A client with atopic dermatitis is ordered a potent topical corticosteroid to be covered with an occlusive dressing.

To address a potential client problem associated with this treatment, the nurse formulates the nursing diagnosis of Risk for injury.

To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?

Related to percutaneous absorption of the topical corticosteroid.

Related to vasodilatory effects of the topical corticosteroid.

Related to potential interactions between the topical corticosteroid and other ordered drugs.

Related to topical corticosteroid application to the face, neck, and intertriginous sites.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Percutaneous absorption of topical corticosteroids increases systemic exposure, potentially causing side effects like adrenal suppression, hyperglycemia, and Cushing's syndrome. This is particularly significant when potent corticosteroids are applied to large body areas or under occlusive dressings, enhancing absorption and systemic effects.

Choice B rationale

Topical corticosteroids primarily induce vasoconstriction, not vasodilation, reducing inflammation and redness in skin conditions. Incorrect understanding of their vasodilatory effects may misguide nursing interventions, making it less relevant to the injury risk in atopic dermatitis treatments.

Choice C rationale

Topical corticosteroids have minimal systemic interactions compared to oral or intravenous forms, making drug interaction concerns less pertinent. The risk of significant drug interactions is low unless the medication is systemically absorbed in substantial amounts.

Choice D rationale

Application to face, neck, and intertriginous sites increases the risk of local side effects like skin atrophy, but is not a primary concern for systemic injury risk. These areas have thinner skin, enhancing absorption and risk of local adverse effects, but not necessarily systemic harm.

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Correct Answer is A

Explanation

Choice A rationale

Assessing the client's verbal response is the first step in evaluating their level of consciousness (LOC). It provides immediate information about their ability to communicate and follow commands.

Choice B rationale

Assessing the client's response to pain is a later step in the LOC assessment if the client does not respond to verbal stimuli. It helps determine the level of consciousness if the client is not verbally responsive.

Choice C rationale

Assessing the client's judgment is part of a cognitive assessment but is not the first action when assessing LOC. It evaluates higher brain functions, not the initial level of responsiveness.

Choice D rationale

Assessing the client's ability to follow complex commands is part of a cognitive assessment and provides information about higher brain function but is not the first step in LOC assessment.

A. Risk for increased intracranial pressure. B. Dysfunction in the cerebrum. C. Dysfunction in the brain stem. D. Dysfunction in the spinal column.

Correct Answer is C

Explanation

Choice A rationale

Increased intracranial pressure can result from various conditions, including brain injuries, tumors, or infections. However, decerebrate posturing is specifically associated with brain stem dysfunction rather than increased intracranial pressure alone.

Choice B rationale

Dysfunction in the cerebrum can lead to different posturing responses, such as decorticate posturing, which involves abnormal flexion of the arms. Decerebrate posturing, on the other hand, indicates more severe damage lower in the brain stem.

Choice C rationale

Dysfunction in the brain stem is indicated by decerebrate posturing, which involves extension and outward rotation of the arms and legs in response to painful stimuli. This type of posturing signifies serious damage to the brain stem and carries a poor prognosis.

Choice D rationale

Dysfunction in the spinal column may result in various neurological deficits but does not specifically cause decerebrate posturing. This type of posturing is indicative of brain stem damage rather than spinal column issues.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this client?

Correct Answer is A

Explanation

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:

Correct Answer is C

Explanation

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:

Which posture is exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?

A client who has sustained a head injury cannot identify a familiar object. The nurse knows that this deficit is called which of the following?

Which term describes the fibrous connective tissues that cover the brain and spinal cord?

Which lobe of the brain is responsible for spatial relationships?

The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?

The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate action?

A client has difficulty interpreting their awareness of body position in space. Which lobe is most likely to be damaged?