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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Observing the client's fingers is essential as early signs of rheumatoid arthritis often manifest in the small joints of the hands, including swelling, redness, and pain.
B. While lymph nodes may be palpated for other conditions, they are not directly indicative of rheumatoid arthritis.
C. Observing the skin for lesions is important for other conditions but is not a primary assessment technique for rheumatoid arthritis.
D. Palpating large joints for nodules is more relevant in later stages of the disease; early signs focus more on the small joints and their characteristics.

A. Perform the drainage immediately after meals. B. Explain that the client may be placed in five positions. C. Instruct the client to breathe shallow and fast. D. Obtain an arterial blood gas (ABG) prior to the procedure.

Correct Answer is B

Explanation

A. Performing postural drainage immediately after meals can lead to discomfort or aspiration; it is usually advised to wait at least one hour after eating.
B. This statement is correct, as postural drainage involves positioning the client in various positions to help mobilize secretions from different lung segments, typically five positions are used.
C. Shallow and fast breathing is not recommended during postural drainage; deep breathing is encouraged to facilitate effective clearance of secretions.
D. Obtaining an arterial blood gas (ABG) is not routinely necessary before postural drainage; the focus is on mobilizing secretions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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