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

Choice A reason: Inserting an indwelling catheter can increase the risk of urinary tract infections, which is particularly dangerous for immunosuppressed clients. Monitoring for sediment can be done through less invasive methods.

Choice B reason: Taking the client's temperature once per shift may not be frequent enough. More frequent monitoring is recommended to detect early signs of infection.

Choice C reason: Providing fresh fruit, while beneficial for preventing constipation, can pose an infection risk due to potential contamination. Alternatives like canned or cooked fruits should be considered.

Choice D reason: Limiting the number of health care workers entering the room reduces the risk of introducing infections to the immunosuppressed client. This is a key measure to protect clients with weakened immune systems.

Choice A reason: Positioning the client supine may increase intracranial pressure. The client should be positioned with the head of the bed elevated to promote drainage and reduce pressure.

Choice B reason: The correct answer is b because changing the nasal drip pad as needed helps monitor for excessive drainage, cerebrospinal fluid leaks, and infection following pituitary gland removal.

Choice C reason: Frequent brushing of teeth should be avoided initially to prevent disruption of the surgical site and decrease the risk of infection. Gentle oral hygiene can be encouraged instead.

Choice D reason: Encouraging the client to cough every 2 hours can increase intracranial pressure and is not recommended following pituitary gland surgery. Deep breathing exercises without coughing are more appropriate.