Lippincott NCLEX Review - Addison's Disease

72. The client's wife asks the nurse whether the IV infusion is meeting her husband's nutritional needs because he has vomited several times. The nurse's response should be based on the knowledge that 1 L of 5% dextrose in normal saline solution delivers: 1. 170 cal. 2. 250 cal. 3. 340 cal. 4. 500 cal.

1. Each liter of 5% dextrose in normal saline solution contains 170 cal. The nurse should consult with the physician and dietitian when a client is on IV therapy or is on nothing-by-mouth status for an extended period because further electrolyte supplementation or alimentation therapy may be needed.

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.

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 lifethreatening 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 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 and symptoms include mood changes, emotional lability, irritability, weight loss, muscle weakness, fatigue, nausea, and vomiting. Most clients experience a loss of appetite. Muscles become weak, not spastic, because of adrenocortical insufficiency.

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 to 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.

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 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.

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.

Which of the following would be an expected finding in a client with adrenal crisis (addisonian crisis)? 1. Fluid retention. 2. Pain. 3. Peripheral edema. 4. Hunger.

2. Adrenal hormone deficiency can cause profound physiologic changes. The client may experience severe pain (headache, abdominal pain, back pain, or pain in the extremities). Inhibited gluconeogenesis commonly produces hypoglycemia, and impaired sodium retention causes decreased, not increased, fluid volume. Edema would not be expected. Gastrointestinal disturbances, including nausea and vomiting, are expected findings in Addison's disease, not hunger.

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 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.

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.

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.

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.

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 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-g 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.

The client is receiving an IV infusion of 5% dextrose in normal saline running at 125 mL/h. When hanging a new bag of fluid, the nurse notes swelling and hardness at the infusion site. The nurse should first: 1. Discontinue the infusion. 2. Apply a warm soak to the site. 3. Stop the flow of solution temporarily. 4. Irrigate the needle with normal saline.

1. Signs of infiltration include slowing of the infusion and swelling, pain, hardness, pallor, and coolness of the skin at the site. If these signs occur, the IV line should be discontinued and restarted at another infusion site. The new anatomic site, time, and type of cannula used should be documented. The nurse may apply a warm soak to the site, but only after the IV line is discontinued. Parenteral administration of fluids should not be stopped intermittently. Stopping the flow does not treat the problem, nor does it address the client's needs for fluid replacement. Infiltrated IV sites should not be irrigated; doing so will only cause more swelling and pain.

Cortisone acetate and fludrocortisone acetate are prescribed as replacement therapy for a client with Addison's disease. What administration schedule should be followed for this therapy? 1. Take both drugs three times a day. 2. Take the entire dose of both drugs first thing in the morning. 3. Take all the fludrocortisone acetate and two-thirds of the cortisone acetate in the morning, and take the remaining cortisone acetate in the afternoon. 4. Take half of each drug in the morning and the remaining half of each drug at bedtime.

3. Fludrocortisone acetate can be administered once a day, but cortisone acetate administration should follow the body's natural diurnal pattern of secretion. Greater amounts of cortisol are secreted during the day to meet the increased demand of the body. Typically, baseline administration of cortisone acetate is 25 mg in the morning and 12.5 mg in the afternoon. Taking it three times a day would result in an excessive dose. Taking the drug only in the morning would not meet the needs of the body later in the day and evening.

The nurse should teach the client with Addison's disease that the bronzecolored 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.