrome. The nurse identifies nursing interventions related to this problem and includes these interventions in the plan of care. Which nursing intervention is inappropriate? a. Encourage the client's expression of feelings. b. Assess the client's understanding of the disease process. c. Encourage family members to share their feelings about the disease process. d. Encourage the client to recognize that the body changes need to be dealt with.

ANS: D Encouraging the client to understand that the body changes that occur in this disorder need to be dealt with is an inappropriate nursing intervention. This option does not address the client's feelings. The remaining options are appropriate because they address the client and family feelings regarding the disorder.

A client with aldosteronism is being treated with spironolactone. Which finding indicates to the nurse that the medication is effective? a. Decrease in body metabolism b. Decrease in sodium excretion c. Decrease in potassium excretion d. Decrease in aldosterone production

ANS: D Spironolactone antagonizes the effect of aldosterone and decreases circulating volume by inhibiting tubular reabsorption of sodium and water. Thus, it produces a decrease in blood pressure. It increases the excretion of sodium and plasma potassium. It has no effect on body metabolism.

The nurse is caring for a client with a diagnosis of Addison's disease and is monitoring the client for signs of Addisonian crisis. The nurse would assess the client for which manifestation that would be associated with this crisis? a. Agitation b. Diaphoresis c. Restlessness d. Severe abdominal pain

ANS: D The client in Addisonian crisis may demonstrate any of the signs and symptoms of Addison's disease, but the primary problems are sudden profound weakness; severe abdominal, back, and leg pain; hyperpyrexia followed by hypothermia; peripheral vascular collapse; coma; and renal failure.

The nurse is providing instructions to a client with a diagnosis of Addison's disease regarding the administration of prescribed glucocorticoids. The nurse would provide which instruction to the client? a. To stop the medication if side effects occur b. To avoid taking the medication if nausea occurs c. That minimal side effects will occur with use of this medication d. That an increased dose of medication may be needed during times of stress

ANS: D The client with Addison's disease will require lifelong replacement of adrenal hormones. The medications must be taken daily, and an alternate route of administration must be used if the client cannot take oral medications for any reason, such as nausea and vomiting. Additional doses of glucocorticoids will be needed during times of stress. The nurse must emphasize that the client must call the primary health care provider (PHCP) to obtain a prescription for a dosage increase when experiencing stressful situations. Abrupt withdrawal of this medication can result in addisonian crisis. Although side effects are mild at lower doses, more severe side effects occur with long-term glucocorticoid administration. It is very unsafe to stop taking the medication without first consulting the PHCP.

A client has been diagnosed with Cushing's syndrome. The nurse would assess the client for which expected manifestations of this disorder? a. Dizziness b. Weight loss c. Hypoglycemia d. Truncal obesity

ANS: D The client with Cushing's syndrome may exhibit a number of different manifestations. These may include moon face, truncal obesity, and a "buffalo hump" fat pad. Other signs include hyperglycemia, hypernatremia, hypocalcemia, peripheral edema, hypertension, increased appetite, and weight gain. Dizziness is not part of the clinical picture for this disorder.

A 44-year-old female patient with Cushing syndrome is admitted for adrenalectomy. Which intervention by the nurse will be most helpful for a nursing diagnosis of disturbed body image related to changes in appearance? a. Reassure the patient that the physical changes are very common in patients with Cushing syndrome. b. Discuss the use of diet and exercise in controlling the weight gain associated with Cushing syndrome. c. Teach the patient that the metabolic impact of Cushing syndrome is of more importance than appearance. d. Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery.

ANS: D The most reassuring communication to the patient is that the physical and emotional changes caused by the Cushing syndrome will resolve after hormone levels return to normal postoperatively. Reassurance that the physical changes are expected or that there are more serious physiologic problems associated with Cushing syndrome are not therapeutic responses. The patients physiological changes are caused by the high hormone levels, not by the patients diet or exercise choices.

The nurse is performing an assessment on a client with a diagnosis of Cushing's syndrome. Which would the nurse expect to note on assessment of the client? a. Skin atrophy b. The presence of sunken eyes c. Drooping on one side of face d. A rounded "moonlike" appearance to face

ANS: D With excessive secretion of adrenocorticotropic hormone (ACTH) and chronic corticosteroid use, the person with Cushing's syndrome develops a rounded moonlike face; prominent jowls; red cheeks; and hirsutism on the upper lip, lower cheek, and chin.

The nurse is caring for a client with a diagnosis of Cushing's syndrome. Which expected signs and symptoms would the nurse monitor for? Select all that apply. a. Anorexia b. Dizziness c. Weight loss d. Moon face e. Hypertension f. Truncal obesity

ANS: D, E, F A client with Cushing's syndrome may exhibit a number of different manifestations. These could include moon face, truncal obesity, and a buffalo hump fat pad. Other signs include hypokalemia, peripheral edema, hypertension, increased appetite, and weight gain. Dizziness is not part of the clinical picture for this disorder.