Addison Disease and Cushing Syndrome: What the NCLEX Tests
What it is
The adrenal cortex makes cortisol (a glucocorticoid) and aldosterone (a mineralocorticoid). In Addison disease (primary adrenal insufficiency) the cortex is destroyed, so the client loses sodium and water, retains potassium, and cannot raise blood glucose or blood pressure under stress. Cushing syndrome is cortisol excess, most often from long-term corticosteroid therapy, and produces the opposite picture: hyperglycemia, sodium and water retention, hypokalemia, protein breakdown and immunosuppression. Thinking "too little versus too much" predicts nearly every finding and nursing action.
What the NCLEX focuses on
- Addison signs: fatigue, weight loss, salt craving, orthostatic hypotension, hyponatremia, hyperkalemia, hypoglycemia, and bronze hyperpigmentation of skin creases and mucous membranes (primary disease only, from high ACTH).
- Adrenal crisis: severe hypotension, tachycardia, confusion, vomiting, abdominal pain and shock, triggered by infection, surgery, trauma or abrupt withdrawal of long-term corticosteroids.
- Cushing signs: moon face, truncal obesity with thin extremities, buffalo hump, purple striae, thin skin with easy bruising, hirsutism, muscle weakness, mood changes and hypertension.
- Cushing risks: hyperglycemia, infection with masked fever and inflammation, osteoporosis and fractures, poor wound healing and fluid retention.
- Hydrocortisone replacement mimics the normal rhythm: two-thirds of the dose on waking, one-third in the late afternoon; fludrocortisone replaces aldosterone in primary disease.
- Overnight dexamethasone suppression test: failure of cortisol to suppress supports Cushing syndrome.
- After adrenalectomy the client needs glucocorticoid replacement (lifelong after bilateral removal); watch for hypotension and hypoglycemia.
Priority nursing actions
- Recognize adrenal crisis in a client with Addison disease or long-term steroid use who has hypotension, vomiting or confusion, and call the rapid response team.
- Give the prescribed IV hydrocortisone without waiting for cortisol results.
- Infuse prescribed IV 0.9% sodium chloride rapidly, with dextrose if glucose is low.
- Monitor blood pressure, heart rate and cardiac rhythm, glucose, sodium, potassium and urine output.
- Treat the trigger, such as infection, and change to oral replacement once the client tolerates oral intake.
Numbers to know
| Finding | Addison disease | Cushing syndrome |
|---|---|---|
| Sodium (136 to 145 mEq/L [136 to 145 mmol/L]) | Low | Normal or high |
| Potassium (3.5 to 5.0 mEq/L [3.5 to 5.0 mmol/L]) | High | Low |
| Fasting glucose (70 to 99 mg/dL [3.9 to 5.5 mmol/L]) | Low | High |
| Blood pressure | Low, orthostatic | High |
| Weight | Loss | Gain, truncal |
| Skin | Bronze hyperpigmentation | Thin, bruised, purple striae |
Common exam traps
- Choosing to stop long-term prednisone once symptoms improve: wrong because therapy suppresses the adrenal glands; abrupt withdrawal causes adrenal crisis, so doses are tapered.
- Choosing a double oral prednisone dose for a client who is vomiting: wrong because the oral dose is not retained; the client needs IV hydrocortisone and IV fluids.
- Choosing to take the full hydrocortisone dose at bedtime: wrong because it reverses the normal morning cortisol peak and causes insomnia.
- Choosing a sodium restriction in Addison disease: wrong because aldosterone loss wastes sodium and causes hypovolemia.
- Choosing "no fever, so no infection" in Cushing syndrome: wrong because cortisol excess masks fever and inflammation.
What to teach
- Take replacement for life with food; never skip or stop doses; take the larger dose on waking.
- During fever or illness, call the provider about increasing the dose; with vomiting or diarrhea, use the emergency injection and seek emergency care.
- Wear medical alert identification and keep an injectable hydrocortisone kit; teach a family member to give it.
- With Cushing syndrome: wash hands often, check glucose as instructed, prevent falls, and report signs of infection even without fever.
Try 2 NCLEX-style questions on this topic
From the NCLEXPace question bank. Pick your answers, then check them inside NCLEXPace.
The nurse compares assessment findings of two clients on the endocrine unit, one with adrenal cortex hypofunction and one with adrenal cortex hyperfunction. For each finding, select the condition it best supports.
For each finding, select the condition it best supports. Each row has one answer.
| Adrenal insufficiency (Addison disease) | Cortisol excess (Cushing syndrome) | |
|---|---|---|
| Truncal obesity with thin extremities and purple striae | ||
| Craving for salty foods with weight loss | ||
| Hyperpigmentation of skin creases and mucous membranes | ||
| Fasting glucose persistently above the reference range | ||
| Blood pressure 92/58 mm Hg with orthostatic dizziness | ||
| Multiple ecchymoses and thin, fragile skin |
A client on long-term prednisone for rheumatoid arthritis is admitted after two days of influenza with vomiting and inability to keep medications down. The client is lethargic. Findings:
| Finding | Value |
|---|---|
| Blood pressure | 78/50 mm Hg |
| Heart rate | 122/min |
| Glucose | 58 mg/dL |
| Sodium | 128 mEq/L |
Intravenous access has been established. Which prescription should the nurse implement first?
- A. Administer rectal acetaminophen for fever and reassess blood pressure, glucose, and mental status in 30 to 60 minutes
- B. 0.9% sodium chloride bolus with intravenous hydrocortisone
- C. Obtain two sets of blood cultures before fluids, glucocorticoids, or glucose are administered so infection can be documented first
- D. Give twice the usual oral prednisone dose with an antiemetic and reassess whether the client can tolerate oral replacement
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Endocrine Map: DKA vs. HHS, Addison’s vs. Cushing’s, Thyroid EmergenciesElectrolyte Imbalances: One Table for All of ThemMore tips on Medical-Surgical
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- Harding MM, Kwong J, Hagler D, Reinisch C. Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 12th ed. Elsevier; 2023; Chapter: Endocrine Problems.
- Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(2):364-389.
- Nieman LK, Biller BMK, Findling JW, et al. The Diagnosis of Cushing's Syndrome: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2008;93(5):1526-1540.
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