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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Manage the emotions: Managing emotions is an important aspect of conflict resolution, but it typically occurs after the problem has been clarified and during the negotiation process to promote constructive dialogue and prevent escalation of conflict.
B. Breaking the ground rules: Breaking the ground rules refers to violating established guidelines or principles for effective communication and negotiation. This step is not evident in the scenario described.
C. Disregard the conflict: Disregarding the conflict would involve ignoring or avoiding addressing the issues altogether, which is not an appropriate approach to conflict resolution. The scenario indicates that the nurse manager is actively engaged in addressing the conflict.
D. Clarify the problem: In negotiation, clarifying the problem involves identifying and defining the underlying issues or concerns contributing to the conflict. Creating a list of main issues helps ensure that all parties have a clear understanding of what needs to be addressed and provides a foundation for developing potential solutions.
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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