# 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.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617367&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

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.

Condition

Select 1
Septic shock
Adrenal crisis
Myxedema coma
Hypovolemic shock from vomiting

Actions to take

Select 2
Administer prescribed oral fludrocortisone
Administer the prescribed IV levothyroxine
Give IV hydrocortisone 100 mg as prescribed
Obtain a cosyntropin test before any steroid
Give prescribed IV dextrose for hypoglycemia

Parameters to monitor

Select 2
Blood glucose
Thyroid-stimulating hormone
Core temperature
Blood pressure
Urine specific gravity

## Explanation

Known primary adrenal insufficiency with missed glucocorticoid doses, fluid-refractory hypotension, hyponatremia, hyperkalemia, and hypoglycemia is adrenal crisis. The nurse gives prescribed IV hydrocortisone 100 mg immediately and IV dextrose for hypoglycemia while fluids continue. Blood pressure and blood glucose show response.

## In-depth explanation

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.

References
1Endocrine Society — Primary Adrenal Insufficiency GuidelineImmediate parenteral hydrocortisone 100 mg and fluid resuscitation in adrenal crisis
2NCSBN 2026 NCLEX-RN Test PlanClient Needs category and clinical judgment framework

## Clinical scenario

Scenario
A client with known primary adrenal insufficiency who could not retain oral hydrocortisone presents with fluid-refractory hypotension, hypoglycemia, hyponatremia, and hyperkalemia.

## Key concepts

- **Adrenal crisis** — Life-threatening acute cortisol deficiency causing shock, hypoglycemia, and electrolyte imbalance.
- **Stress-dose hydrocortisone** — High-dose parenteral glucocorticoid given during crisis or major physiologic stress.
- **Mineralocorticoid deficiency** — Loss of aldosterone effect causing sodium loss and potassium retention.

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