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 D
Explanation
Choice A reason: Reviewing relaxation techniques can be beneficial for managing anxiety during an asthma attack, but it is not the highest priority in an acute situation.
Choice B reason: Providing immediate rest can help the client conserve energy and reduce the work of breathing, but it does not address the underlying cause of the asthma exacerbation.
Choice C reason: Reminding the client not to try to talk helps reduce the work of breathing, but it is not the most urgent intervention.
Choice D reason: The correct answer is d because administering a short-acting beta-adrenergic medication, such as albuterol, is the highest priority. These medications act quickly to relax the bronchial muscles, reduce bronchospasm, and improve airflow, which is critical in an acute asthma exacerbation.
Correct Answer is C
Explanation
Choice A reason: Lactulose is a laxative used to treat constipation and hepatic encephalopathy by reducing blood ammonia levels, but it is not effective in lowering serum potassium levels. Therefore, it would not be the appropriate medication for treating hyperkalemia.
Choice B reason: Triamterene is a potassium-sparing diuretic, which means it helps the body retain potassium. Administering Triamterene in a client with high potassium levels (hyperkalemia) would exacerbate the condition rather than improve it. Hence, it is not a suitable choice for this scenario.
Choice C reason: Sodium polystyrene sulfonate (Kayexalate) is used to treat hyperkalemia by binding to potassium in the intestines and facilitating its removal from the body through feces. It effectively reduces serum potassium levels, making it the appropriate medication for a client with hyperkalemia.
Choice D reason: Acetylcysteine is used primarily as a mucolytic agent to break down mucus in the airways or as an antidote for acetaminophen (paracetamol) overdose. It does not have any effect on serum potassium levels and is not suitable for treating hyperkalemia.
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