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.

Answer and Explanation

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.

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Correct Answer is ["B","C","E"]

Explanation

A. Lime: Lime can cause chemical burns, especially when in contact with moisture (e.g., skin or eyes), but it is less common than some other agents listed.

B. Hydrofluric acid: Hydrofluoric acid is highly corrosive and can cause severe burns upon contact with the skin or mucous membranes.

C. Bleach: Bleach, particularly sodium hypochlorite, is a common household chemical that can cause chemical burns, especially in concentrated forms.

D. Fabric softener: While fabric softeners contain chemicals, they are not typically known to cause significant chemical burns unless ingested or used improperly.

E. Gasoline: Gasoline is a flammable liquid that can cause chemical burns upon skin contact.

A. Client has increased urine specific gravity. B. Changes in the client's behavior. C. Client is complaining of nausea. D. Client is complaining of severe headache. E. Client's urine output is only 50 cc/hr.

Correct Answer is ["A","B","C","D"]

Explanation

A. Client has increased urine specific gravity: Increased urine specific gravity indicates concentrated urine, which is a hallmark of SIADH and should be reported as it reflects the excessive retention of water.

B. Changes in the client's behavior: Behavioral changes can be indicative of hyponatremia, a serious complication of SIADH, and should be reported immediately.

C. Client is complaining of nausea: Nausea is a symptom of hyponatremia, which is a common and dangerous consequence of SIADH that needs prompt attention.

D. Client is complaining of severe headache: A severe headache can also be a sign of hyponatremia and potential cerebral edema, both of which are critical conditions needing urgent intervention.

E. Client's urine output is only 50 cc/hr: While reduced urine output can be associated with SIADH, 50 cc/hr is not extremely low and might not be immediately alarming on its own. The other symptoms are more critical and should take precedence in reporting to the provider.

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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?

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Naxlex Comprehensive Predictor Exams

A client is admitted to the burn unit with chemical burns. The nurse understands that which of the following agents are potential causes of the client's burn injuries? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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Correct Answer is ["A","B","C","D"]

Explanation

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