A 63-year-old patient hospitalized with polymyositis has joint pain, an erythematosus facial rash, eyelid edema, and a weak, hoarse voice. The priority nursing diagnosis for the patient is

a. risk for aspiration related to dysphagia.
b. disturbed visual perception related to swelling.
c. acute pain related to generalized inflammation.
d. risk for impaired skin integrity related to scratching.


ANS: A
The patient's vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a high risk for aspiration. The other nursing diagnoses also are appropriate but are not as high a priority as the maintenance of the patient's airway.

Nursing

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Nursing

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Nursing