Acute conditions--test 4--Adrenal and corticosteroid therapy--

A patient with suspected adrenal insufficiency has been ordered an adrenocorticotropic hormone (ACTH) stimulation test. Administration of ACTH caused a marked increase in cortisol levels. How should the nurse interpret this finding? A. the patient's pituitary function is compromised B. the patient's adrenal insufficiency is not treatable C. the patient has insufficient hypothalmic function D. the patient would benefit from surgery

A An adrenal response to the administration of a stimulating hormone suggests inadequate production of the stimulating hormone. In this case, ACTH is produced by the pituitary and, consequently, pituitary hypofunction is suggested. Hypothalamic function is not relevant to the physiology of this problem. Treatment exists, although surgery is not likely indicated.

Critical actions the nurse takes specifically when caring for the client with Cushing's syndrome who had an adrenalectomy include (Select all that apply) a. ambulate the client as soon as the client is able. b. begin discharge planning on admission for the operation. c. use strict aseptic technique when changing dressings. d. strongly encourage client to cough and deep breathe.

A, B The client receiving steroid replacement is at high risk for infection because of lowered resistance to stress and a compromised immune system. Protecting this client from infection is vital. Discharge planning begins on admission for all clients. Most postoperative clients benefit from ambulation as soon as they are able.

A patient with Cushing syndrome has been hospitalized after a fall. The dietician consulted works with the patient to improve the patient's nutritional intake. What foods should a patient with Cushing syndrome eat to optimize health? Select all that apply. A. Foods high in vitamin D B. Foods high in calories C. Foods high in protein D. Foods high in calcium E. Foods high in sodium

A, C, D Foods high in vitamin D, protein, and calcium are recommended to minimize muscle wasting and osteoporosis. Referral to a dietitian may assist the patient in selecting appropriate foods that are also low in sodium and calories.

The nurse is performing a shift assessment of a patient with aldosteronism. What assessments should the nurse include? Select all that apply. A. urine output B. signs or symptoms of venous thromboembolism C. peripheral pulses D. blood pressure E. skin integrity

A, D The principal action of aldosterone is to conserve body sodium. Alterations in aldosterone levels consequently affect urine output and BP. The patient's peripheral pulses, risk of VTE, and skin integrity are not typically affected by aldosteronism.

The nurse is caring for a patient with Addison's disease who is scheduled for discharge. When teaching the patient about hormone replacement therapy, the nurse should address what topic? A. the possibility of precipitous weight gain B. the need for lifelong steroid replacement C. the need to match the daily steroid dose to immediate symptoms D. the importance of monitoring liver function

B Because of the need for lifelong replacement of adrenal cortex hormones to prevent addisonian crises, the patient and family members receive explicit education about the rationale for replacement therapy and proper dosage. Doses are not adjusted on a short-term basis. Weight gain and hepatotoxicity are not common adverse effects.

While assisting with the surgical removal of an adrenal tumor, the OR nurse is aware that the patient's vital signs may change upon manipulation of the tumor. What vital sign changes would the nurse expect to see? A. hyperthermia and tachypnea B. hypertension and heart rate changes C. hypotension and hypothermia D. hyperthermia and bradycardia

B Manipulation of the tumor during surgical excision may cause release of stored epinephrine and norepinephrine, with marked increases in BP and changes in heart rate. The use of sodium nitroprusside and alpha-adrenergic blocking agents may be required during and after surgery. While other vital sign changes may occur related to surgical complications, the most common changes are related to hypertension and changes in the heart rate.

A patient who has been taking corticosteroids for several months has been experiencing muscle wasting. The patient has asked the nurse for suggestions to address this adverse effect. What should the nurse recommend? A. Activity limitation to conserve energy B. Consumption of a high-protein diet C. Use of OTC vitamin D and calcium supplements D. Passive range-of-motion exercises

B Muscle wasting can be partly addressed through increased protein intake. Passive ROM exercises maintain flexibility, but do not build muscle mass. Vitamin D and calcium supplements do not decrease muscle wasting. Activity limitation would exacerbate the problem.

A patient is prescribed corticosteroid therapy. What would be priority information for the nurse to give the patient who is prescribed long-term corticosteroid therapy? A. the patient's diet should be low protien with ample fat B. the patient may experience short-term changes in cognition C. the patient is at an increased risk for developing infection D. the patient is at a decreased risk for development of thrombophlebitis and thromboembolism

C The patient is at increased risk of infection and masking of signs of infection. The cardiovascular effects of corticosteroid therapy may result in development of thrombophlebitis or thromboembolism. Diet should be high in protein with limited fat. Changes in appearance usually disappear when therapy is no longer necessary. Cognitive changes are not common adverse effects.

