A nurse is planning care for a client diagnosed with systemic scleroderma. The nurse recognizes that an appropriate nursing diagnosis for systemic scleroderma is altered tissue perfusion secondary to which of the following?
Joint contractures.
Peripheral arterial dilation.
Raynaud's phenomenon.
Pulmonary fibrosis.
The Correct Answer is C
A. Joint contractures: Joint contractures are a common manifestation of systemic scleroderma, but they are not directly related to altered tissue perfusion. They are more related to skin and tissue fibrosis.
B. Peripheral arterial dilation: Peripheral arterial dilation is not typically associated with systemic scleroderma. Instead, peripheral vasoconstriction, such as in Raynaud's phenomenon, is more common.
C. Raynaud's phenomenon: Raynaud's phenomenon, characterized by episodic vasospasm of small arteries in response to cold or stress, can lead to impaired tissue perfusion, especially in the extremities.
D. Pulmonary fibrosis: Pulmonary fibrosis is a complication of systemic scleroderma that affects lung tissue, but it is not directly related to altered tissue perfusion. It may lead to impaired gas exchange rather than altered perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Elevating the head of the bed 30 to 45 degrees helps prevent aspiration, which is a risk factor for ventilator-associated pneumonia.
B. Performing hand hygiene before touching the ventilator tubing is crucial to prevent the introduction of pathogens into the ventilator system.
C. Refraining from suctioning the client is incorrect; suctioning should be performed as needed to keep the airway clear.
D. Providing mouth care every 2-4 hours can reduce the risk of pathogens entering the lower respiratory tract.
E. Performing hand hygiene before touching the client reduces the risk of transmitting infectious agents to the client.
Correct Answer is B
Explanation
A. Heart rate of 90 bpm: While an elevated heart rate may be expected in response to burn injury and the body's stress response, a heart rate of 90 bpm alone may not be concerning without additional context.
B. Blood pressure of 96/50 mm Hg: This blood pressure reading indicates hypotension, which can be a sign of inadequate tissue perfusion, fluid loss, or shock. It requires prompt notification of the healthcare provider for further assessment and intervention.
C. Urine output of 2 mL/kg per hour: Adequate urine output is important for renal function and fluid balance, and a urine output of 2 mL/kg per hour is within the normal range. While changes in urine output should be monitored, this finding alone does not require immediate notification of the healthcare provider.
D. Pain rating of 7 on a 1 to 10 point scale: Pain management is important in burn care, but a pain rating of 7 on a 1 to 10 scale is not unusual in clients with burns and may not require immediate notification of the healthcare provider unless accompanied by other concerning symptoms.
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