A client has advanced systemic sclerosis and presents with a mask-like face and limited ROM of the mouth. Which nursing diagnosis is most important to address an important concept related to this client?
a. Altered Body Image
b. Impaired Skin Integrity
c. Risk for Constipation
d. Risk for Imbalanced Nutrition
A
While all the above diagnoses may be pertinent, a client with such physical deformities to the face must be assessed for Altered Body Image. Coping with such alterations in body image can be an overwhelming task for the client. There are no data to show the client has impaired skin, and the other two diagnoses are "risk for" diagnoses, and therefore lower priority.
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The nurse is assessing the client's pupillary responses. The client is found to have no consensual response. Which conclusion by the nurse is the most appropriate?
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Which are the energy-providing food groups? (Select all that apply.)
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