# A 58-year-old male client with HFrEF taking spironolactone 25 mg orally daily for 8 weeks reports new painful breast enlargement and tenderness. Recent labs show K+ 4.4 mEq/L (normal), and the EF remains improved at 40%. Which response by the nurse is most appropriate?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=374911&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A 58-year-old male client with HFrEF taking spironolactone 25 mg orally daily for 8 weeks reports new painful breast enlargement and tenderness. Recent labs show K+ 4.4 mEq/L (normal), and the EF remains improved at 40%. Which response by the nurse is most appropriate?

## Option

1. "Painful breast enlargement is a known anti-androgen effect of spironolactone; the provider may switch you to eplerenone, which is a selective aldosterone antagonist with much less gynecomastia." **✔ Correct answer**
2. "Breast changes like this can occur when fluid overload is present; we will need to intensify your diuretic regimen and possibly add a loop diuretic to manage this symptom and monitor your potassium levels closely."
3. "It is important to discontinue spironolactone due to this side effect; your provider may consider switching you to an ACE inhibitor or digoxin to control your symptoms and reduce the risk of hospitalization."
4. "This is a separate issue likely not related to your heart medication; you should schedule an appointment with your primary care provider for a breast examination and possible mammogram to rule out malignancy."

**Correct answer: 1**

## Explanation

Spironolactone — non-selective aldosterone antagonism and gynecomastia
Spironolactone is a potassium-sparing aldosterone receptor antagonist used in HFrEF, resistant HTN, primary hyperaldosteronism, cirrhotic ascites, hirsutism, and acne. It is non-selective — it also blocks androgen and progesterone receptors and inhibits androgen synthesis. Anti-androgen effects produce gynecomastia (10%·dose-dependent), breast tenderness, decreased libido, and erectile dysfunction in men, and menstrual irregularity in women. Standard management when this becomes intolerable: switch to eplerenone, a selective aldosterone antagonist with similar HF/HTN benefit but markedly fewer anti-androgen side effects. Patient should not stop the medication independently; abrupt discontinuation in HFrEF can lead to decompensation. Other key teaching: monitor K+ (especially with ACEi/ARB co-prescription), avoid K+ supplements and salt substitutes containing K+, and report new muscle weakness/cramps/palpitations.

## In-depth explanation

Clinical reasoning summary
Spironolactone — non-selective aldosterone antagonism and gynecomastia
Spironolactone is a potassium-sparing aldosterone receptor antagonist used in HFrEF, resistant HTN, primary hyperaldosteronism, cirrhotic ascites, hirsutism, and acne. It is non-selective — it also blocks androgen and progesterone receptors and inhibits androgen synthesis. Anti-androgen effects produce gynecomastia (10%·dose-dependent), breast tenderness, decreased libido, and erectile dysfunction in men, and menstrual irregularity in women. Standard management when this becomes intolerable: switch to eplerenone, a selective aldosterone antagonist with similar HF/HTN benefit but markedly fewer anti-androgen side effects. Patient should not stop the medication independently; abrupt discontinuation in HFrEF can lead to decompensation. Other key teaching: monitor K+ (especially with ACEi/ARB co-prescription), avoid K+ supplements and salt substitutes containing K+, and report new muscle weakness/cramps/palpitations.

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