Question 1

A patient is given 1 mg of dexamethasone at 11:00 PM; a plasma cortisol level recorded at 8:00 PM the next day is normal. The nurse knows that this is an indication that the patient has what condition?

A) Addison's disease
B) Congenital adrenal hyperplasia
C) Cushing's syndrome
D) Secondary adrenal insufficiency

Cushing's syndrome

Accepted Answer

The overnight dexamethasone suppression test, which is performed by administering dexamethasone as described, is used to diagnose Cushing's syndrome. In normal individuals, dexamethasone suppresses the release of adrenocorticotropic hormone (ACTH), thereby suppressing the synthesis and release of cortisol, which results in a low cortisol level. In patients with Cushing's syndrome, the cortisol level is normal or only mildly low. This is not an indication of Addison's disease, which is diagnosed by administering cosyntropin. Neither test is useful for diagnosing congenital adrenal hyperplasia or secondary adrenal insufficiency.

Question 2

The nurse is providing patient education to a patient who will begin taking fludrocortisone [Florinef] as adjunctive therapy to hydrocortisone. Which statement by the patient indicates understanding of the teaching?

A) "I should move from sitting to standing slowly."
B) "I should report any swelling of my hands and feet."
C) "I should report weight loss to my provider."
D) "I should report excessive urine output."

"I should report any swelling of my hands and feet."

Accepted Answer

Fludrocortisone is a mineralocorticoid that regulates sodium, potassium, and water balance. Water and sodium retention is a particular concern, so the patient should be taught to report any signs of fluid retention, such as swelling of the hands and feet. Fludrocortisone elevates the blood pressure, so hypotension is not a concern. Because fluid retention causes weight gain, patients should be taught to report any increase in weight. Patients should report decreased urine output.

Question 3

A patient with Cushing's syndrome has undergone surgery and radiation treatment. The nurse will expect to teach the patient about which medication?&#10;A) Cosyntropin&#10;B) Dexamethasone&#10;C) Fludrocortisone acetate [Florinef]&#10;D) Ketoconazole [Nizoral]

Accepted Answer

The role of drugs in the treatment of Cushing's syndrome is limited; drugs are used only as adjuncts to surgery and radiation therapy. The most effective agent is ketoconazole, which suppresses steroid synthesis. Cosyntropin is used to diagnose adrenal insufficiency. Dexamethasone is a glucocorticoid used for replacement therapy and to diagnose Cushing's syndrome. Fludrocortisone is used for chronic mineralocorticoid replacement.

Question 4

A nurse is explaining congenital adrenal hyperplasia (CAH) to a group of nursing students. Which statement by a student indicates understanding of the teaching?&#10;A) &#34;CAH is caused by a deficiency of ACTH production.&#34;&#10;B) &#34;CAH is the result of an inability to synthesize glucocorticoids.&#34;&#10;C) &#34;Newborn screening provides a definitive diagnosis for CAH&#34;&#10;D) &#34;The enzyme 21-alpha-hydroxylase increases the production of androgens.&#34;

Accepted Answer

CAH results from an inborn deficiency of the enzymes needed for glucocorticoid synthesis. The condition is marked by increased production of ACTH, because the pituitary attempts to enhance glucocorticoid synthesis. Newborn screening indicates a deficiency of 21-alpha-hydroxylase; if this is noted, follow-up testing must be done to confirm a diagnosis of CAH. The enzyme 21-alpha-hydroxylase increases the production of glucocorticoids. When this enzyme is deficient, androgens are produced in excess because of stimulation by ACTH.

Question 5

The nurse is providing patient education about glucocorticoid therapy to a patient preparing to be discharged home. Which statement made by the patient best demonstrates understanding of glucocorticoid therapy?

A) "I will take the entire dose early with breakfast."
B) "I may take two-thirds of the dose in the morning and one-third in the afternoon."
C) "I will divide the dose in half and take half in the morning and half in the evening."
D) "I will take a dose with each meal."

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Accepted Answer

Patients should be instructed to follow the prescribed dosing schedule. Some prescribers recommend dividing the daily dose by taking two-thirds in the morning and one-third in the evening. Other prescribers recommend taking the entire daily dose at bedtime. Taking the dose at breakfast, dividing the dose in half, and taking a dose with each meal are not recommended dosing schedules.

Question 6

A patient who has been taking 25 mg of hydrocortisone each morning for several months reports feeling fatigued late in the day each day. What will the nurse tell the patient to discuss with the provider?

