# A client receiving pembrolizumab for melanoma develops worsening fatigue, hypotension, hyponatremia, and low cortisol. Which is the nurse's priority interpretation?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=391871&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A client receiving pembrolizumab for melanoma develops worsening fatigue, hypotension, hyponatremia, and low cortisol. Which is the nurse's priority interpretation?

## Option

1. Immune-related adverse event (irAE) — likely hypophysitis or primary adrenal insufficiency; hold pembrolizumab, start stress-dose hydrocortisone, endocrine workup **✔ Correct answer**
2. Sepsis secondary to immunotherapy-related immunosuppression; obtain cultures, start broad-spectrum antibiotics, give IV fluids, and continue pembrolizumab for cancer control.
3. Symptoms unrelated to pembrolizumab therapy; likely due to progressive melanoma with adrenal metastases, manage with supportive care and continue immunotherapy.
4. Hypovolemia from poor oral intake causing hyponatremia and hypotension; administer intravenous normal saline boluses, monitor electrolytes, and resume pembrolizumab when stable.

**Correct answer: 1**

## Explanation

Correct (2): Checkpoint inhibitors (pembrolizumab, nivolumab, ipilimumab) cause immune-related adverse events affecting any organ — pneumonitis, colitis, hepatitis, thyroid, hypophysitis/adrenal, myocarditis, nephritis, dermatitis. Endocrine irAE: hypophysitis, adrenal insufficiency, thyroiditis, T1DM. Treatment: hold drug + high-dose steroids for moderate-severe irAE; endocrine deficiencies often need lifelong replacement. (1,3,4) Miss diagnosis.

## In-depth explanation

Memory Tip Checkpoint inhibitor (-pembro·nivol·ipilim·atezol·durvalo) = "ITIS everywhere" — pneumonITIS, colITIS, hepatITIS, thyroidITIS, hypophysITIS, myocardITIS, etc. Steroids first-line.

## Clinical scenario

Scenario 62-year-old male on pembrolizumab for metastatic melanoma; new fatigue, BP 92/60, Na 128, cortisol 2 mcg/dL.

## Key concepts

- **Immune checkpoint inhibitor** — Pembrolizumab/nivolumab (PD-1), atezolizumab/durvalumab (PD-L1), ipilimumab (CTLA-4).
- **Immune-related adverse events** — Autoimmune-like inflammation in any organ; managed with steroids ± other immunosuppressants.
- **Endocrine irAE** — Hypophysitis, primary adrenal insufficiency, thyroiditis, T1DM; lifelong hormone replacement common.

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