Adrenocortical Agents

1.

The nurse administers fludrocortisone (Florinef) to a patient diagnosed with salt-losing adrenogenital syndrome and then assesses for what therapeutic action?
A)
Development of hypokalemia and elevated serum glucose level
B)
An increase in sodium and water reabsorption and potassium excretion
C)
Headache, edema, weakness, arrhythmias, and hypertension
D)
Sodium and water depletion along with potassium retention
Ans:
B

Feedback:

Fludrocortisone’s therapeutic effects include an increase in sodium and water reabsorption with potassium excretion. Headache, edema, weakness, arrhythmias, and hypertension are adverse, and not therapeutic, effects. Hypokalemia is possible but glucose levels should not be impacted.

2.

When developing a plan of care for the patient receiving a glucocorticoid, what nursing diagnosis would be of highest priority?
A)
Deficient fluid volume related to water retention
B)
Risk for injury related to muscle weakness
C)
Imbalanced nutrition: less than body requirements
D)
Risk for infection related to immunosuppression
Ans:
D

Feedback:

Risk for infection related to immunosuppression would be the appropriate nursing diagnosis because steroids suppress the immune system, which puts the patient at risk for infection. Nutritional imbalance is more likely to be “more than body requirements” than “less than body requirements.” Excess fluid volume is more appropriate than deficient fluid volume. Glucocorticoids are not associated with muscle weakness.

3.

What glucocorticoids could the nurse only administer orally?
A)
Cortisone (Cortone Acetate)
B)
Hydrocortisone (Cortef)
C)
Prednisone (Deltasone)
D)
Triamcinolone (Aristocort)
Ans:
C

Feedback:

Prednisone is available in oral form only and is used for replacement therapy for adrenal insufficiency, and treatment of allergic and inflammatory disorders. Cortisone can be administered orally or intramuscularly and is used for replacement therapy. Hydrocortisone, used for replacement therapy, is administered by the oral, IV, intramuscular, topical, ophthalmic, rectal, and intra-articular routes. Triamcinolone is administered by the oral, intramuscular, inhalant, intra-articular, and topical routes and is used for treatment of allergic and inflammatory disorders and in the management of asthma.

4.

The mother asks the nurse for a steroid cream to put on her infant’s diaper rash. What teaching will the nurse provide the mother? (Select all that apply.)
A)
“Topical corticosteroids are very effective treatment for diaper rash.”
B)
“Topical corticosteroid application should not be occluded with a diaper.”
C)
“Topical corticosteroids should not be applied to open lesions.”
D)
“Use of topical corticosteroids should be limited in children.”
E)
“Topical corticosteroids should be applied in a thick coat to the rash.”
Ans:
B, C, D

Feedback:

Topical use of corticosteroids should be limited in children because their body surface area is comparatively large and the amount of the drug absorbed in relation to weight is greater than in an adult. When the medication is used in children, it should be applied sparingly and the area should not be occluded with a diaper. The nurse should not make a judgment nor should he or she allow a patient or family member to dictate a treatment just because he or she wants it. More effective treatments for diaper rash than corticosteroids are available.

5.

An older adult patient taking high-dose corticosteroids to treat arthritis requests a pneumonia vaccine. What is the nurse’s best response?
A)
“Pneumonia vaccines are only given if you are at risk for serious pulmonary problems.”
B)
“Live virus vaccines cannot be given to people who are significantly immunosuppressed.”
C)
“Patients taking corticosteroids are well protected from viruses and do not need vaccines.”
D)
“Corticosteroids interact with the pneumococcal vaccine to create serious adverse effects.”
Ans:
B

Feedback:

Corticosteroids block the inflammatory response and are very helpful in conditions such as arthritis. However, they also block the immune response, making a person immunosuppressed. The vaccine would not be given to this patient because of the increased risk for infection. An older adult would be considered at high risk for pneumonia so getting the vaccine would be encouraged if not for taking corticosteroids. Corticosteroids do not protect against viruses. The vaccine is contraindicated because of risk for infection and not because of a potential drug–drug interaction.

