A nurse is monitoring a patient with Addison's disease who has just been prescribed hydrocortisone. Which of the following signs should the nurse monitor for to detect acute adrenal insufficiency?

Choice A rationale Elevated blood glucose and increased appetite are side effects of chronic glucocorticoid therapy rather than signs of acute adrenal insufficiency. Cortisol normally stimulates gluconeogenesis and antagonizes insulin; therefore, an excess causes hyperglycemia. In acute insufficiency, the opposite occurs: glucose levels typically drop below 70 mg/dL because there is insufficient cortisol to maintain carbohydrate metabolism. Increased appetite is a classic sign of Cushing's syndrome or steroid-induced polyphagia, not an acute adrenal crisis. Choice B rationale Fatigue, weakness, and dizziness are early clinical manifestations of an addisonian crisis resulting from severe cortisol and aldosterone depletion. These symptoms occur due to a combination of hypoglycemia and decreased cardiac output. As fluid volume decreases and blood pressure drops, the brain and muscles receive inadequate perfusion, leading to profound lethargy. Monitoring for these signs is vital when a patient begins hydrocortisone, as it may indicate that the dosage is insufficient to meet the body's metabolic demands. Choice C rationale Increased blood pressure and tachycardia are not typical of acute adrenal insufficiency; rather, hypotension is the hallmark sign. While tachycardia can occur as a compensatory mechanism for low stroke volume, the lack of mineralocorticoids usually prevents the body from maintaining a high blood pressure. In a crisis, the systolic blood pressure often falls below 90 mmHg. If a patient displays hypertension, it is more likely an indication of over-replacement of steroids or another unrelated cardiovascular condition. Choice D rationale Fluid retention and hypertension are symptoms of mineralocorticoid excess, often seen in conditions like primary aldosteronism or as a side effect of excessive hydrocortisone administration. Acute adrenal insufficiency is characterized by the massive loss of water and sodium through the kidneys, leading to profound hypovolemia and vascular collapse. Normal blood pressure is roughly 120/80 mmHg; in insufficiency, these values decrease significantly. Therefore, the nurse should be looking for signs of dehydration and low blood pressure instead. .