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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Free Nursing Study Resources

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Scales represent the accumulation of dead skin cells that flake off, a common secondary lesion in eczema resulting from the chronic inflammation and rapid skin cell turnover.

Choice B rationale

Erosion occurs when the superficial layer of skin is lost, typically due to scratching or friction in eczema, exposing the underlying epidermis and sometimes leading to infection.

Choice C rationale

Crusts form when serum, blood, or purulent exudate dries on the skin surface, often seen in eczema as a result of weeping lesions and subsequent drying.

Choice D rationale

Ulcers are deeper lesions extending into the dermis or subcutaneous tissue and are not typically associated with eczema. Eczema usually affects the epidermis, causing secondary lesions like scales, erosion, and crusts rather than deep tissue ulcers.

A. Assessing the client's verbal response. B. Assessing the client's response to pain. C. Assessing the client's judgment. D. Assessing the client's ability to follow complex commands.

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which secondary skin lesions are associated with eczema?

Correct Answer is ["A","B","C"]

Explanation

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 critical care nurse is caring for a client diagnosed with acute pancreatitis. The nurse knows this client should be started on parenteral nutrition (PN) after what indications?

A nurse practitioner prescribes a therapeutic bath for a client with an exacerbation of psoriasis. The nurse tells the client to make sure the bath area is well ventilated. Which of the following is the therapeutic bath solution prescribed by the nurse?

Which drug is a topical corticosteroid used to treat psoriasis?

A nurse is caring for a 78-year-old client with a history of osteoarthritis (OA). When planning the client's care, what goal should the nurse prioritize?

A client diagnosed with Parkinson's disease has developed slurred speech and drooling. The nurse knows that these symptoms indicate which of the following?

What should the nurse suspect when hourly assessment of urine output on a client post craniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours?

A client receives treatment for a dermatophyte infection of the toenail. How would the nurse document this condition in the chart?

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?