A nurse is caring for a client diagnosed with systemic scleroderma five years ago. The nurse plans to assess the client to document the disease’s progression. In addition to skin changes, which of the following findings should the nurse expect?

Choice A rationale
The situation component of the SBAR tool typically involves a brief description of the current problem or concern. Stating that a bowel resection was performed does not describe a current problem or concern.
Choice B rationale
The recommendation component of the SBAR tool involves suggesting a course of action or asking for assistance. Stating that a bowel resection was performed does not suggest a course of action or ask for assistance.
Choice C rationale
The assessment component of the SBAR tool involves sharing your analysis or opinion about the situation. Stating that a bowel resection was performed does not share an analysis or opinion.
Choice D rationale
This is the correct answer. The background component of the SBAR tool involves providing context or background information relevant to the situation. Stating that a bowel resection was

performed provides relevant background information about the patient’s recent medical history. DysphagiaDysphagia Explore

Choice A rationale
While it is true that an increased weight in the abdomen can lead to discomfort when lying down, simply having extra pillows in bed may not be sufficient to address the issue. Ascites, or the accumulation of fluid in the peritoneal cavity, can cause significant discomfort and even

pain. It can also lead to respiratory issues as the fluid puts pressure on the diaphragm, making breathing difficult. Therefore, while extra pillows may help to some extent by allowing the patient to find a more comfortable position, they are not a comprehensive solution.
Choice B rationale
Advising the patient not to wear undergarments because they will not fit due to the increased weight in the abdomen is not a medically sound advice. While it is true that ascites can cause distension of the abdomen, the focus should be on treating the underlying condition and managing the symptoms, rather than on the fit of the patient’s clothing. Moreover, the choice of clothing is a personal decision and may have psychological implications for the patient.
Choice C rationale
The statement that the increased weight in the abdomen means that the patient can no longer exercise due to the strain on the heart is not entirely accurate. While it is true that ascites can put additional strain on the heart and other organs, it does not necessarily mean that all forms of exercise are contraindicated. In fact, gentle forms of exercise may be beneficial for overall health and well-being. However, any exercise regimen should be discussed with and approved by a healthcare provider.
Choice D rationale
This is the correct choice. Due to the increased abdominal weight from ascites, the patient’s balance might indeed be affected, increasing the risk of falls. Therefore, advising the patient to take their time with walking is a valid precaution. Fall prevention is a key aspect of care for patients with ascites due to end-stage liver disease.