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.
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Related Questions
Correct Answer is D
Explanation
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.
Correct Answer is A
Explanation
A. HIV primarily targets and destroys helper T-cells (CD4 cells), which are crucial for orchestrating the immune response, leading to immune system suppression and increased vulnerability to infections.
B. An increase in B-lymphocytes and IgM is not a direct action of HIV; in fact, B-cell function is also impaired as the disease progresses.
C. Proliferation of suppressor T-cells is not a characteristic effect of HIV; instead, it is the helper T-cells that are predominantly affected, leading to immune dysfunction.
D. While cytotoxic T cells may be present, their function is impaired due to the loss of helper T-cells, but deficiency of cytotoxic T cells is not the primary mechanism by which HIV suppresses the immune system.
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