6.

A patient who is steroid dependent due to adrenocortical insufficiency calls the clinic and is very upset, telling the nurse of the extreme stress he or she is experiencing right now. What does the nurse expect the health care provider will order concerning his or her medication?
A)
The dosage may continue as ordered.
B)
The medication may be discontinued until stress declines.
C)
The dosage of the medication may be increased.
D)
The dosage of the medication may be decreased.
Ans:
C

Feedback:

The patient’s body will initiate a stress reaction. Normally, activation of the stress reaction can cause release of adrenocorticotropic hormone (ACTH) and secretion of the adrenocortical hormones. A patient with adrenocortical insufficiency may not be able to supplement the increased need for ACTH. The stress reaction may block the immune and inflammatory systems, making the body more susceptible to pathogens. Therefore, an increase in medication may be necessary to prevent further adrenal insufficiency and to meet the increased demands for corticosteroids in the body under stress.

7.

A nurse is providing patient education to a patient who has had corticosteroids prescribed. What drug will the nurse teach the patient to avoid while taking the corticosteroids?
A)
Aspirin
B)
Dimenhydrinate (Dramamine)
C)
Ibuprofen (Advil)
D)
Famotidine (Pepcid)
Ans:
A

Feedback:

Serum levels and effectiveness may decrease if corticosteroids are combined with salicylates. Dimenhydrinate, ibuprofen, and famotidine have not been found to produce drug–drug interaction.

8.

The nurse is caring for a patient with a heightened stress response following a fearful experience. When assessing this patient, what findings will the nurse attribute to this response? (Select all that apply.)
A)
Elevated serum blood glucose
B)
Reduced inflammatory response
C)
Heightened immune response
D)
Increased blood volume
E)
Extreme hunger
Ans:
A, B, D

Feedback:

The stress response causes an increase in blood volume and a release of glucose for energy. It also slows the rate of protein production and blocks the activities of the inflammatory and immune systems, which reserves energy. This patient is unlikely to be hungry.

9.

The nurse is providing patient education to a patient taking a glucocorticoid and advises the patient to take his or her medication at what time of the day?
A)
At bedtime
B)
With the noon meal
C)
At 3:00 PM
D)
Immediately on awakening in the morning
Ans:
D

Feedback:

Glucocorticoids should be taken immediately on awaking in the morning to mimic the normal diurnal pattern. The peak levels of cortisol usually come between 6:00 and 8:00 AM. The levels then fall off slowly and reach a low in the late evening with the lowest levels around midnight. For those patients who work night shifts, the schedule would be changed to accommodate their sleep pattern. Waiting until later in the day could result in sleeplessness.

10.

An 8-year-old with asthma has been prescribed triamcinolone (Aristocort). What dosage of medication would the nurse appropriately deliver?
A)
One inhalation per day
B)
One inhalation b.i.d.
C)
Two inhalations every 3 hours
D)
Two inhalations t.i.d.
Ans:
D

Feedback:

Pediatric dosage is individualized based on severity and response. However, children between 6 and 12 years of age are prescribed one to two inhalations t.i.d. or q.i.d. The other options are incorrect based on the recommended dosage.

11.

The nurse, caring for a patient experiencing stress, knows that activation of the stress reaction will cause the release of what?
A)
Glucose
B)
Aldosterone
C)
Adrenocorticotropic hormone (ACTH)
D)
Oxytocin
Ans:
C

Feedback:

Activation of the stress reaction through the sympathetic nervous system bypasses the usual diurnal rhythm and causes release of ACTH and secretion of the adrenocortical hormones—an important aspect of the stress (“fight-or-flight”) response. Glucose will eventually be released to supply energy, but first ACTH and adrenocortical hormones must stimulate this response. Aldosterone can be released without ACTH stimulation when the blood surrounding the adrenal gland is high in potassium. This is a direct stimulus for aldosterone release. Oxytocin is released to promote the let-down reflex in the lactating woman and to stimulate uterine contractions but is not involved in the stress response.

