CUSHING SYNDROME

1. Cushing's Disease and Cushing's Syndrome have the same cause.

a. True
b. False

RATIONALE: Cushing syndrome refers to the general state characterized by excessive

levels of cortisol in the body. Cushing disease is a specific type of Cushing syndrome and
occurs when a pituitary tumor causes the body to make too much cortisol. Elevated
cortisol levels can occur for reasons other than a pituitary tumor, including: tumors of the
adrenal glands, ectopic ACTH secretion by non-pituitary tumors, and prolonged intake of
cortisol-like medications.

2. A patient who was suspected of having a Cushing’s syndrome may be

ordered to undergo a confirmatory diagnostic exam of what possible
procedures?

a. Pituitary MRI
b. Magic 8 blood chem
c. 24-hour UFC test
d. Dexamethasone suppression test
e. Needle biopsy

RATIONALE: 24-hour urinary free-cortisol test measures the level of the hormone
cortisol in the urine. Overnight dexamethasone suppression test measures whether
adrenocorticotrophic hormone (ACTH) secretion by the pituitary can be suppressed.
Magnetic resonance imaging (MRI) scans can help the doctor spot any abnormalities in
the pituitary gland and/or adrenal glands.

3. A nurse is reviewing discharge teaching with a client who has Cushing's

syndrome. Which statement by the client indicates that the instructions
related to dietary management were understood?

a. "I can eat foods that contain potassium."

b. "I will need to limit the amount of protein in my diet."
c. "I am fortunate that I can eat all the salty foods I enjoy."
d. "I am fortunate that I do not need to follow any special diet."

RATIONALE: In Cushing’s syndrome, the elevation of cortisol levels leads to a decrease

in the blood levels of potassium, a condition called hypokalemia. It is advised that patient
eat foods rich in potassium (banana, prunes, spinach, broccoli, sweet potatoes, avocado,
etc.) to replenish the insufficient supply of this electrolyte in the body. A balanced protein
diet is also recommended because muscle wasting (loss of muscle mass) is evident in
Cushing’s syndrome. Intake of salty foods should be limited as Cushing’s syndrome
causes high levels of sodium retention in the body.

4. A nursing instructor asks a student to describe the pathophysiology that

occurs in Cushing's disease. Which statement by the student indicates an
accurate understanding of this disorder?
a. "Cushing's disease is characterized by an oversecretion of insulin."
b. "Cushing's disease is characterized by an oversecretion of glucocorticoid
hormones."
c. "Cushing's disease is characterized by an undersecretion of corticotropic
hormones."
d. "Cushing's disease is characterized by an undersecretion of glucocorticoid
hormones."

RATIONALE: Cushing’s syndrome happens when there is an abnormal increased in the

production of glucocorticoids in the body (specially the cortisol) caused by either
presence of tumor in the pituitary gland (ectopic tumor) and overused of steroid
medications. Deficiency in this hormone production is linked to Addison’s disease, while
over secretion of insulin is called hyperinsulinemia, which is often associated with type
2-diabetes.

5. All of these subjective statements are considered manifestations/symptoms of

Cushing syndrome except?

a. “I feel weak most of the time and find it hard to concentrate. My back hurts too
and this small wound in my left foot I’ve got from a month ago still looks new
and fresh.”

b. “I can’t sleep properly at night because I keep on going back and forth to the
bathroom to urinate. I guess it’s because of my excessive water intake, but I can’t
help it, I feel thirsty most of the time.”

c. “I feel sad and blue and just don’t have the energy to do anything at all.”

d. “I often feel shaky, nervous, and intolerant to heat, add that with some
bothersome palpitations. And despite the fact that I eat a normal healthy diet, my
weight is gradually decreasing as it is.”
 RATIONALE: Anxiety, tremor, weight loss despite normal eating habits, and high
sensitivity to heat are probable signs of grave’s disease. Some clinical manifestations
of Cushing syndrome often include muscle-wasting (a condition that causes
myopathy and muscle weakness), osteoporosis (which can lead to vertebral
compression fractures and can cause back pain), impaired wound healing, mood
alterations, and sometimes polyuria/nocturia (caused by cortisol interfering with
antidiuretic hormones action at the renal tubules).

6. Cushing Syndrome causes the anterior pituitary gland to secret an excess

amount of which hormone?

a. CRH
b. HGH
c. ACTH
d. Cortisol

RATIONALE: ACTH is a hormone produced by the pituitary gland that stimulates the
adrenal cortex to secrete cortisol. Excessive ACTH production leads to the presence of
hypercortisolism (Cushing syndrome). HGH is also produced by pituitary gland but does
not necessarily cause Cushing syndrome when overproduced but rather is associated with
acromegaly. CRH on the other hand is a hormone produced by the hypothalamus.

