# 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?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630309  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

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?

## 보기

1. Give an extra dose of fludrocortisone orally now
2. Give hydrocortisone once the cortisol result returns
3. Give his usual hydrocortisone dose orally now
4. Give hydrocortisone 100 mg intravenously now **✔ 정답**

**정답: 4**

## 해설

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.

## 심화 해설

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].References (research sources)

- [1]Adrenal crisis: prevention and management in adult patients.Research articleDineen R, Thompson CJ, Sherlock M (2019) · DOI: 10.1177/2042018819848218

- [2]Diagnosis and Management of Adrenal Insufficiency and Adrenal Crisis in the Emergency Department.Research articleLentz S, Collier KC, Willis G, Long B (2022) · DOI: 10.1016/j.jemermed.2022.06.005

- [3]Addison's Disease: Diagnosis and Management Strategies.Research articleCarsote M, Nistor C (2023) · DOI: 10.2147/IJGM.S390793

- [4]Adrenal crisis and mortality rate in adrenal insufficiency and congenital adrenal hyperplasia.Research articleLousada LM, Mendonca BB, Bachega TASS (2021) · DOI: 10.20945/2359-3997000000392

## 임상 시나리오

Adrenal Crisis: Immediate IV HydrocortisoneDo not delay treatment for labs or use oral route in vomiting
Suspect adrenal crisis in any patient with adrenal insufficiency who presents with vomiting, diarrhea, and shock. Hypotension (78/46 mmHg) and tachycardia (124 beats/min) reflect hypovolemia plus loss of vascular tone from cortisol deficiency.

Give hydrocortisone 100 mg IV immediately along with rapid 0.9% sodium chloride infusion. Cortisol replacement restores vascular responsiveness to catecholamines and stabilizes blood pressure.

CautionNever delay treatment while waiting for cortisol or electrolyte results. Oral hydrocortisone is unreliable during vomiting, and extra fludrocortisone does not correct the cortisol deficit causing shock.

## 핵심 개념

- **adrenal crisis** — Acute life-threatening emergency in adrenal insufficiency where the body cannot mount a cortisol response to stress, causing shock.
- **hydrocortisone** — Glucocorticoid replacement used in high intravenous doses to treat adrenal crisis and restore vascular tone.
- **fludrocortisone** — Mineralocorticoid replacement for adrenal insufficiency; does not correct acute cortisol deficiency.
- **primary adrenal insufficiency** — Addison disease; adrenal glands fail to produce cortisol and aldosterone.
- **hypotension** — Low blood pressure; in adrenal crisis reflects hypovolemia and loss of vascular tone from cortisol deficiency.

## 같은 주제 문제

- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630291)
- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630292)
- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630293)
- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630294)
- [Situation: A 58-year-old man with alcohol-associated cirrhosis is admitted with tense asci…](https://mymerci.kr/pages/nclex_q.php?qn_id=630295)
- [Situation: A 46-year-old woman with obesity is admitted with acute cholangitis caused by a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630296)
- [Situation: A 46-year-old woman with obesity is admitted with acute cholangitis caused by a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630297)
- [Situation: A 46-year-old woman with obesity is admitted with acute cholangitis caused by a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630298)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._