The Client with Cushing’s Disease

1. A client reports that she has gained weight and that her face and body are “rounder,” while her
legs and arms have become thinner. A tentative diagnosis of Cushing’s disease is made. When
examining this client, the nurse would expect to find:

1. Orthostatic hypotension.

2. Muscle hypertrophy in the extremities.

3. Bruised areas on the skin.

4. Decreased body hair.

2. Signs and symptoms of Cushing’s disease include:

1. Weight loss.

2. Thin, fragile skin.

3. Hypotension.

4. Abdominal pain.

3. Cushing’s disease is manifested by the excessive secretion of corticosteroids. The hormones

involved are:

1. Glucocorticoids and aldosterone.

2. Adrenocorticotropic hormone (ACTH).

3. Glucocorticoids, aldosterone, and androgens.

4. Catecholamines.

4. The nurse should monitor the client with Cushing’s disease for which of the following?

1. Postprandial hypoglycemia.

2. Hypokalemia.
3. Hyponatremia.

4. Decreased urine calcium level.

5. The client with Cushing’s disease needs to modify dietary intake to control symptoms. In
addition to increasing protein, which strategy would be most appropriate?

1. Increase calories.

2. Restrict sodium.

3. Restrict potassium.

4. Reduce fat to 10%.

6. Bone resorption is a possible complication of Cushing’s disease. Which of the following

interventions should the nurse recommend to help the client prevent this complication?

1. Increase the amount of potassium in the diet.

2. Maintain a regular program of weight-bearing exercise.

3. Limit dietary vitamin D intake.

4. Perform isometric exercises.

7. A client has an adrenal tumor and is scheduled for a bilateral adrenalectomy. During
prepoperative teaching, the nurse teaches the client how to do deep breathing exercises after
surgery by telling the client to:

1. “Sit in an upright position and take a deep breath.”

2. “Hold your abdomen firmly with a pillow and take several deep breaths.”

3. “Tighten your stomach muscles as you inhale and breathe normally.”

4. “Raise your shoulders to expand your chest.”

8. A priority in the first 24 hours after a bilateral adrenalectomy is:

1. Beginning oral nutrition.

2. Promoting self-care activities.

3. Preventing adrenal crisis.

4. Ambulating in the hallway.

9. In the early postoperative period after a bilateral adrenalectomy, the client has an increased
temperature. The nurse should assess the client further for signs of:

1. Dehydration.

2. Poor lung expansion.

3. Wound infection.

4. Urinary tract infection.

10. A client who is recovering from a bilateral adrenalectomy has a patient-controlled analgesia
(PCA) system with morphine sulfate. Which of the following actions is a priority nursing
intervention for the client?

1. Observing the client at regular intervals for opioid addiction.

2. Encouraging the client to reduce analgesic use and tolerate the pain.

3. Evaluating pain control at least every 2 hours.

4. Increasing the amount of morphine if the client does not administer the medication.

11. As the nurse assists the postoperative client out of bed, the client reports having gas pains in
the abdomen. Which of the following is the most effective nursing intervention to relieve this
discomfort?

1. Encourage the client to ambulate.

2. Insert a rectal tube.

3. Insert a nasogastric (NG) tube.

4. Encourage the client to drink carbonated liquids.

12. Because of steroid excess after a bilateral adrenalectomy, the nurse should assess the client
for:

1. Postoperative confusion.

2. Delayed wound healing.

3. Emboli.

4. Malnutrition.

13. After a bilateral adrenalectomy for Cushing’s disease, the client will receive periodic
testosterone injections. The expected outcome of these injections is:

1. Balanced reproductive cycle.

2. Restored sodium and potassium balance.

3. Stimulated protein metabolism.

4. Stabilized mood swings.

ANSWERS AND RATIONALES

1. 3. Skin bruising from increased skin and blood vessel fragility is a classic sign of Cushing’s
disease. Hyperpigmentation and bruising are caused by the hypersecretion of glucocorticoids.
Fluid retention causes hypertension, not hypotension. Muscle wasting occurs in the extremities.
Hair on the head thins, while body hair increases.

2. 2. In Cushing’s disease, excessive cortisol secretion causes rapid protein catabolism, depleting
the collagen support of the skin. The skin becomes thin and fragile and susceptible to easy
bruising. The typical “cushingoid” appearance of the client includes a moon face, buffalo hump,
central obesity, and thin musculature. Weight gain, mood swings, and slow wound healing are
other signs and symptoms of Cushing’s disease. Hypertension, not hypotension, is a sign of
Cushing’s disease. Abdominal pain is not a symptom of Cushing’s disease.