12.

The nurse is developing a plan of care for an 84-year-old diabetic patient who is receiving oral hydrocortisone 40 mg daily for treatment of arthritis. What is this patient’s priority nursing intervention?
A)
Increasing sodium in diet
B)
Restricting protein in diet
C)
Increasing fluids to 2,000 mL/d
D)
Monitoring blood glucose levels frequently
Ans:
D

Feedback:

Caution should be used in patients with diabetes because the glucose-elevating effects disrupt glucose control. More frequent blood sugar monitoring is this patient’s priority intervention. Sodium, protein, and fluid intake do not need to be altered.

13.

A patient with adrenal insufficiency has been admitted to the intensive care unit in adrenal crisis. What assessment findings support this diagnosis? (Select all that apply.)
A)
Physiological exhaustion
B)
Hypertension
C)
Fluid shift
D)
Shock
E)
Septicemia
Ans:
A, C, D

Feedback:

Symptoms of adrenal crisis include physiological exhaustion, hypotension, fluid shift, shock, and even death. Hypotension rather than hypertension would be expected. Septicemia is a possible cause of adrenal crisis, not a symptom.

14.

The nurse is providing discharge teaching for a patient prescribed prednisone to be taken on alternate days. The patient asks why he cannot take half a pill every day. What is the nurse’s best response?
A)
To eliminate adverse side effects
B)
To prolong therapeutic effects
C)
To prevent steroid tolerance
D)
To decrease adrenal suppression
Ans:
D

Feedback:

Alternate-day maintenance therapy is used with short-acting drugs whenever possible to decrease the risk of adrenal suppression. Alternate-day therapy would not eliminate adverse effects or prolong therapeutic effects. There is no such thing as steroid tolerance.

15.

The clinic nurse receives a call from the mother of a 4-year-old child on long-term corticosteroid therapy saying the child woke up with a cold and is pulling on his ear. What instructions will the nurse provide?
A)
“Encourage fluids, monitor his temperature, and he will be better in 3 days.”
B)
“Take him to the emergency room (ER) immediately.”
C)
“Bring him to the clinic to be seen today.”
D)
“Hang up and call 911.”
Ans:
C

Feedback:

Children receiving long-term therapy should be protected from exposure to infection. Special precautions should be instituted to avoid injury. If injuries or infections do occur, the child should be seen by a primary care provider as soon as possible. There is no need to treat this as an emergency so the mother need not rush the child to the ER or call 911, but she should be encouraged to have the child seen today at the clinic. It would not be appropriate to give home care instructions until he has been seen at the clinic.

16.

When doing a shift assessment on the patient, the nurse would report what symptoms as a possible adverse effect of intranasal methylprednisolone? (Select all that apply.)
A)
Headache
B)
Impaired wound healing
C)
Epistaxis
D)
Hypotension
E)
Nasal irritation
Ans:
A, B, C, D, E

Feedback:

Intranasal administration of hydrocortisone can result in headache, nausea, nasal irritation, fungal infections, epistaxis, rebound congestion, perforation of the nasal septum, anosmia, and urticaria. Systemically administered hydrocortisone has many possible adverse effects including impaired wound healing and hypotension, but these would not be likely to be associated with intranasal administration of hydrocortisone.

17.

The nurse is providing dietary teaching to the patient on long-term mineralocorticoid therapy and includes what teaching point?
A)
Decreasing sodium
B)
Increasing calcium
C)
Increasing vitamin D
D)
Increasing potassium
Ans:
D

Feedback:

Mineralocorticoids cause sodium and water retention and potassium excretion. These patients benefit from a diet with increased potassium. They would not decrease sodium intake as the drug is often administered for the purpose of increasing serum sodium levels. Calcium and vitamin D intake would be the same for this patient as any other patient of similar age and gender.

