A client who recently stopped long-term prednisone has vomiting, severe weakness, blood pressure 78/44 mm Hg, sodium 126 mEq/L, glucose 58 mg/dL, and potassium 5.8 mEq/L. Which intervention should the nurse anticipate first?
1Give parenteral hydrocortisone and isotonic fluid, adding dextrose as clinically indicated.✓ Correct answer
2Restrict fluids and administer a loop diuretic to correct the sodium concentration.
3Give oral prednisone after the vomiting resolves and reassess the blood pressure tomorrow.
4Administer potassium replacement and encourage ambulation to improve vascular tone.
Explanation
Abrupt withdrawal after long-term glucocorticoid therapy can precipitate adrenal crisis. Hypotension, vomiting, hyponatremia, hypoglycemia, and hyperkalemia require emergency parenteral hydrocortisone and rapid isotonic fluid resuscitation, with dextrose when hypoglycemia is present. Treatment should not wait for confirmatory testing. Fluid restriction, delayed oral therapy, and potassium replacement would worsen immediate threats.
Clinical reasoning Loss of cortisol impairs vascular tone and glucose regulation, while mineralocorticoid deficiency contributes to sodium loss, volume depletion, and potassium retention.
Decision rule Suspected adrenal crisis with hemodynamic instability is treated immediately with parenteral glucocorticoid and fluid resuscitation; correct hypoglycemia concurrently.
Scenario 48-year-old female on high-dose ICS + prednisone 7.5 mg/day × 2 years for severe asthma. Presents with fever, vomiting, BP 86/52, weak, confused, fingerstick glucose 62.
Adrenal crisis — An acute, life-threatening cortisol deficiency that can cause shock, vomiting, electrolyte abnormalities, and hypoglycemia.
Stress-dose hydrocortisone — Parenteral glucocorticoid replacement given urgently when severe adrenal insufficiency or crisis is suspected.
Sick-day rules — Steroid stress dosing during illness, surgery, or trauma to prevent crisis.