A patient with hypofunction of the adrenal cortex has been admitted to the medical unit. What would the nurse most likely find when assessing this patient? A. increased temperature B. jaundice C. copious urine output D. decreased BP

D Decreased BP may occur with hypofunction of the adrenal cortex. Decreased function of the adrenal cortex does not affect the patient's body temperature, urine output, or skin tone.

Health promotion activities a school nurse could teach the student athletes that will help them avoid endocrine problems in the future include a. avoiding alcohol. b. getting plenty of rest. c. not smoking. d. not using steroids.

D Educating clients to avoid using exogenous steroids unless prescribed is an important health promotion activity to avoid iatrogenic Cushing's syndrome.

A patient with Cushing syndrome as a result of a pituitary tumor has been admitted for a transsphenoidal hypophysectomy. What would be most important for the nurse to monitor before, during, and after surgery? A. blood glucose B. assessment of urine for blood C. weight D. oral temperature

A Before, during, and after this surgery, blood glucose monitoring and assessment of stools for blood are carried out. The patient's blood sugar is more likely to be volatile than body weight or temperature. Hematuria is not a common complication.

Following an addisonian crisis, a patient's adrenal function has been gradually regained. The nurse should ensure that the patient knows about the need for supplementary glucocorticoid therapy in which of the following circumstances? A. episodes of high psychosocial stress B. periods of dehydration C. episodes of physical exertion D. administration of a vaccine

A During stressful procedures or significant illnesses, additional supplementary therapy with glucocorticoids is required to prevent addisonian crisis. Physical activity, dehydration and vaccine administration would not normally be sufficiently demanding such to require glucocorticoids.

A patient presents at the walk-in clinic complaining of diarrhea and vomiting. The patient has a documented history of adrenal insufficiency. Considering the patient's history and current symptoms, the nurse should anticipate that the patient will be instructed to do which of the following? A. increase intake of sodium until GI symptoms improve B. increase intake of potassium until GI symptoms improve C. increase intake of glucose until GI symptoms improve D. increase intake of calcium until GI symptoms improve

A The patient will need to supplement dietary intake with added salt during episodes of GI losses of fluid through vomiting and diarrhea to prevent the onset of addisonian crisis. While the patient may experience the loss of other electrolytes, the major concern is the replacement of lost sodium.

A patient is undergoing testing for suspected adrenocortical insufficiency. The care team should ensure that the patient has been assessed for the most common cause of adrenocortical insufficiency. What is the most common cause of this health problem? A. therapeutic use of corticosteroids B. pheochromocytoma C. inadequate secretion of ACTH D. adrenal tumor

A Therapeutic use of corticosteroids is the most common cause of adrenocortical insufficiency. The other options also cause adrenocortical insufficiency, but they are not the most common causes.

A patient has been taking prednisone for several weeks after experiencing a hypersensitivity reaction. To prevent adrenal insufficiency, the nurse should ensure that the patient knows to do which of the following? A. take the drug concurrent with levothyroxine (synthroid) B. take each dose of prednison with a dose of calcium chloride C. gradually replace the prednisone with an OTC alternative D. slowly taper down the dose of prednison, as ordered.

D Corticosteroid dosages are reduced gradually (tapered) to allow normal adrenal function to return and to prevent steroid-induced adrenal insufficiency. There are no OTC substitutes for prednisone and neither calcium chloride nor levothyroxine addresses the risk of adrenal insufficiency.

In a client with addisonian crisis, assessment would indicate that the drug Kayexalate is not effective when the nurses assesses the clinical manifestation of A. decreasing blood pressure. B. low back pain. C.pedal edema. D. rapid erratic pulse

D Sodium polystyrene sulfonate (Kayexalate) is given to reduce hyperkalemia. If Kayexalate is not effective, hyperkalemia results and can cause cardiac dysrhythmias.

A patient on corticosteroid therapy needs to be taught that a course of corticosteroids of 2 weeks' duration can suppress the adrenal cortex for how long? A. Up to 4 weeks B. Up to 3 months C. Up to 9 months D. Up to 1 year

D Suppression of the adrenal cortex may persist up to 1 year after a course of corticosteroids of only 2 weeks' duration.