18.

The nurse anticipates an order for a glucocorticoid when caring for a patient with what condition?
A)
Hypoglycemia
B)
Appendicitis
C)
Arthritis
D)
Septicemia
Ans:
C

Feedback:

Glucocorticoids are indicated for the short-term treatment of many inflammatory disorders, to relieve discomfort, and to give the body a chance to heal from the effects of inflammation. They block the actions of arachidonic acid, which leads to a decrease in the formation of prostaglandins and leukotrienes. Without these chemicals, the normal inflammatory reaction is blocked. Hypoglycemia would more safely be treated with glucose. Appendicitis and septicemia are infections that would contraindicate the use of glucocorticoids because of the immunosuppressant effects of the drugs.

19.

The 2-year-old patient with asthma is placed on a short-term dose of prednisone. What important instruction will the nurse provide the patient about this drug?
A)
“Increase intake of carbohydrates.”
B)
“The child may receive immunizations while on this drug.”
C)
“Do not stop this medication suddenly; you will have to taper dosage gradually.”
D)
“Reduce intake of protein until drug therapy is complete.”
Ans:
C

Feedback:

Prednisone is usually ordered for short-term use with tapering dosage. It is important to instruct the parent to taper doses and to not just stop the drug suddenly when discontinuing from high doses so as to give the adrenal glands a chance to recover and produce adrenocorticoids. This is the priority instruction. Parents should also be told to wait to get the child immunizations until after drug therapy is completed. There is no need to alter carbohydrate or protein intake.

20.

When caring for a patient receiving long-term therapy with corticosteroids, the nurse would plan care incorporating interventions aimed at preventing what?
A)
Allergies
B)
Inflammation
C)
Infection
D)
Anemia
Ans:
C

Feedback:

When planning care for a patient taking long-term corticosteroid therapy, the nurse needs to incorporate interventions aimed at reducing risk of infection because the patient’s immune system will be suppressed, which places the patient at increased risk. The nurse would not try to prevent the anti-inflammatory effects of the drug. The drug is not associated with causing allergies or anemia.

21.

A 66-year-old female patient is on long-term oral glucocorticoid therapy to treat chronic obstructive pulmonary disease. When providing drug teaching, the nurse will inform this patient that she is at particular risk for what?
A)
Hyponatremia
B)
Spontaneous fractures
C)
Respiratory depression
D)
Ineffective temperature regulation
Ans:
B

Feedback:

Only spontaneous fractures are considered an adverse effect of glucocorticoids; this patient would be at increased risk because her age and gender put her at higher risk for osteoporosis, which also has the adverse effect of spontaneous fractures. Long-term glucocorticoid therapy is not associated with hyponatremia, respiratory depression, or ineffective temperature regulation.

22.

The nurse provides teaching to a patient with chronic obstructive pulmonary disease who has been prescribed budesonide (Pulmicort) two puffs and fluticasone (Flovent) three puffs t.i.d. The nurse evaluates that further teaching is needed when the patient makes what statement?
A)
“Take all five puffs as quickly as possible.”
B)
“Replace the inhalers before they run out.”
C)
“Rinse the mouth after taking the medication.”
D)
“Continue medication even when symptoms start to subside.”
Ans:
A

Feedback:

The nurse needs to review how to administer the drug via inhalation because the patient must hold the medication in the airways as long as possible before exhaling and should not try to rush the treatment. The other statements are correct and would not require clarification.

23.

The home health nurse provides patient teaching to his or her patient who is taking oral prednisolone. The nurse provides what instruction to reduce the occurrence of nausea?
A)
“Take with a meal.”
B)
“Take 1 hour before meals.”
C)
“Take before bedtime.”
D)
“Split the dose into two equal doses.”
Ans:
A

Feedback:

Steroids, taken on an empty stomach, would exacerbate the nausea. If the patient takes only one dose per day, it should be taken immediately after breakfast. If spaced throughout the day, eating something before taking the pill will reduce risk of nausea. Timing is dictated by frequency of administration, and if only taken once daily, the medication should be taken in the morning (so bedtime is inappropriate). Splitting the dose would decrease effectiveness and would be inappropriate for the nurse to suggest because it is outside the scope of nursing practice. Taking the medication before meals would mean it was being taken on an empty stomach.

