Situation: A 46-year-old man with primary adrenal insufficiency (Addison disease) is brought to the emergency department after 2 days of vomiting and diarrhea. He usually takes hydrocortisone 15 mg every morning and 5 mg every afternoon, and fludrocortisone 0.1 mg daily. He was treated for pulmonary tuberculosis 5 years ago. His blood pressure is 78/46 mmHg and heart rate 124 beats/min. An intravenous line is in place, 0.9% sodium chloride is infusing rapidly, and blood for cortisol and electrolytes has been drawn. Which action should the nurse carry out next?

Adrenal crisis is treated with immediate intravenous hydrocortisone 100 mg together with rapid intravenous 0.9% sodium chloride, and treatment is never delayed for test results. Oral drugs are unreliable while he is vomiting, and extra fludrocortisone does not correct the cortisol deficit that is causing shock.

Clinical situation
A 46-year-old man with primary adrenal insufficiency presents with vomiting, diarrhea, and shock. Blood pressure is 78/46 mmHg and heart rate is 124 beats/min. He takes hydrocortisone 15 mg in the morning and 5 mg in the afternoon, plus fludrocortisone 0.1 mg daily.

Why the correct answer is intravenous hydrocortisone 100 mg now
This presentation is an adrenal crisis, an acute life-threatening emergency in which the body cannot mount a cortisol response to physiologic stress. Vomiting and diarrhea are classic precipitants because they both reduce oral drug absorption and increase glucocorticoid demand. The hypotension and tachycardia reflect hypovolemia combined with loss of vascular tone from cortisol deficiency.

Treatment must begin immediately with intravenous hydrocortisone and must never be delayed while waiting for cortisol or electrolyte results. Cortisol is the missing hormone driving the shock, and replacing it rapidly restores vascular responsiveness to catecholamines and helps stabilize blood pressure. The intravenous route bypasses the unreliable oral route in a vomiting patient.

Watch out! Oral hydrocortisone, even the patient’s usual dose, is not appropriate during vomiting because absorption is unpredictable and the dose is far too low for crisis-level stress. Key point! Fludrocortisone replaces mineralocorticoid activity, but it does not correct the cortisol deficit that is causing the current shock; giving extra fludrocortisone now misses the primary problem.

Pathophysiology of adrenal crisis
Primary adrenal insufficiency means the adrenal cortex cannot produce adequate cortisol and aldosterone. Cortisol normally supports vascular tone, cardiac contractility, and glucose regulation. During infection, vomiting, diarrhea, surgery, or other stress, the body needs several times the baseline cortisol dose. If that stress dose is not given, patients rapidly develop hypotension, tachycardia, abdominal pain, fever, and altered mental status.

The incidence of adrenal crisis is estimated at 8 per 100 patient-years in patients with adrenal insufficiency ^[1]. This patient’s history of pulmonary tuberculosis 5 years ago is relevant because tuberculous adrenalitis remains a common cause of primary adrenal insufficiency worldwide ^[3].

Emergency management priorities
The immediate priorities are fluid resuscitation and parenteral glucocorticoid administration. Rapid infusion of 0.9% sodium chloride corrects hypovolemia and sodium deficit. Simultaneously, hydrocortisone 100 mg IV bolus is the standard initial dose for adrenal crisis in adults, followed by continued hydrocortisone every 6–8 hours or as a continuous infusion depending on institutional protocol ^[2].

Blood for cortisol and electrolytes may be drawn before treatment, but treatment is not withheld for results. A random cortisol level in a critically ill patient with suspected adrenal insufficiency can help confirm the diagnosis, but the clinical picture of shock in a patient with known adrenal insufficiency is sufficient to initiate crisis therapy ^[2].

Why the other options are incorrect

Option	Problem
1. Extra fludrocortisone orally now	Fludrocortisone does not replace cortisol; oral route is unreliable during vomiting; mineralocorticoid excess is not the immediate life threat.
2. Hydrocortisone once cortisol result returns	Delaying treatment for laboratory confirmation increases mortality risk; adrenal crisis is a clinical diagnosis requiring immediate therapy.
3. Usual hydrocortisone dose orally now	Maintenance dose is inadequate for stress; vomiting prevents reliable absorption; oral route is contraindicated in crisis.

Nursing implications for licensure exams
Adrenal crisis is a high-yield emergency scenario. The expected nursing action is to recognize shock in a patient with known adrenal insufficiency and administer IV hydrocortisone without waiting for diagnostic confirmation. Fluid resuscitation with isotonic saline runs concurrently. Monitoring includes blood pressure, heart rate, glucose, electrolytes, and mental status. Key point! Stress-dose steroids are required for any significant illness, injury, or procedure in a patient with adrenal insufficiency; failure to increase glucocorticoid dose during stress is a major preventable cause of adrenal crisis and mortality ^[4].