A) Adding a mineralocorticoid to the drug regimen
B) Assessing serum electrolytes to check for toxicity
C) Increasing the dose to 50 mg daily
D) Splitting the daily dose into a morning and an afternoon dose

Accepted Answer

Patients generally take hydrocortisone once daily in the morning to mimic the body's natural cortisol release cycle. However, some patients develop fatigue late in the day. These patients may split the daily dose, taking two-thirds in the morning and one-third in the afternoon or early evening. Mineralocorticoids are given to maintain intravascular volume and regulate sodium, potassium, and hydrogen, so adding this drug would not help with fatigue. Fatigue is not a sign of steroid toxicity. Increasing the dose is not indicated.

Question 7

A patient with arthritis is admitted to the hospital. The patient's serum glucose level is 350 gm/dL, and the blood pressure is 182/98 mm Hg. The nurse notes that the patient's face appears rounded and puffy. The patient complains of feeling weak. What will the nurse do?

A) Ask which drugs the patient takes for arthritis.
B) Contact the provider to discuss whether the patient has a pituitary carcinoma.
C) Request an order for ketoconazole [Nizoral].
D) Suspect that this patient has Addison's disease.

Accepted Answer

Many patients with arthritis are treated with glucocorticoids. Because the doses necessary to suppress inflammation are larger than the physiologic doses used to treat adrenal insufficiency, patients can develop signs of cortisol excess with cushingoid symptoms. This patient has an elevated glucose level, hypertension, and the characteristic moon facies and muscle weakness of Cushing's syndrome; therefore, the nurse would be correct to ask about the medications the patient takes for arthritis. A pituitary carcinoma could be the cause but is less likely. Ketoconazole is used after chemotherapy and radiation therapy in the treatment of a pituitary adenoma. This patient does not show signs of Addison's disease.

Question 8

A patient who has chronic adrenal insufficiency is admitted to the hospital for an open cholecystectomy. The nurse obtaining the admission history learns that the patient takes hydrocortisone 25 mg PO daily in the morning. The patient's surgery is scheduled for the next morning. The nurse will expect an order to:

A) administer the usual morning dose of hydrocortisone 25 mg PO.
B) administer hydrocortisone 50 mg PO in the morning.
C) administer hydrocortisone 50 mg IV before surgery.
D) withhold the morning dose of hydrocortisone and give it after surgery.

Accepted Answer

Patients who take steroids need extra steroid before situations that cause stress, such as surgery. Failure to administer the increased dose can prove fatal. For surgeries that cause moderate stress, such as a cholecystectomy, patients should be given 50 mg of hydrocortisone intravenously the day of the procedure, followed by a taper over 1 to 2 days to the usual replacement dose. Giving the usual dose or giving an increased oral dose is not indicated.

Question 9

A patient who has been newly diagnosed with adrenal hormone deficiency will begin taking hydrocortisone. The nurse provides teaching for this patient. Which statement by the patient indicates understanding of the teaching?

A) "I may take all of my daily dose in the morning or divide it in half and take it twice daily."
B) "I will need to take this medication until my symptoms completely clear, and then I may stop."
C) "Side effects are common with hydrocortisone, even with therapeutic doses."
D) "When I am sick, I should take 3 times the normal dose for 3 days in a row."

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Accepted Answer

Patients who take hydrocortisone as replacement need to be taught to increase their daily dose during times of stress, because the drug causes adrenal suppression, and the adrenals will not be able to release cortisone as usual during stress. A general rule of thumb is the "3 by 3 rule": take 3 times the usual dose for 3 days when sick. The daily dose is usually given once in the morning; if late-day fatigue occurs, patients may split the dose and take two-thirds in the morning and one-third in the late afternoon or evening. Treatment is lifetime. Side effects are uncommon when hydrocortisone is given in therapeutic doses.

Question 10

A patient is admitted with nausea, vomiting, diarrhea, and abdominal pain. The patient appears emaciated and complains of feeling weak. The nurse notes a heart rate of 98 beats/min and a blood pressure of 88/54 mm Hg. The nurse reviews the chart and notes an increased serum potassium level and a decreased serum sodium level. The nurse expects the provider to order which medication initially?

A) Cosyntropin [Cortrosyn]
B) Dexamethasone
C) Fludrocortisone [Florinef]
D) Hydrocortisone

Accepted Answer

Cosyntropin is used to diagnose adrenal insufficiency, which this patient shows signs of having. Dexamethasone is used to diagnose Cushing's syndrome. Fludrocortisone, a mineralocorticoid, is used with hydrocortisone to treat primary adrenal insufficiency; both of these drugs will be administered after the diagnosis has been confirmed.

Deck 60: Drugs for Disorders of the Adrenal Cortex