3. 3. Excessive levels of glucocorticoids, aldosterone, and androgens secreted from the adrenal
cortex result in the constellation of symptoms known as Cushing’s disease. Cushing’s disease
can be caused by a tumor, overstimulation from the pituitary, or the use of prescription steroid
drugs. Androgens are also secreted in excess. ACTH is only one hormone that is abnormal in
Cushing’s disease. Excessive secretion of catecholamines accompanies pheochromocytoma, a
disease of the adrenal medulla.

4. 2. Sodium retention is typically accompanied by potassium depletion. Hypertension,

hypokalemia, edema, and heart failure may result from the hypersecretion of aldosterone. The
client with Cushing’s disease exhibits postprandial or persistent hyperglycemia. Clients with
Cushing’s disease have hypernatremia, not hyponatremia. Bone resorption of calcium increases
the urine calcium level.

5. 2. A primary dietary intervention is to restrict sodium, thereby reducing fl uid retention.

Increased protein catabolism results in loss of muscle mass and necessitates supplemental protein
intake. The client may be asked to restrict total calories to reduce weight. The client should be
encouraged to eat potassium-rich foods because serum levels are typically depleted. Although
reducing fat intake as part of an overall plan to restrict calories is appropriate, fat intake of less
than 20% of total calories is not recommended.

6. 2. Osteoporosis is a serious outcome of prolonged cortisol excess because calcium is

reabsorbed out of the bone. Regular daily weight-bearing exercise (e.g., brisk walking) is an
effective way to drive calcium back into the bones. The client should also be instructed to have a
dietary or supplemental intake of calcium of 1,500 mg daily. Potassium levels are not relevant to
prevention of bone resorption. Vitamin D is needed to aid in the absorption of calcium. Isometric
exercises condition muscle tone but do not build bones.

7. 2. Effective splinting for a high incision reduces stress on the incision line, decreases pain, and
increases the client’s ability to deep-breathe effectively. Deep breathing should be done hourly
by the client after surgery. Sitting upright ignores the need to splint the incision to prevent pain.
Tightening the stomach muscles is not an effective strategy for promoting deep breathing.
Raising the shoulders is not a feature of deep-breathing exercises.

8. 3. The priority in the first 24 hours after adrenalectomy is to identify and prevent adrenal
crisis. Monitoring of vital signs is the most important evaluation measure. Hypotension,
tachycardia, orthostatic hypotension, and arrhythmias can be indicators of pending vascular
collapse and hypovolemic shock that can occur with adrenal crisis. Beginning oral nutrition is
important, but not necessarily in the first 24 hours after surgery, and it is not more important than
preventing adrenal crisis. Promoting self-care activities is not as important as preventing adrenal
crisis. Ambulating in the hallway is not a priority in the first 24 hours after adrenalectomy.

9. 2. Poor lung expansion from bed rest, pain, and retained anesthesia is a common cause of
slight postoperative temperature elevation. Nursing care includes turning the client and having
the client cough and deep-breathe every 1 to 2 hours, or more frequently as ordered. The client
will have postoperative I.V. fluid replacement ordered to prevent dehydration. Wound infections
typically appear 4 to 7 days after surgery. Urinary tract infections would not be typical with this
surgery.

10. 3. Pain control should be evaluated at least every 2 hours for the client with a PCA system.
Addiction is not a common problem for the postoperative client. A client should not be
encouraged to tolerate pain; in fact, other nursing actions besides PCA should be implemented to
enhance the action of opioids. One of the purposes of PCA is for the client to determine
frequency of administering the medication; the nurse should not interfere unless the client is not
obtaining pain relief. The nurse should ensure that the client is instructed on the use of the PCA
control button and that the button is always within reach.

11. 1. Decreased mobility is one of the most common causes of abdominal distention related to
retained gas in the intestines. Peristalsis has been inhibited by the general anesthesia, analgesics,
and inactivity during the immediate postoperative period. Ambulation increases peristaltic
activity and helps move gas. Walking can prevent the need for a rectal tube, which is a more
invasive procedure. An NG tube is also a more invasive procedure and requires a physician’s
order. It is not a preferred treatment for gas postoperatively. Walking should prevent the need for
further interventions. Carbonated liquids can increase gas formation.

12. 2. Persistent cortisol excess undermines the collagen matrix of the skin, impairing wound
healing. It also carries an increased risk of infection and of bleeding. The wound should be
observed and documentation performed regarding the status of healing. Confusion and emboli
are not expected complications after adrenalectomy. Malnutrition also is not an expected
complication after adrenalectomy. Nutritional status should be regained postoperatively.

13. 3. Testosterone is an androgen hormone that is responsible for protein metabolism as well as
maintenance of secondary sexual characteristics; therefore, it is needed by both males and
females. Removal of both adrenal glands necessitates replacement of glucocorticoids and
androgens. Testosterone does not balance the reproductive cycle, stabilize mood swings, or
restore sodium and potassium balance.