Which of the following are risk factors associated with the development of frostbite?

Choice A rationale

While the client reports abdominal distension, tenderness, and a lack of bowel movements, administering a stimulant laxative is not the most urgent priority compared to respiratory compromise. Constipation and hypoactive bowel sounds indicate a potential paralytic ileus or obstruction, which requires further diagnostic evaluation before stimulating peristalsis. While important for comfort and gastrointestinal function, this intervention does not address the immediate life-threatening issues of hypoxemia or potential respiratory failure noted in the assessment.

Choice B rationale

Increasing the frequency of vital sign monitoring to every 15 minutes provides more data but does not directly treat the client's current physiological distress. The client's blood pressure is dropping and their oxygen saturation has decreased from 94 to 92. While frequent monitoring is necessary in an unstable patient, the priority nursing action must be an intervention that stabilizes the patient's condition. Observation alone cannot correct the worsening oxygenation or the underlying cause of the client's respiratory and circulatory decline.

Choice C rationale

The client is demonstrating signs of respiratory distress, including a respiratory rate of 24, decreased oxygen saturation of 92, cyanosis, and diminished lung sounds. The hemoglobin level is also low at 9.3 gm/dL, which reduces the oxygen-carrying capacity of the blood. Normal hemoglobin for an adult is generally 12 to 18 gm/dL. Applying supplemental oxygen is the priority to ensure adequate tissue perfusion and prevent further cellular hypoxia, especially given the client's oncology status and recent clinical deterioration.

Choice D rationale

Significant weight loss and fatigue suggest that the client is in a catabolic state or experiencing cancer-related cachexia, making nutritional support essential for long-term recovery. However, nutritional interventions are considered a secondary priority when a client is experiencing acute physiological instability such as worsening oxygenation and potential shock. The immediate focus must remain on the ABCs of nursing care. Once the respiratory and hemodynamic status is stabilized, the nurse can then implement strategies to improve the client's caloric and protein intake. .

Choice A rationale

Hypertension is not a manifestation of this disease; instead, patients typically exhibit hypotension. The deficiency of mineralocorticoids, specifically aldosterone, leads to decreased sodium reabsorption and increased water excretion by the kidneys. This results in a reduction in extracellular fluid volume and cardiac output. Normal blood pressure is maintained by these hormones; without them, patients often experience chronic low blood pressure and orthostatic changes, which can lead to syncope or dizziness.

Choice B rationale

Hyperpigmentation is a classic sign of primary adrenal insufficiency due to elevated levels of adrenocorticotropic hormone. When the adrenal glands fail, the pituitary gland increases production of this hormone to stimulate them. Since it shares a precursor with melanocyte-stimulating hormone, the excess levels lead to increased melanin production. This is most visible in skin creases, pressure points, and mucous membranes, giving the skin a bronzed appearance even in areas not exposed to sunlight.

Choice C rationale

Increased sweating is not a typical finding in this condition. In fact, patients may have decreased sweating or dry skin due to chronic dehydration and electrolyte imbalances. Excessive sweating is more commonly associated with conditions of sympathetic overactivity, such as hyperthyroidism or pheochromocytoma. In adrenal insufficiency, the metabolic rate is generally low, and the body's focus is on conserving what little fluid and salt remain, rather than expending them through thermoregulatory sweating.

Choice D rationale

Hyperkalemia occurs because of the lack of aldosterone, which normally promotes the excretion of potassium in exchange for sodium in the distal renal tubules. Without sufficient aldosterone, the kidneys retain potassium, leading to serum levels above the normal range of 3.5 to 5.0 mEq/L. High potassium can cause dangerous cardiac arrhythmias and muscle weakness. Monitoring electrolyte levels is critical in managing these patients to prevent life-threatening complications related to cardiac conduction abnormalities.

Choice E rationale

Weight loss is a common and often early manifestation of this disorder. It results from a combination of anorexia, nausea, and the loss of body fluids due to sodium wasting. Additionally, the deficiency of glucocorticoids like cortisol leads to impaired metabolism of carbohydrates, proteins, and fats, contributing to the depletion of body mass. Patients often report a significant and unintentional reduction in weight over weeks or months as the adrenal function progressively declines.

Choice F rationale

Bradycardia is not a standard sign of this condition; instead, patients often present with tachycardia. The rapid heart rate is a compensatory mechanism by the body to maintain cardiac output in the face of low blood volume and hypotension. While severe hyperkalemia can eventually cause heart blocks or slow rhythms, the initial and more common response to the fluid volume deficit in adrenal insufficiency is an increased heart rate to ensure tissue perfusion.