MSN Client with Addison’s Disease Quiz 1

1. The client is receiving an I.V. infusion of 5% dextrose in normal saline running at 125 mL/ hour. When hanging a new bag of fluid, the nurse notes swelling and hardness at the infusion site. The nurse should first:

Discontinue the infusion.

Apply a warm soak to the site.

Stop the flow of solution temporarily.

Irrigate the needle with normal saline.

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 I.V. 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 I.V. 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 I.V. sites should not be irrigated; doing so will only cause more swelling and pain.

Explanation

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 I.V. 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 I.V. 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 I.V. sites should not be irrigated; doing so will only cause more swelling and pain.

2. After stabilization of Addison's disease, the nurse teaches the client about stress management. The nurse should instruct the client to:

Remove all sources of stress from daily life.

Use relaxation techniques such as music.

Take antianxiety drugs daily.

Avoid discussing stressful experiences.

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.

Explanation

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.

3. When teaching a client newly diagnosed with primary Addison's disease, the nurse should explain that the disease results from:

Insufficient secretion of growth hormone (GH).

Dysfunction of the hypothalamic pituitary.

Idiopathic atrophy of the adrenal gland.

Oversecretion of the adrenal medulla.

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.

Explanation

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.

4. The nurse should assess a client with Addison's disease for which of the following?

Weight gain.

Hunger.

Lethargy.

Muscle spasms.

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.

Explanation

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.

5. A nurse is assessing a client with Addison's disease. The nurse should review laboratory reports for which condition?

Hypokalemia.

Hypernatremia.

Hypoglycemia.

Decreased blood urea nitrogen (BUN) level.

Decreased hepatic gluconeogenesis and increased tissue glucose uptake cause hypoglycemia in clients with Addison’s disease. Hyperkalemia and hyponatremia are characteristic of Addison’s disease.

There is decreased renal perfusion and excretion of waste products, which causes an elevated BUN level.

Explanation

Decreased hepatic gluconeogenesis and increased tissue glucose uptake cause hypoglycemia in clients with Addison’s disease. Hyperkalemia and hyponatremia are characteristic of Addison’s disease.

There is decreased renal perfusion and excretion of waste products, which causes an elevated BUN level.

6. 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?

Skin turgor.

Temperature.

Thirst.

Daily weight.

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.

Explanation

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.

7. Which of the following is the priority for a client in addisonian crisis?

Controlling hypertension.

Preventing irreversible shock.

Preventing infection.

Relieving anxiety.

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 life-threatening 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.

Explanation

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 life-threatening 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.

8. A client with Addison's disease is admitted to the medical unit. The nurse diagnoses the client with Deficient fluid volume related 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?

Milk and diet soda.

Water and eggnog.

Bouillon and juice.

Coffee and milkshakes.

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 defi cit. Milk contains potassium and sodium.

Explanation

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 defi cit. Milk contains potassium and sodium.

9. 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.

Addison’s disease will resolve over a few weeks, requiring no further treatment.

Avoiding stress and maintaining a balanced lifestyle will minimize risk for exacerbations.

Fatigue, weakness, dizziness, and mood changes need to be reported to the physician.

A medical identification bracelet should be worn.

Family members need to be informed about the warning signals of adrenal crisis.

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.

Explanation

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.

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10. 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?

“Various circumstances increase the need for glucocorticoids, so I will need to adjust the dosage.”

“My need for glucocorticoids will stabilize and I will be able to take a predetermined dose once a day.”

“Glucocorticoids are cumulative, so I will take a dose every third day.”

“I must take a dose every 6 hours to ensure consistent blood levels of glucocorticoids.”

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 a.m. and the remainder at about 4 p.m. This schedule approximates the diurnal pattern of normal secretion, with highest levels between 4 a.m. and 6 a.m. and lowest levels in the evening.

Explanation

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 a.m. and the remainder at about 4 p.m. This schedule approximates the diurnal pattern of normal secretion, with highest levels between 4 a.m. and 6 a.m. and lowest levels in the evening.

11. Cortisone acetate (Cortone) and fludrocortisone acetate (Florinef Acetate) are prescribed as replacement therapy for a client with Addison's disease. What administration schedule should be followed for this therapy?

Take both drugs three times a day.

Take the entire dose of both drugs first thing in the morning.

Take half of each drug in the morning and the remaining half of each drug at bedtime.

Fludrocortisone acetate (Florinef Acetate) can be administered once a day, but cortisone acetate (Cortone) administration should follow the body’s natural diurnal pattern of secretion. Greater amounts of cortisol are secreted during the day to meet 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.

Explanation

Fludrocortisone acetate (Florinef Acetate) can be administered once a day, but cortisone acetate (Cortone) administration should follow the body’s natural diurnal pattern of secretion. Greater amounts of cortisol are secreted during the day to meet 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.

12. The nurse should tell the client to do which of the following when teaching the client about taking oral glucocorticoids?

“Take your medication with a full glass of water.”

“Take your medication on an empty stomach.”

“Take your medication at bedtime to increase absorption.”

“Take your medication with meals or with an antacid.”

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.

Explanation

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.

13. 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?

Completing the spring semester of school.

Gaining 4 pounds.

Becoming engaged.

Undergoing a root canal.

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.

Explanation

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.

14. Which of the following would be an expected finding in a client with adrenal crisis (addisonian crisis)?

Fluid retention.

Pain.

Peripheral edema.

Hunger.

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.

Explanation

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.

15. The client's wife asks the nurse whether the I.V. 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:

170 calories.

250 calories.

340 calories.

500 calories.

Each liter of 5% dextrose in normal saline solution contains 170 calories. The nurse should

consult with the physician and dietitian when a client is on I.V. therapy or is on nothing-by-mouth

status for an extended period because further electrolyte supplementation or alimentation therapy

may be needed.

Explanation

Each liter of 5% dextrose in normal saline solution contains 170 calories. The nurse should

consult with the physician and dietitian when a client is on I.V. therapy or is on nothing-by-mouth

status for an extended period because further electrolyte supplementation or alimentation therapy

may be needed.