7. When teaching a client with Cushing syndrome about dietary changes, the
nurse should instruct the client to increase intake of:

a. fresh fruits
b. dairy products
c. processed meats
d. cereals and grains

RATIONALE: Cushing syndrome causes sodium retention, which increases urinary

potassium loss. Therefore, the nurse should advise the client to increase intake of
potassium-rich foods, such as fresh fruit. The client should restrict consumption of dairy
products, processed meats, cereals, and grains because they contain significant amounts
of sodium.

8. These are drug therapy that can be considered for a patient with Cushing
syndrome to take for his/her treatment includes all except:

a. Metyrapone
b. Mitotane
 c. Mifepristone
d. Hydrocortisone

RATIONALE: Hydrocortisone is a corticosteroid medicine, which if taken by a patient

with Cushing syndrome, may further exacerbate his/her existing disease. Metyrapone and
mitotane are both adrenal enzyme inhibitors used to reduce hyperadrenalism and helps
control levels of cortisol production in patient’s with Cushing’s syndrome. Mifepristone
does not decrease cortisol production but blocks the effect of cortisol on the tissues and is
used as treatment for patients with Cushing’s syndrome and co-existing glucose
intolerance.

9. Which treatment of choice is directed for patients with Cushing syndrome

caused by ectopic ACTH secretion by a tumor?

a. Adrenalectomy
b. Low-dose dexamethasone
c. Administration of adrenal enzyme inhibitors
d. Transphenoidal hypophysectomy

RATIONALE: Adrenal enzyme inhibitors are drugs used to reduce hyperadrenalism

caused by ectopic ACTH secretion by a tumor that cannot be eradicated. Adrenalectomy
is the treatment o choice in patients with primary adrenal hypertrophy. If Cushing’s
syndrome is caused by pituitary tumors then transphenoidal hypophysectomy is the
choice of treatment. Low-dose dexamethasone suppression test is a diagnostic exam
performed on patients for confirmatory of suspected Cushing’s syndrome.

10. The nurse is caring for a client who has had an adrenalectomy and is
monitoring the client for signs of adrenal insufficiency. Which signs and
symptoms indicate adrenal insufficiency in this client?

a. Hypotension and fever

b. Mental status changes and hypertension
c. Subnormal temperature and hypotension
d. Complaints of weakness and hypertension

RATIONALE: The nurse should be alert to signs and symptoms of adrenal insufficiency
after adrenalectomy. These signs and symptoms include weakness, hypotension, fever,
and mental status changes.
 ADDISON’S DISEASE

11. Which of the following is the priority for a client in addisonian crisis?
a. Controlling hypertension.
b. Preventing irreversible shock.
c. Preventing infection.
d. Relieving anxiety.

RATIONALE: 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.

12. After stabilization of Addison's disease, the nurse teaches the client about
stress management. The nurse should instruct the client to:
a. Remove all sources of stress from daily life.
b. Use relaxation techniques such as music.
c. Take antianxiety drugs daily.
d. Avoid discussing stressful experiences.

RATIONALE: 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.

13. Mr. X was prescribed to take fludrocortisone oral as a treatment for his
Addison’s disease. Which in this statement would implicate that nurse
Ghenel will need to further educate her patient about the medication?
 a. “It is important that my blood sugar levels be monitored for this particular
medication.
b. “I should call my doctor right away if any swelling or rash appears on my
skin after taking this medicine.”

c. “I should increase my intake of foods high in salt to help this medication

replace my electrolyte sodium loss.”

d. “I can’t get vaccinated during the course of taking this medicine.”

RATIONALE: Fludrocortisone can make you retain lots of salt (sodium) in your body.
High amounts of salt in your body can lead to: high blood pressure, water retention
(swelling), weight gain, low potassium levels, which may cause muscle aches or
weakness, and abnormal heartbeat. Receiving vaccines while you’re taking
fludrocortisone could cause brain, spinal cord, and nerve problems. Taking this drug can
also increase your blood sugar levels so you should monitor your blood sugar level more
closely. If any signs (trouble breathing, swelling of your face or throat, hives or a rash) of
allergic reaction presents after ingesting the medicine, patient must be able to report it
immediately to the nurse/doctor.

14. 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?

a. Milk and diet soda.

b. Water and eggnog
c. Broth and juice.
d. Coffee and milkshakes.

RATIONALE: Electrolyte imbalances associated with Addison's disease include

hypoglycemia, hyponatremia, and hyperkalemia. Salted broth 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.

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

a. Muscle spasms.
 b. Weight gain.
c. Hunger.
d. Lethargy.

RATIONALE: 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.

