# Situation: A 44-year-old woman has a rounded face, a fat pad at the back of the neck, purple abdominal striae, and bruises on her forearms. Her blood pressure is 162/98 mmHg. A computed tomography (CT) scan shows a 3-cm mass in the left adrenal gland. She has never taken corticosteroid medicines. While she awaits surgery, the nurse reviews four assessment findings. Which finding should the nurse follow up FIRST?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630505  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 44-year-old woman has a rounded face, a fat pad at the back of the neck, purple abdominal striae, and bruises on her forearms. Her blood pressure is 162/98 mmHg. A computed tomography (CT) scan shows a 3-cm mass in the left adrenal gland. She has never taken corticosteroid medicines.

While she awaits surgery, the nurse reviews four assessment findings. Which finding should the nurse follow up FIRST?

## 보기

1. New bruises on both forearms after minor bumps
2. Capillary glucose of 168 mg/dL (9.3 mmol/L) after lunch
3. Temperature 37.6 °C (99.7 °F) and a new productive cough **✔ 정답**
4. Thin skin with purple streaks on the abdomen

**정답: 3**

## 해설

Excess cortisol suppresses inflammation and fever, so a serious infection may show only a slight temperature rise; a new productive cough with any temperature elevation needs prompt follow-up. Easy bruising, thin skin with striae, and moderate hyperglycemia are expected features of her cortisol excess.

## 심화 해설

Cortisol masks infection
Cortisol is a powerful anti-inflammatory and immunosuppressive hormone. It reduces the release of the chemical signals that produce fever, redness, and swelling, and it suppresses white cell function. In a client with cortisol excess, a serious infection may cause only a slight temperature rise and few local signs. Her temperature of 37.6 °C (99.7 °F) with a new productive cough could therefore represent pneumonia that would cause a much higher fever in someone else. In cortisol excess, any new sign of infection with even a low-grade fever needs prompt follow-up.

Why this finding comes first
Prioritization questions ask which finding is new, unexpected, and potentially dangerous. Infection is a major cause of complications in Cushing syndrome, and she is awaiting surgery, where an untreated chest infection would increase risk. The nurse follows up by assessing her respiratory status, oxygen saturation, and breath sounds, and reports the findings so that the provider can evaluate for pneumonia before the operation.

| Finding | Expected in cortisol excess? | Priority |
| --- | --- | --- |
| New bruises after minor bumps | Yes: thin skin, fragile vessels | Monitor |
| Glucose 168 mg/dL after lunch | Yes: cortisol raises glucose | Monitor |
| Temperature 37.6 °C with new productive cough | No: possible masked infection | Follow up first |
| Thin skin with purple striae | Yes: known feature | Monitor |

Why the other findings can wait
Easy bruising results from thin skin and fragile capillaries caused by cortisol's effect on collagen; it is an expected feature of her condition. A post-meal capillary glucose of 168 mg/dL (9.3 mmol/L) reflects cortisol's effect on glucose production and insulin resistance; it is monitored but is not an emergency. Thin skin with purple abdominal striae is part of her presenting picture, not a new problem. Watch out! The infection option may look minor because the temperature is only slightly raised, which is exactly why it is easy to miss.

Exam takeaway
When choosing what to follow up first, separate expected features of the disease from new findings that suggest a complication. Key point! Cortisol excess blunts fever and inflammation, so a low-grade temperature with a new cough may signal a serious infection. Infection prevention, including hand hygiene, skin protection, and early reporting of symptoms, is a key part of her care.

## 임상 시나리오

Masked Infection in Cortisol ExcessPrioritizing assessment findings
Cortisol suppresses fever and inflammation, so a serious infection may cause only a low-grade temperature such as 37.6 °C.

A new productive cough with any temperature rise needs prompt follow-up: assess breath sounds, oxygen saturation, and report.

Easy bruising, thin skin with striae, and moderate post-meal hyperglycemia are expected features.

CautionDo not dismiss a slight temperature rise in a client with cortisol excess; infection can progress with few signs.

## 핵심 개념

- **Cushing syndrome** — A condition of chronic cortisol excess causing central obesity, striae, bruising, hypertension, and infection risk.
- **Immunosuppression** — Reduced ability of the immune system to fight infection, a known effect of excess cortisol.
- **Purple striae** — Wide, violet stretch marks on the abdomen caused by thin skin and collagen loss in cortisol excess.

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