What should the nurse teach a patient on corticosteroid therapy in order to reduce the patient's risk of adrenal insufficiency? A. Take the medication late in the day to mimic the body's natural rhythms. B. Always have enough medication on hand to avoid running out. C. Skip up to 2 doses in cases of illness involving nausea. D. Take up to 1 extra dose per day during times of stress.

B The patient and family should be informed that acute adrenal insufficiency and underlying symptoms will recur if corticosteroid therapy is stopped abruptly without medical supervision. The patient should be instructed to have an adequate supply of the corticosteroid medication always available to avoid running out. Doses should not be skipped or added without explicit instructions to do so. Corticosteroids should normally be taken in the morning to mimic natural rhythms.

A client has Cushing's syndrome secondary to needing large doses of glucocorticoids to control asthma. Today the client calls the clinic complaining of "not feeling very well," but has no other complaints. The nurse should advise this client to A. come in for an examination and lab work. B. cut the steroid dose in half for the next week C. make an appointment for next week. D. rest and drink plenty of fluids.

A Clients with Cushing's syndrome have altered immunity that leads them to be vulnerable to infection with few manifestations. This client needs to be seen this day. All the other options would make the client's condition worse: cutting steroids could lead to addisonian crisis; waiting until next week to be seen or self-treating with fluids and rest could cause the client to become acutely ill.

The nurse recognizes that the manifestations of Addison's disease are primarily related to the pathophysiology of A. adrenal insufficiency B. increased intracranial pressure C. renal disease D. thyroid hyperfunction

A Commonly known as Addison's disease, primary adrenal insufficiency results from idiopathic atrophy or destruction of the adrenal glands by an autoimmune process or another disease. The other three options are not involved in Addison's disease.

The nurse formulating a discharge plan for a client with Addison's disease should place the highest emphasis on A. compliance with replacement therapy. B. prevention of the complication of hypertension. C. teaching the client how to cope with a chronic disease. D. weight control and the importance of good nutrition

A The nurse should provide the client and significant others with written instructions for self-administration of steroids. This information should include the importance of taking medications daily, without fail, exactly as prescribed. Teaching the client measures to increase coping are also important, but do not take the priority that option a does.

The nurse providing care for a patient with Cushing syndrome has identified the nursing diagnosis of risk for injury related to weakness. How should the nurse best reduce this risk? A. Establish falls prevention measures. B. Encourage bed rest whenever possible. C. Encourage the use of assistive devices. D. Provide constant supervision.

A The nurse should take action to prevent the patient's risk for falls. Bed rest carries too many harmful effects, however, and assistive devices may or may not be necessary. Constant supervision is not normally required or practicable.

You are developing a care plan for a patient with Cushing syndrome. What nursing diagnosis would have the highest priority in this care plan? A. risk for injury related to weakness B. ineffective breathing pattern related to muscle weakness C risk for loneliness related to disturbed body image D. autonomic dysreflexia related to neurologic changes

A The nursing priority is to decrease the risk of injury by establishing a protective environment. The patient who is weak may require assistance from the nurse in ambulating to prevent falls or bumping corners or furniture. The patient's breathing will not be affected and autonomic dysreflexia is not a plausible risk. Loneliness may or may not be an issue for the patient, but safety is a priority.

A 30 year-old female patient has been diagnosed with Cushing syndrome. What psychosocial nursing diagnosis should the nurse most likely prioritize when planning the patient's care? A. decisional conflict related to treatment options B. spiritual distress related to changes in cognitive function C. disturbed body image related to changes in physical appearance D. powerlessness related to disease progression

C Cushing syndrome causes characteristic physical changes that are likely to result in disturbed body image. Decisional conflict and powerless may exist, but disturbed body image is more likely to be present. Cognitive changes take place in patients with Cushing syndrome, but these may or may not cause spiritual distress.

The nurse would assess that the individual most at risk for adrenal insufficiency is the a. asthmatic client taking hydrocortisone once a week who has emergency surgery. b. athlete who stops daily doses of steroids after taking them for 2 years. c. COPD client using an aerosol bronchodilator daily who becomes pregnant. d. hypertensive client taking a diuretic who contracts a febrile illness.

B Sudden cessation of steroids after a more than every-other-day schedule could greatly increase the risk for development of adrenal insufficiency.

