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 ["A","C","D","E"]
Explanation
A. Performing hand hygiene is crucial to prevent the spread of infection before any patient interaction or procedure.
B. Brushing the client’s teeth is not necessary before applying an oxygen mask and does not pertain to immediate care.
C. Checking the skin around the face is important to ensure there are no irritations or breakdowns that could affect the mask's fit and the patient's comfort.
D. Identifying the client using 2 identifiers is a critical safety step to ensure the correct patient receives the intended care.
E. Assessing respiratory function is important to determine the severity of the client’s condition and the appropriate oxygen delivery method.
F. Donning gloves is not required for applying a simple face mask unless there is potential for contact with blood or bodily fluids.
G. Determining if the client needs to go to the bathroom is not directly related to applying the face mask and should be assessed but is not critical before mask application.
Correct Answer is D
Explanation
A. While H. pylori can be related to gastrointestinal issues, it is not the primary focus in pancreatitis management, and urine output is less critical than pancreatic enzyme levels.
B. Assessing bowel sounds and abdominal pain is important, but specific laboratory results provide more concrete information regarding the condition.
C. Chronic constipation and serum gastrin levels are not directly relevant to acute pancreatitis.
D. The severity of nausea and vomiting, along with serum amylase results, directly indicates the status of pancreatitis, as elevated amylase levels are typically associated with this condition. This information is vital for guiding treatment decisions.
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