A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?
Determine the client's last dose of corticosteroids.
Determine neurological baseline prior to the fall.
Administer a PRN IV antiemetic as prescribed.
Complete head-to-toe neurological assessment.
The Correct Answer is D
A. Determine the client's last dose of corticosteroids: This may be helpful later in understanding the client's MS management, but it is not the immediate priority in an acute neurological situation.
B. Determine neurological baseline prior to the fall: While important for comparison, establishing the client’s current status through assessment takes priority.
C. Administer a PRN IV antiemetic as prescribed: Vomiting may be a sign of increased intracranial pressure (ICP); treating the symptom without assessing for underlying neurological compromise could delay recognition of a critical condition.
D. Complete head-to-toe neurological assessment: This is the priority. The client’s confusion and projectile vomiting may indicate a traumatic brain injury with increased ICP. Immediate neurological assessment is necessary to identify life-threatening changes and guide urgent interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Storing the medication at room temperature is appropriate and indicates correct understanding.
B. Priming the inhaler with 7 pumps is excessive. Generally, ipratropium inhalers require only 2-3 pumps to prime before first use, indicating that the client needs additional teaching on the proper priming technique.
C. Attaching a spacer device is a beneficial action that can enhance medication delivery and is recommended for use with metered-dose inhalers.
D. Rinsing the mouth after each use is good practice to minimize the risk of oral side effects, such as dryness or irritation.
Correct Answer is D
Explanation
A. Uncontrollable shaking can be a side effect of albuterol, but it is not as critical as other potential cardiovascular concerns.
B. Increased anxiety is common with respiratory distress but is not immediately life-threatening.
C. Throat irritation may occur but is generally not a severe concern compared to cardiovascular effects.
D. An irregular rapid heart rate is a significant sign of potential adverse effects from albuterol, indicating possible toxicity or worsening of the client’s condition, which requires immediate intervention.
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