A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect?
A dry raised rash
Excessive salivation
Periorbital edema
Hardened skin
The Correct Answer is D
Choice A reason: A dry raised rash is not a typical finding in scleroderma. Scleroderma primarily affects the skin and connective tissues, leading to hardening and tightening of the skin.
Choice B reason: Excessive salivation is not associated with scleroderma. Clients with scleroderma may experience dry mouth (xerostomia) instead.
Choice C reason: Periorbital edema is not a characteristic feature of scleroderma. Scleroderma involves systemic sclerosis that affects the skin, blood vessels, and internal organs.
Choice D reason: The correct answer is d because hardened skin is a hallmark of scleroderma. This autoimmune disease causes the skin to become thickened, tight, and stiff due to excessive collagen deposition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Asking "Why have you changed your mind about the surgery?" may come across as confrontational or judgmental. It does not address the client's emotions and may make the client feel defensive.
Choice B reason: The correct answer is b because acknowledging the client's feelings by saying, "Bypass surgery must be very frightening for you," shows empathy and understanding. It opens up a supportive conversation where the client can express concerns and emotions related to the surgery.
Choice C reason: Telling the client, "Your provider would not have scheduled the surgery unless you needed it," may dismiss the client's concerns and make them feel that their feelings are not important. It is important to address the client's emotional state and provide support.
Choice D reason: While it is appropriate to involve the healthcare provider in discussing the surgery, simply stating, "I will call your doctor and have him discuss your surgery with you," without first addressing the client's emotions and concerns, may seem dismissive. Providing emotional support should be the first step.
Correct Answer is B
Explanation
Choice A reason: Brudzinski's sign is an indicator of meningitis, where flexion of the neck causes involuntary flexion of the hips and knees. This sign is not related to hypocalcemia and is more specific to central nervous system infections.
Choice B reason: Chvostek's sign is a clinical sign of hypocalcemia. It is elicited by tapping on the facial nerve in front of the ear, which causes twitching of the facial muscles. This sign indicates neuromuscular irritability due to low calcium levels and is a key indicator for diagnosing hypocalcemia.
Choice C reason: Cullen's sign is a superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. It is associated with acute pancreatitis and intra-abdominal bleeding, not hypocalcemia. Therefore, it is not an appropriate sign to monitor for in clients with hypocalcemia.
Choice D reason: Kernig's sign is another indicator of meningitis. It involves pain and resistance to knee extension when the hip is flexed. Like Brudzinski's sign, it is specific to meningitis and is not related to hypocalcemia. Monitoring for this sign would not be relevant for a client with low calcium levels.
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