16. Nurse Ghemil should expect a client with Addison's Disease to report which
health concerns?

a. Hypotension, weakness, Diarrhea

b. Obesity, bruising, edema
c. Hypertension, sweating and headaches
d. Husky-sounding voice, swollen hands and feet, skin tags

RATIONALE: Orthostatic hypotension, weakness and diarrhea is a clinical manifestation

of Addison's disease related to low levels of cortisol and fluid imbalances in the body.
Signs and symptoms of Cushing's disease include obesity, bruising and edema. Signs and
symptoms of pheochromocytoma includes, hypertension, sweating and headaches.

17. When caring for client with Addison's disease nurse John expects to
administer.

a. 10 % dextrose
b. propranolol (Inderal)
c. hydrocortisone (Cortef)
d. Insulin

RATIONALE: Because Addison's disease occurs when your body doesn't produce
enough of certain hormones or produce too little cortisol and, often, too little aldosterone.
hydrocortisone (Cortef) work by replacing the cortisol and bringing your levels up to
normal. Propranolol is a non-selective beta adrenergic antagonist used to treat
hypertension and Insulin and dextrose are use to treat diabetes mellitus which is not
indicated for the client.

18. A client diagnosed with Addison's disease is concerned about dark areas of
skin around his knees and elbows. The nurse's best response would be:
 a. This change is related to sun exposure and should not be a concern
b. This finding is not related to Addison's disease. I will refer you to a
dermatologist
c. This skin change is related to your medication therapy, and should subside
in a few weeks
d. This is related to hormonal changes caused by Addison's disease

RATIONALE: This is related to hormonal changes caused by Addison's disease. The low
level of cortisol triggers the release of another hormone called adrenocorticotropic
hormone (ACTH). High ACTH leads to high levels of melanin, the chemical that gives
skin its color and causes skin discoloration known as hyperpigmentation.

19. The adrenal glands are underactive in Addison disease, resulting in low
levels of adrenal hormones. Although the exact cause of Addison disease is
unknown in most cases, the adrenal glands are affected by which of the
following?

a. An infection
b. An autoimmune reaction
c. Cancer
d. A genetic abnormality

RATIONALE: In 70% of people with Addison disease, the cause is not precisely known,
but the adrenal glands are affected by an autoimmune reaction in which the body’s
immune system attacks and destroys the adrenal cortex. In the other 30%, the adrenal
glands are destroyed by cancer (choice C), an infection (choice A) such as tuberculosis,
or another identifiable disease. D: In infants and children, Addison disease may be due to
a genetic abnormality of the adrenal glands.

20. Which of the following abnormal electrolyte imbalances is expected with

Addisonian Crisis?

a. Potassium level of 3.2

b. Sodium level of 112
c. Blood glucose level of 120
d. Phosphate level of 1.2

RATIONALE: Remember with Addisonian Crisis the 3'H (hypoglycemia, hyponatremia,

and hyperkalemia). The potassium and blood glucose levels are normal in this question.
Phosphate levels are not significant in Addisonian Crisis. The sodium level is very low
which represents hyponatremia. Normal sodium level is 135-145.
 PHEOCHROMOCYTOMA

21. A nurse is caring for a client with pheochromocytoma who is scheduled for
adrenalectomy. In the preoperative period, the priority nursing action would
be to monitor:

a. Vital Signs
b. Urine for glucose and ketones
c. Intake and Output
d. Blood Urea

RATIONALE: Pheochromocytoma is a catecholamine-producing tumor. Hypertension is

the hallmark of pheochromocytoma. Hypertension is the most common sign in PPGL and
is present in 90% of patients. Severe hypertension can precipitate a stroke or sudden
blindness. Although all the options are accurate nursing interventions for the client with
pheochromocytoma, the priority nursing action is to monitor the vital signs, particularly
the blood pressure.

22. Which statement is incorrect about pheochromocytoma?

a. A rare, usually noncancerous tumor that develops in an adrenal gland
b. An adrenalectomy is the only surgical treatment for pheochromocytoma.
c. Patients with pheochromocytoma are at risk for hypertensive crisis.
d. Low salt Diet is advised such as canned, or dried fruits.

RATIONALE: High Salt Diet is more likely to be advised for patients with
pheochromocytoma. Alpha and beta blockers widen the blood vessels, causing the
amount of fluid within the blood vessels to be low. This can cause dangerous drops in
blood pressure with standing. A high-salt diet will draw more fluid inside the blood
vessels, preventing the development of low blood pressure during and after surgery.

23. A patient is admitted with uncontrolled hypertension and the doctor suspects
pheochromoctyoma. On assessment, you note the blood pressure to be
196/120 and HR 130. The patient reports feeling very anxious, sweaty, and
having palpations. What do you expect the doctor will order to confirm a
diagnosis of pheochromocytoma?

a. 8-hour urine
b. 24-hour urine
c. Urine culture
 d. Urinalysis
RATIONALE: A 24-hour urine is ordered to check for catecholamine and metanephrines
(which are metabolites formed when the body breaks down catecholamines).Urine
metanephrines testing is used to help detect or rule out the presence of a rare tumor called
a pheochromocytoma that releases excess metanephrines. Since these tumors produce
these hormones in excess, measuring the amount in the blood and/or urine may help
detect the tumors.

