When working with a patient with diffuse scleroderma who is ...

[Jipu 123]

When working with a patient with diffuse scleroderma who is exhibiting a stone face expression, the nurse should consider which of the following to be a priority nursing diagnosis for this patient?
 
  A)
  Ineffective tissue perfusion related to tightening of the facial skin
  B)
  Activity intolerance related to muscle tightening in lower extremities
  C)
  Oral mucous membrane, impaired due to restricted motion of the mouth
  D)
  Aspiration, risk related to swallowing impairments

Question 2

A nurse is providing care for a client who has had a cast applied to her fractured arm 6 hours prior.
 
  The client is now complaining of severe pain that she describes as even worse than when I broke my arm. What would be the nurse's best course of action?
  A)
  Administration of analgesics and teaching the client about the normal course of pain after a fracture
  B)
  Teaching the client simple range of motion exercises to promote circulation and perfusion
  C)
  Taking the client's temperature due to the possibility of infection
  D)
  Assessment of motor and sensory function with the goal of identifying compartment syndrome

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Answer to Question 1

Ans:
D

Feedback:

Diffuse scleroderma is characterized by severe and progressive disease of the skin and the early onset of organ involvement. The typical person has a stone facies due to tightening of the facial skin with restricted motion of the mouth. Involvement of the esophagus leads to hypomotility and difficulty in swallowing. The other NANDAs would be of lower priority if at all given the assessment data presented.

Answer to Question 2

Ans:
D

Feedback:

Severe pain in the site of a fracture that is out of proportion to the original injury is a hallmark of compartment syndrome. Assessment of sensory and motor function would be an appropriate first action. Analgesia alone and exercises would be insufficient to diagnose or address compartment syndrome, and infection would be an unlikely etiology of sudden pain after cast application.