A nurse is caring for an older client who has had a hemorrhagic stroke. The client has exhibited impulsive behavior and, despite reminders from the nurse, doesn’t recognize their limitations. Which priority measure should the nurse implement to prevent injury?

Reasoning:

Choice A reason: Administering aspirin is contraindicated in DIC, as it inhibits platelet function, worsening bleeding risk in a condition already characterized by thrombocytopenia and coagulopathy. Aspirin’s antiplatelet effect could exacerbate hemorrhage, making it an inappropriate intervention for a client with active DIC-related bleeding tendencies.

Choice B reason: Placing a pressure-reducing mattress is appropriate in DIC to prevent skin breakdown, as clients are at risk for bleeding and bruising due to low platelets and coagulopathy. Immobility from critical illness increases pressure injury risk, and a specialized mattress minimizes tissue damage and supports skin integrity.

Choice C reason: Administering meperidine intramuscularly is inappropriate in DIC, as intramuscular injections can cause hematomas due to low platelets and impaired clotting. Pain management in DIC should use intravenous or oral routes to avoid bleeding complications, making this intervention unsafe for the client’s condition.

Choice D reason: Lemon-glycerin swabs for mouth care are not ideal in DIC, as they can dry mucous membranes, increasing bleeding risk in thrombocytopenic clients. Gentle oral care with saline or soft brushes is preferred to maintain mucosal integrity, making this intervention less appropriate for DIC management.

Reasoning:

Choice A reason: Pale thick skin is not a typical effect of long-term corticosteroid use. Corticosteroids cause skin thinning due to reduced collagen production, leading to fragile, atrophic skin prone to bruising. Thick skin is more associated with conditions like scleroderma, not the catabolic effects of corticosteroids on skin tissue.

Choice B reason: Moon face is a classic sign of long-term corticosteroid use, resulting from fat redistribution to the face due to glucocorticoid-induced lipolysis and lipogenesis. Excess cortisol promotes fat deposition in the face and trunk, creating a rounded facial appearance, a hallmark of Cushing syndrome or iatrogenic corticosteroid effects.

Choice C reason: Weight loss is not expected with long-term corticosteroid use. Corticosteroids increase appetite and promote fat redistribution, leading to weight gain, particularly in the trunk and face. Weight loss may occur in conditions like Addison’s disease, where cortisol is deficient, not in hypercortisolism states.

Choice D reason: Hypotension is not a common effect of corticosteroids. They can cause fluid retention and increased blood volume due to mineralocorticoid activity, potentially leading to hypertension. Hypotension is more associated with adrenal insufficiency, where cortisol and aldosterone deficiencies reduce vascular tone and fluid balance.