24.

What would be important for the nurse to teach the parents of a pediatric patient about the use of topical corticosteroids?
A)
“Apply the medication sparingly.”
B)
“Apply directly to open lesions.”
C)
“After applying cover with a bandage.”
D)
“Reapply as often as needed to keep the rash coated with the medication.”
Ans:
A

Feedback:

Topical use of corticosteroids should be limited in children, because their body surface area is comparatively large, so that the amount of the drug absorbed in relation to weight is greater than in an adult. Apply sparingly and do not use in the presence of open lesions. Do not occlude treated areas with dressings or diapers, which may increase the risk of systemic absorption.

25.

The nurse is teaching the patient who will require long-term corticosteroid therapy how to reduce the risk of infection. What suggestions will the nurse include?
A)
“Avoid large crowds of people tightly packed together.”
B)
“Avoid working in areas with other people.”
C)
“Avoid exercising to reduce risk of injury.”
D)
“Avoid touching other people who may carry germs.”
Ans:
A

Feedback:

With long-term therapy, the importance of avoiding exposure to infection—crowded areas, people with colds or the flu, activities associated with injury—should be stressed. If an injury or infection should occur, the patient should be encouraged to seek medical care. These patients do not need to avoid work, exercise, or touching others but they should use good hand hygiene to avoid infection from these sources.

26.

The nurse is caring for an African American patient who received a kidney transplant and receives methylprednisolone for immunosuppression. What is the nurse’s priority assessment specific to this patient?
A)
Assessing capillary refill time
B)
Assessing cardiac rhythm
C)
Assessing white blood cell count
D)
Assessing blood glucose levels
Ans:
D

Feedback:

African Americans develop increased toxicity to the corticosteroid methylprednisolone—particularly when it is used for immunosuppression after renal transplantation. This toxicity can include severe steroid-induced diabetes mellitus. A priority intervention with this patient is monitoring blood glucose levels. Assessment of capillary refill time and cardiac rhythm would not be indicated by the data supplied about this patient. White blood cell counts should be monitored on any patient receiving long-term corticosteroids but is not specific to this patient.

27.

The nurse is caring for a patient who is diagnosed with protein-deficient malnutrition. Why would an order to administer androgens to this patient be appropriate?
A)
Androgens reduce the body’s requirement for protein.
B)
Androgens increase the body’s absorption of protein from the bowel.
C)
Androgens stimulate protein production and decrease protein breakdown.
D)
Androgens reduce carbohydrate metabolism and promote lipid absorption.
Ans:
C

Feedback:

Androgens are a form of the male sex hormone called testosterone. They affect electrolytes, stimulate protein production, and decrease protein breakdown, which will help to reverse the patient’s protein malnutrition in addition to a high-protein diet. They do not reduce the body’s need for protein, increase protein absorption from the bowel, or impact carbohydrate and lipid metabolism.

28.

The nurse is caring for a patient who works night shift from 2200 (10 pm) to 0600 (6am) and normally sleeps from 0800 (8 am) until 1600 (4 pm) each day. The nurse would teach this patient to take his or her corticosteroid at what time of the day?
A)
06:00 (6 am)
B)
08:00 (8 am)
C)
16:00 (4 pm)
D)
22:00 (10 pm)
Ans:
C

Feedback:

If a person works all night and goes to bed at 8 am, arising at 4 pm to carry on the day’s activities before going to work at 10 pm, the hypothalamus will release corticotropin-releasing hormone at about 4 pm in accordance with the new sleep–wake cycle. It usually takes 2 or 3 days for the hypothalamus to readjust. A patient on this schedule who is taking replacement corticosteroids would then need to take them at 4 pm, or on arising. All other options would not be optimal.

