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.

Answer and Explanation

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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Correct Answer is ["B","C","D","E"]

Explanation

A. Sterilize dishes before using: This is not typically necessary. Washing dishes with hot water and soap or using a dishwasher is sufficient to ensure they are clean.

B. Maintain good hygiene: Good hygiene practices are crucial for immunocompromised individuals to prevent infections.

C. Cook meats and fish well: Properly cooking meats and fish helps to kill any harmful bacteria and parasites that could cause infections.

D. Avoid consuming raw foods: Raw foods, especially meats, eggs, and some vegetables, can harbor harmful bacteria and parasites, posing a risk of infection.

E. Wash hands frequently: Frequent handwashing is one of the most effective ways to prevent the spread of infections.

A. Elevate the head of the bed 30 to 45 degrees. B. Perform hand hygiene before touching the ventilator tubing. C. Refrain from suctioning the client. D. Provide mouth care every 2-4 hours. E. Perform hand hygiene before touching the client.

Correct Answer is ["A","B","D","E"]

Explanation

A. Elevating the head of the bed 30 to 45 degrees helps prevent aspiration, which is a risk factor for ventilator-associated pneumonia.
B. Performing hand hygiene before touching the ventilator tubing is crucial to prevent the introduction of pathogens into the ventilator system.
C. Refraining from suctioning the client is incorrect; suctioning should be performed as needed to keep the airway clear.
D. Providing mouth care every 2-4 hours can reduce the risk of pathogens entering the lower respiratory tract.
E. Performing hand hygiene before touching the client reduces the risk of transmitting infectious agents to the client.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instructions to a client who is severely immunocompromised by HIV. Which of the following should the nurse include in the discharge instructions? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

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Correct Answer is ["A","B","D","E"]

Explanation

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