The nurse is caring for a patient at risk for an addisonian crisis. For what associated signs and symptoms should the nurse monitor the patient? Select all that apply. A. Epistaxis B. Pallor C. Rapid respiratory rate D. Bounding pulse E. Hypotension

B, C, E The patient at risk is monitored for signs and symptoms indicative of addisonian crisis, which can include shock; hypotension; rapid, weak pulse; rapid respiratory rate; pallor; and extreme weakness. Epistaxis and a bounding pulse are not symptoms or signs of an addisonian crisis.

In reviewing laboratory data for a client with Cushing's syndrome, the nurse might expect to see the laboratory abnormalities of (Select all that apply) a. hypercalcemia. b. hyperglycemia. c. hyperproteinemia. d. hypoglycemia. e. hypokalemia. f. hyponatremia.

B, E The exaggerated physiologic action of glucocorticoids appears as persistent hyperglycemia (steroid diabetes) and potassium depletion, leading to hypokalemia.

The nurse caring for a patient with Cushing syndrome is describing the dexamethasone suppression test scheduled for tomorrow. What does the nurse explain that this test will involve? A. administration of dexamethasone orally, followed by a plasma cortisol level every hour for 3 hours B. administration of dexamethasone IV, followed by an X-ray of adrenal glands C. administration of dexamethasone orally at 11pm and a plasma cortisol level at 8 am the next morning D. The administration IV, followed by a plasma cortisol level 3 hours after the drug is administered

C Dexamethasone (1 mg) is administered orally at 11 PM, and a plasma cortisol level is obtained at 8 AM the next morning. This test can be performed on an outpatient basis and is the most widely used and sensitive screening test for diagnosis of pituitary and adrenal causes of Cushing syndrome.

During assessment of a 45-year-old man with the medical diagnosis of Cushing's syndrome, the nurse would note the most consistent finding of a. male pattern baldness. b. peripheral edema c. hypertension. d. jaundice.

C Aldosterone affects tubular reabsorption of sodium and water and excretion of potassium and hydrogen ions in the renal tubular epithelial cells. This leads to the development of hypernatremia, hypervolemia, hypokalemia, and metabolic alkalosis. With the hypovolemia and hypernatremia, blood pressure increases, often to very high levels, and renin production is suppressed.

The nurse is caring for a patient with a diagnosis of Addison's disease. What sign or symptom is most closely associated with this health problem? A. truncal obesity B. hypertension C. muscle weakness D. moon face

C Patients with Addison's disease demonstrate muscular weakness, anorexia, gastrointestinal symptoms, fatigue, emaciation, dark pigmentation of the skin, and hypotension. Patients with Cushing syndrome demonstrate truncal obesity, moon face, acne, abdominal striae, and hypertension.

A patient has been assessed for aldosteronism and has recently begun treatment. What are priority areas for assessment that the nurse should frequently address? Select all that apply. A. pupillary response B. creatinine and BUN levels C. potassium level D. peripheral pulses E. BP

C, E Patients with aldosteronism exhibit a profound decline in the serum levels of potassium, and hypertension is the most prominent and almost universal sign of aldosteronism. Pupillary response, peripheral pulses, and renal function are not directly affected.

The home care nurse is conducting patient teaching with a patient on corticosteroid therapy. To achieve consistency with the body's natural secretion of cortisol, when would the home care nurse instruct the patient to take his or her corticosteroids? A. in the evening between 4pm and 6pm B. prior to going to sleep at night C. at noon every day D. in the morning between 7am and 8am

D In keeping with the natural secretion of cortisol, the best time of day for the total corticosteroid dose is in the morning from 7 to 8 AM. Large-dose therapy at 8 AM, when the adrenal gland is most active, produces maximal suppression of the gland. Also, a large 8 AM dose is more physiologic because it allows the body to escape effects of the steroids from 4 PM to 6 AM, when serum levels are normally low, thus minimizing cushingoid effects.

In making the care plan for a client with Cushing's disease, the nurse would choose which diagnosis as a priority? a. Activity Intolerance b. Pain, Chronic c. Risk for Fluid Volume Deficit d. Risk for Injury

D The client should be protected against falls and accidents. Clients with Cushing's syndrome have osteoporosis and tend to develop fractures with even minor trauma.

A client has Addison's disease. The nurse should teach the client to carry an injection kit at all times with the medication A. adrenaline. B. Benadryl. C. epinephrine. D. hydrocortisone.

D The nurse should instruct the client to wear an emergency identification bracelet and carry an emergency kit for hydrocortisone injection in case of an adrenal crisis.