29.

For what reason might a nurse administer androgen injections to a 9-year-old boy?
A)
Ovarian atrophy
B)
Dwarfism
C)
Acromegaly
D)
Hypogonadism
Ans:
D

Feedback:

Androgens are used pharmacologically to treat hypogonadism or to increase protein growth and red blood cell production. Androgens are not used in a male to treat ovarian atrophy. Androgens are not used to treat dwarfism or acromegaly.

30.

A patient is taking low-dose corticosteroids on a long-term basis for chronic obstructive pulmonary disease. The nurse assesses this patient knowing prolonged use of corticosteroids puts the patient at risk for what?
A)
Adrenal storm
B)
Adrenal atrophy
C)
Stunted growth
D)
Hypothalamic insufficiency
Ans:
B

Feedback:

Prolonged use of corticosteroids suppresses the normal hypothalamic–pituitary axis and leads to adrenal atrophy from lack of stimulation. The other options are all distracters for this question with no connection to long-term use of corticosteroids.

31.

The nurse administers prednisone orally at 8 am. When would the nurse expect the drug to reach peak effect?
A)
9 to 10 am
B)
12 to 1 pm
C)
8:30 to 9:00 am
D)
4 to 6 pm
Ans:
A

Feedback:

Prednisone’s peak effect occurs 1 to 2 hours after administering the drug. If given at 8am, the expected peak would occur between 9 and 10 am.

32.

Nursing care for the postoperative patient requiring long-term glucocorticoid therapy will be directed at overcoming what adverse effect of the drug?
A)
Poor wound healing
B)
Inflammation
C)
Autoimmune response
D)
Lack of mobility
Ans:
A

Feedback:

Patients taking long-term glucocorticoid therapy will have impaired wound healing so nursing care is directed toward promoting healing. The drug has an anti-inflammatory effect so that would not need to be overcome. There is no autoimmune response or lack of mobility so these do not have to be overcome.

33.

The nurse is teaching a class for his or her peers about glucocorticoids. What will the nurse say is initially blocked, resulting in the drug’s anti-inflammatory action?
A)
Arachidonic acid
B)
Phagocytes
C)
Lymphocytes
D)
Antibodies
Ans:
A

Feedback:

Glucocorticoids block the actions of arachidonic acid, which leads to a decrease in the formation of prostaglandins and leukotrienes. They also impair the ability of phagocytes to leave the bloodstream and move to injured tissues; they inhibit the ability of lymphocytes to act within the immune system, including blocking the production of antibodies. Blocking arachidonic acid is, however, the initial action.

34.

What hormones does the adrenal medulla secrete?
A)
Renin and erythropoietin
B)
Norepinephrine and epinephrine
C)
Epinephrine and dopamine
D)
Dopamine and serotonin
Ans:
B

Feedback:

The adrenal medulla is actually part of the sympathetic nervous system (SNS). It is a ganglion of neurons that releases the neurotransmitters norepinephrine and epinephrine into circulation when the SNS is stimulated.

35.

The adrenal cortex responds to adrenocorticotropic hormone (ACTH), which responds to corticotropin-releasing hormone (CRH) from the hypothalamus in a daily pattern called what?
A)
Pituitary rhythm
B)
hypothalamic–pituitary axis
C)
Diurnal rhythm
D)
Circadian rhythm
Ans:
C

Feedback:

The adrenal cortex responds to ACTH released from the anterior pituitary. ACTH, in turn, responds to CRH released from the hypothalamus. This happens regularly during a normal day in what is called “diurnal rhythm.” Pituitary rhythm is a distracter; the term does not exist. The hypothalamic–pituitary axis involves the interaction between the two glands. Circadian rhythm involves when people prefer to be most active, such as people who say they are “morning people.”