A client with primary adrenal insufficiency has vomited for 2 days and could not keep down oral hydrocortisone. The client is confused, with blood pressure 78/42 mm Hg, heart rate 122/min, temperature 37.4°C, and respiratory rate 20/min. Sodium is 129 mEq/L, potassium 5.8 mEq/L, glucose 51 mg/dL, and WBC 8,900/mm³. Hypotension persists after the first 1-L bolus of 0.9% sodium chloride. There is no cough, dysuria, or abdominal tenderness, and the client takes no thyroid medication. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Quick answer
Adrenal crisis; give IV hydrocortisone 100 mg and IV dextrose as prescribed; monitor blood pressure and blood glucose.

Why this is correct
Vomiting stopped cortisol replacement in a client who cannot make it, and the pattern of low sodium, high potassium, low glucose, and shock that does not respond to saline alone is the signature of cortisol and aldosterone deficiency. The Endocrine Society recommends immediate parenteral hydrocortisone 100 mg with fluid resuscitation and glucose correction. Rising blood pressure and normal glucose show that cortisol replacement is working.

Easy analogy or mental picture
Cortisol is the backup generator the body switches on under stress. With the generator unplugged, fluids alone cannot keep the lights (blood pressure) and the fuel gauge (glucose) up — plug the generator back in.

Memory hook
Low sodium, High potassium, Low sugar, Low pressure = "Salt out, K in, sugar gone" — give hydrocortisone first.

NCLEX decision rule
In a client with known adrenal insufficiency and shock, give parenteral hydrocortisone immediately; never delay it for diagnostic testing.

Why the other choices are wrong
Septic shock is tempting, but temperature and WBC are normal with no source, and hyperkalemia with hypoglycemia is not typical. Hypovolemic shock from vomiting usually causes hypokalemia and should respond to saline. Myxedema coma causes hypothermia and bradycardia, not tachycardia and normal temperature, so levothyroxine, TSH, and core temperature target the wrong condition. Fludrocortisone is not needed when high-dose hydrocortisone is given and oral intake is not possible. A cosyntropin test is appropriate for diagnosis but must not delay steroid in crisis. Urine specific gravity reflects hydration but not response to cortisol.