24. A pheochromocytoma patient is being cared for by a nurse. The customer

requests a snack and something warm to drink. Which of the following
would be the best option for meeting this client's nutritional needs?

a. Graham crackers and warm milk

b. Toast with peanut butter and cocoa
c. Crackers with cheese and tea
d. Vanilla wafers and coffee with cream and sugar

RATIONALE The client with pheochromocytoma needs to be provided with a diet that is
high in vitamins, minerals, and calories. Of particular importance is that food or
beverages that contain caffeine (e.g., chocolate, coffee, tea, and cola) are prohibited.

25. It results in the release of too much epinephrine and norepinephrine,

hormones that control heart rate, metabolism, and blood pressure. a
noncancerous benign tumor that develops in an adrenal gland.

a. Hypercorticolism
b. Myxoma
c. Pheochromocytoma
d. Osteoblastoma

RATIONALE: Pheochromocytoma is a rare tumor of adrenal gland tissue. It results in

the release of too much epinephrine and norepinephrine, hormones that control heart rate,
metabolism, and blood pressure . Myxoma s a non-cancerous (benign) tumor of the heart.
Osteoblastoma is a benign, bone-forming tumor

26. Surgery is scheduled for a patient with pheochromocytoma. The surgeon has
directed that an alpha-blocking agent be administered prior to surgery.
What is the nurse's understanding of this substance?

a. It prevents secretion of catecholamines by the adrenal tumor.

b. It reduces contraction of smooth muscles in the adrenal medulla.
 c. It is ordered to prevent perioperative hypertensive crisis.
d. It is given chronically after the surgery to prevent hypertension.

RATIONALE: Manipulation of the adrenal tumor in patients with pheochromocytoma

can cause a massive catecholamine release. Alpha-adrenergic antagonists are given to
reduce the risk of acute hypertension during surgery. These agents do not prevent
secretion of catecholamines; they block catecholamine receptor sites. They do not act on
the tissue of the adrenal medulla. They are given chronically in patients who have
inoperable tumors.

27. Which of the following laboratory tests/ diagnostic procedures is not

indicated for identifying pheochromocytoma?

a. M-iodobenzylguanidine (MIBG) imaging

b. Water deprivation test
c. 24-hour urine test
d. Genetic testing

RATIONALE: The water deprivation test is the best test to diagnose central diabetes
insipidus. (MIBG) imaging a scanning technology that can detect tiny amounts of an
injected radioactive compound taken up by pheochromocytoma, 24-hour urine test and
Genetic testing is indicated for pheochromocytoma.

28. Pheochromocytomas, even small ones, produce large amounts of

catecholamines including the hormones adrenaline, norepinephrine, and
dopamine. If symptoms appear suddenly and forcefully, patients can feel as
though they have which of the following conditions?

a. Stroke
b. Depression
c. Panic Attack
d. Food Poisoning

RATIONALE: Panic attack. Symptoms such as a fast and pounding heart rate, excessive
sweating, light-headedness when standing, rapid breathing, cold and clammy skin,
tingling fingers, and other symptoms may feel like a panic attack. Choices A, B, and D
are incorrect, although stomach pain, nausea and vomiting may also be symptoms of
pheochromocytoma.

29. Because high blood pressure is the primary symptom of pheochromocytoma,

doctors may prescribe medications to lower blood pressure. Which of the
 following drugs prescribed to lower blood pressure can actually make high
blood pressure worse in people with this pheochromocytoma?

a. ACE inhibitors
b. Angiotensin receptor blockers (ARB)
c. Beta-blockers
d. Diuretics

RATIONALE: Beta-blockers may be prescribed for high blood pressure before a

diagnosis of pheochromocytoma has been made and may actually worsen the person’s
blood pressure. This paradoxical reaction often makes the diagnosis of
pheochromocytoma clear. Beta-blockers must never be started prior to adequate alpha-
blockade, since in the absence of beta-2-mediated vasodilation, profound unopposed
alpha-mediated vasoconstriction may lead to hypertensive crisis or pulmonary
edema.Choices A, C, and D are other types of medications used to treat high blood
pressure.

30. What is the classic clinical triad of pheochromocytoma?

a. Anorexia, weakness, irritability and depression

b. Increases in thirst, urination, and appetite
c. Palpitations, High blood pressure, sweating and headaches
d. Husky-sounding voice, swollen hands and feet, skin tags

RATIONALE: The classic symptoms of pheochromocytomas are those attributable to

excess adrenaline production. Often these patients will have recurring episodes of
sweating, headache, and a feeling of high anxiety.