A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect?

Choice A reason: Providing a diet high in protein is not appropriate during the oliguric phase of acute kidney injury, as it can increase the workload on the kidneys and worsen kidney function. Protein intake should be carefully managed based on the client's condition.

Choice B reason: Ibuprofen is contraindicated in clients with acute kidney injury because it can further impair kidney function. Pain management should be approached with alternative medications that do not have nephrotoxic effects.

Choice C reason: The correct answer is c because monitoring intake and output hourly is crucial in managing acute kidney injury. Accurate measurement of fluid balance helps guide treatment decisions and prevent complications such as fluid overload or dehydration.

Choice D reason: Encouraging the client to consume at least 2 L of fluid daily is not appropriate in the oliguric phase, as the kidneys' ability to excrete fluids is impaired. Fluid intake should be carefully restricted and monitored to avoid fluid overload.

Choice A reason: Massaging erythematous bony prominences can actually cause further damage to the skin and underlying tissues. It is better to relieve pressure and monitor the skin closely for any signs of breakdown.

Choice B reason: Implementing a turning schedule every 4 hours is not frequent enough. Clients with spinal cord injuries should be repositioned every 2 hours to prevent prolonged pressure on any one area and reduce the risk of skin breakdown.

Choice C reason: The correct answer is c because using pillows to keep the heels off the bed surface helps prevent pressure ulcers on the heels, which are common sites of skin breakdown in immobilized clients. This technique helps distribute pressure more evenly and reduces the risk of ulcers.

Choice D reason: Keeping environmental humidity less than 30% is not recommended, as low humidity can lead to dry and cracked skin, increasing the risk of skin breakdown. Maintaining a moderate humidity level helps keep the skin hydrated and intact.

Choice E reason: The correct answer is e because minimizing skin exposure to moisture, such as sweat, urine, or wound exudate, helps prevent maceration and skin breakdown. Using moisture-wicking materials and keeping the skin dry and clean are important measures in skin care for paralyzed clients.