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
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.
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